Heel pain: A guide for patients

What causes heel pain?

There are a wide variety of causes. Plantar fasciitis (Plan-tar-fas-c-i-tis) - is probably the most common.

Other causes include:

• arthritis in the ankle or heel (different forms of arthritis can lead to heel pain)
• irritation of nerves in and around the heel
• thinning or weakness (atrophy) of the heel pad
• injury of the heel pad or heel bones
• prolonged standing or working on hard surfaces
• flat feet or highly arched feet
• tight calf muscles
• bursitis
• bone infection.

What is plantar fasciitis?

The heel is a highly specialised part of the body designed to absorb the shock of walking and running. The force placed through the heel when walking is 120 per cent of your body weight. When running this increases to 275 per cent of your body weight. During a life time the heel undergoes these repetitive pressures many times and is designed to withstand them due to a strong heel bone – the calcaneus and a tough fatty heel pad which acts as a shock absorber.

A number of muscles and ligaments join the heel bone. The strongest is called the plantar fascia, which originates from the heel bone and runs forwards, on the underside of the foot, and attaches to the metatarsal heads at the ball of the foot. The fascia helps maintain the arch and provides stability to the foot, it is placed under considerable stress during walking, exercise and prolonged standing.

When the fascia is over stressed it can become inflamed. The most common site for inflammation is where the fascia joins the heel bone, but people may also experience pain in the arch of the foot with this condition.

Plantar Fasciitis most commonly occurs around the heel bone area and develops through increased stress and strain.

Flat (pronated) feet or high arched (supinated) feet place additional stress on the heel and plantar fascia and may increase the likelihood of developing problems.

Tightness in the calf muscles and/or Achilles tendon also places stress on the heel. The stiffness in the ankle joint associated with this tightness is one of the main factors leading to plantar fasciitis.

Occasionally people can get similar symptoms in the heel associated with underlying inflammatory conditions such as rheumatoid arthritis.

What is a heel spur?

Heel spurs are a shelf-like protrusion of bone arising from the underside of the calcaneus. They are often wrongly blamed as the cause of heel pain. Many people who have no symptoms have heel spurs. The spurs form due to stress but are rarely the true cause of the pain.

Can I do anything to reduce my heel pain?

• Try to avoid, where possible, the activities and things which can lead to heel pain.
• Try to wear a supportive shoe with a cushioned sole, for example, a running trainer.
• Try to minimise the amount of time you spend standing on hard surfaces.
• An insole or orthosis which supports the arch of the foot may help.
• Regular stretching of your calf muscles will help reduce the stresses on the heel and also increase the flexibility of the plantar fascia.
• Early treatment can prevent the problem deteriorating and prevent recurrence.
• Losing weight if you are overweight can help.

What treatments are there for heel pain?

There are a number of treatments that fall into these two broad categories:

• conservative
• surgical.

As a rule conservative therapy is pursued for at least six to 12 months before surgical treatment is considered. Conservative treatments include calf stretches. These are the most important of all the listed treatments and if not carried out, your heel pain will not improve.

Stretch your calf muscles using a lunge exercise but with your hands on a supporting surface. To do this:

• Place your hands on a wall with your arms outstretched.
• Your hand should be in line with your shoulders.
• Put one leg in front of the other.
• Your feet should be as wide apart as your pelvis and hips – you do not need to be pigeon toed or have your feet too far apart.
• Your feet should be at a right angle (90 degrees) to the wall and you should be facing the wall.
• Foot position is very important and at the beginning you may require help in positioning your feet.
• With your back leg behind you, keep your foot on the ground and your knee extended (locked). The leg that is behind you is the leg that you are stretching.
• Once you are in position, bend the front knee and move your hips and upper body, as a whole, towards the wall. It is important not to bend your back towards the wall as this will not put a stretch on the leg.
• You will feel a stretch down the back of the leg. When you can feel it hold the stretch and do not bounce backwards and forwards. Hold the stretch for one minute.
• After one minute swap legs, reposition yourself and repeat the stretch on the other leg.
• Stretch each leg three times, for one minute, alternating between right and left legs.
• Stretching should be carried out at least twice a day, preferably three times.

Calf stretching can also be done using a calf stretch board. They can be found and purchased online.

