Pain in the heel can be caused by many things. The commonest cause is plantar fasciitis.
Other causes include:
• Being overweight
• Constantly being on your feet, especially on a hard surface and wearing hard-soled footwear
• Thinning or weakness of the fat pads of the heel
• Arthritis in the ankle or heel (subtalar) joint
• Irritation of the nerves on the inner or outer sides of the heel
• Fracture of the heel bone
What is Plantar Fasciitis?
The function of the heel in walking is to absorb the shock of your foot striking the ground and to start springing you forward on the next step. The heel bone, or calcaneum, is cushioned by specialised fat, contained in elastic pockets, within the thickened skin of the heel. It contains a strong bone (the calcaneum).
There are a number of strong ligaments, which run between the calcaneum and the toes. This ligament helps support the arch of the
foot. The strongest of these ligaments is the plantar fascia.
The plantar fascia takes a lot of the stress when you walk, or even just standing. In some people the plantar fascia becomes painful and inflamed. This usually happens where it is attached to the heel bone, although sometimes it happens in the mid-part of the foot. This condition is called plantar fasciitis.
• Constant stress. Plantar fasciitis is therefore commoner in people who spend all day on their feet, or are overweight.
• Stiffness of the ankle or tightness of the Achilles tendon increase the stresses on the heel. Most people with plantar fasciitis have a rather tight Achilles tendon.
• People who have high-arched (‘cavus’) feet or flat feet are less able to absorb the stress of walking and are at risk of plantar fasciitis.
• Occasionally plantar fasciitis starts after an injury to the heel.
• People who have a rheumatic condition such as rheumatoid arthritis or ankylosing spondylitis may get inflammation anywhere a ligament is attached to bone (enthesopathy), and plantar fasciitis in these people is part of their general condition.
Can I do anything about heel pain myself?
You can try to avoid the things that cause heel pain to start:
• Lose weight
• Where your job allows, minimise the shock to your feet from constant pounding on hard surfaces, both by reducing the time you spend on your feet, and wearing shoes with a soft, cushioned heel (such as training shoes).
• Reduce the shocks on your heel by choosing footwear with some padding or shock-absorbing material in the heel. Heel pads, bought from chemists, can be put in standard shoes to reduce the impact of walking.
• If you have an injury to your ankle or foot, make sure you exercise afterwards to get back as much movement as possible to reduce the stresses on your foot and your heel. If you start to get heel pain, doing the above things may enable the natural healing process to get underway and the pain to improve.
When should I take professional advice?
If your heel pain is affecting your normal activities and not getting better with simple self-treatment you may wish to consult your GP. (You may prefer to put up with it, knowing it will probably get better eventually.)
How will my doctor tell what is wrong?
Your doctor will listen to your complaints about your heel and examine you to see what is causing the pain, and whether anything else has started it off. If the cause of your pain seems obvious, your doctor may be happy to start treatment straight away. However, some tests may be helpful in ruling out other problems. Blood tests may be done for arthritis. An X-ray will show any arthritis in the ankle or sub-talar joint, as well as any fracture or cyst in the calcaneum. (It will also show a spur if you have one, but as we know this is not the cause of the pain.)
Occasionally a bone scan may be used to help spot arthritis or a stress fracture.
What can be done about heel pain?
As heel pain is basically a stress problem in the tissues of the heel, the main treatment is to reduce stress.
• Your doctor will advise you about weight-loss and appropriate footwear.
• A soft heel pad is useful to wear in your shoe to act as a shock-absorber when you walk.
• If you have a stiff ankle or tight Achilles tendon simple exercises can be used to stretch the heel cord. Stretching the Achilles tendon and plantar fascia is very effective general treatment for many patients, however it is important that you undertake the exercises regularly.
• Hamstring stretches also help.
• Simple painkillers such as paracetamol or antiinflammatory medicines (for example Brufen, Nurofen) can help reduce the pain. Ask advice from your doctor or pharmacist before taking anti-inflammatory medicines as they can have troublesome side-effects in some people.
The simple measures above will help the majority of people with heel pain. In fact after about one year 95% of people’s symptoms settle. It is important to be patient, and stick to the treatment programme.
If the pain continues, further treatment may be required.
There are numerous options, these include:
• Injection of a steroid (an anti-inflammatory agent) into the attachment of the plantar fascia to damp down the inflammation.
Only if all non-surgical treatments fail would an operation be considered – this is because surgery has risks attached to it, and is not always successful.
Do I need an operation?
It is rare to need an operation for heel pain. It would only be offered if all simpler treatments have failed and, in particular, you are a reasonable weight for your height and the stresses on your heel cannot be improved by modifying your activities or footwear.
The aim of an operation is to release part of the plantar fascia from the heel bone and reduce tension in it. Most people who have an operation are better afterwards. Surgery is between 70% and 90% successful; however, there are risks, including a small number of patients who are worse following surgery.
The principle complications of surgery include:
• The pain fails to settle
• Dividing the fascia can lead to a flat foot, which is painful, and difficult to treat
• Tingling or numbness in the heel or foot, caused by damage to the small nerves in the heel
• Infection of the wound, slowing down healing
• Excessive bruising
• Swelling of the ankle and foot
In the majority of cases the problems settle, but slow the healing process, occasionally the damage is irreversible. Certainly if you do require surgery your recovery will be helped by keeping your foot up for at least a fortnight after surgery, and following the recovery protocol outlined by the surgical team.
Wouldn’t it be better to take out my heel spur?
As you will have seen from reading the section above, the pain is not caused by the spur. Rather, both the pain and the spur are caused by inflammation in the plantar fascia.
Simple removal of the spur has been shown to be ineffective in relieving the pain since the 1960s.