Other treatments include:

• heel cushioning or padding – purchased from your local pharmacy
• molded insoles or over the counter orthoses
• rest
• ice massage – a 500ml drink bottle with an hour glass shape is ideal for this. Empty the bottle, fill with water and freeze. Roll the bottle under your foot for about 10 minutes, three to four times a day
• modifying work and activity
• modifying footwear, for example, wearing running trainers
• night splints
• pain killers and/or anti-inflammatory tablets (as advised by pharmacist or physician)
• steroid injections
• TENS or ultrasound
• Acupuncture
• Extracorporeal shockwave therapy (ESWT).

It is important and heartening to know that 90 per cent of cases get better using conservative treatments. If an underlying arthritic type condition is suspected, then you will be sent for further treatment and/or investigations. If conservative therapy fails to alleviate your symptoms to an acceptable level, surgery may be considered.

What might surgery involve?

Surgery usually involves releasing the plantar fascia either totally or partially to relieve the stress on the heel. The incision is usually three to five centimetres in length on the inside of your heel. The surgery may involve cutting through or releasing the plantar fascia and freeing up nerves, or removing nerves if they are damaged and are contributing to your pain. Sometimes, if there is a large bony spur it will be removed to help decompress the area. Generally you will be placed in a non-weight bearing cast (which stops you putting weight on your foot) for a couple of weeks.

After surgery heel cushions or moulded insoles are usually required to help support the foot, particularly if the fascia has been totally released.

Rehabilitation after surgery can take some time and one should expect to be off work for at least six weeks. The wound can take some time to heal in some cases. You may also experience tingling or numbness in and around the heel after surgery.

Plantar fascial band release surgery

About the operation:

• The operation is performed under a local anaesthetic, either around the ankle or behind the knee.
• Although the operation is relatively short, you will be in the day surgery unit for some time before and after your surgery, to allow you to rest.
• You must have a competent adult at home for the first day and night after surgery. This allows us to be sure you will be safe for the first night.

The first two to four days

• This is the time you will feel the most pain but you will be given painkillers to help. You must rest completely for the first 24 to 48 hours.
• You will usually not be able to put weight on your foot and may be in a cast (using crutches) after the operation for two to three weeks.
• You should restrict your walking to only going to the bathroom and then use your crutches.
• You can get about a little more after three days using crutches in the way you will have been shown.

One week after surgery

• You will need to come in so your foot can be checked and re-dressed.
• You may start to do a little more, as the pain allows. If you are in too much pain it means you are doing too much.

Two weeks after surgery

• You must come in again so your foot can be redressed. Generally sutures will be removed at two weeks, but sometimes need to be left in for a further week.
• You will not need a bandage and may be placed in a walking boot. However, if the foot is still painful you may need a further period of non-weight bearing using crutches.
• Some patients may return to shoes after two weeks although for many this may take longer (six to eight weeks).

Between two to six weeks after surgery

• The foot starts to return to normal and you can return to trainers or supportive footwear.
• The foot may still be quite swollen especially at the end of the day.
• You may return to work after six weeks but may need longer if you have an active job.
• You may return to driving if you can perform an emergency stop. You must check with your insurance company before driving again.

Between six and 12 weeks after surgery

• The foot should continue to improve and begin to feel normal again. There will be less swelling.
• Sport can be considered after three months depending on your recovery.

Six months after surgery

• You will have a final review six months after your surgery.
• The swelling should now be slight and you should be getting the full benefit of surgery.

12 months after surgery

• The foot has stopped improving with all healing complete.

Please note, completely recovering from all the symptoms and restrictions in activity can be expected only in about 50 per cent of cases with only 50 per cent of patients who undergo this type of surgery completely satisfied with the outcome.

Frequent or serious occurring risks

Unfortunately, all operations carry a small risk of complications. In foot surgery at this clinic, complications are rare and are mostly resolved without permanent disability or pain. If you have any concerns about the examples of complications given here, please discuss them with your specialist before deciding to have surgery.

• Infection (two in 100)
• Delayed healing of the skin (eight in 100)
• Prolonged swelling post operatively (four in 100)
• Thick or sensitive scar formation (four in 100)
• Blood clot - Deep Vein Thrombosis (DVT)
• Rupture of the plantar fascia.

Complications following foot surgery are rare events but can occur. It is important to remember that if a complication arises you will be required to visit the hospital more frequently and there could be a significant impact on your recovery and the time it takes to return to work.

If you have any queries regarding your heel pain do not hesitate to ask your podiatrist.