Heel Pain

Types of Heel Pain

1. Plantar heel pain, the most common variety.
2. Mid-plantar pain.
3. Posterior heel pain.
4. Nerve syndromes.

Plantar Heel Pain

A very common condition that is poorly understood with a benign natural history. Treatments vary widely and “snake oil” salesmen abound.

Plantar heel pain is also known as plantar fasciitis, sore heels and heel spurs – even when there are no spurs present.

It is most common in the 20 – 50 age group and slightly more common in women. Obesity is a factor, pes planus (flat feet) is not.

The pain is classically worse in the mornings or after arising from the seated position. It is felt in the medial calcaneal tuberosity which is frequently very tender to palpation.

Differential Diagnosis

Fat pad atrophy in the elderly.
Stress fracture of the os calcis.
Radicular pain.
Local nerve entrapment.
Arthritides.
Tumours.
Vascular insufficiency.

Although the typical syndrome is well recognised, there are no reliable tests to prove or disprove the diagnosis. It remains a clinical diagnosis.

The Role of the Spur

Considered to be incidental for the following reasons:

(a) Found in 125/425 asymptomatic patients (Rubin).
(b) Found in 50% symptomatic patients.
(c) In an anatomically distinct layer – the flexor hallucis brevis.

The Role of Bone Scanning

Williams et al showed increased uptake in 31/52 patients with heel pain syndrome – no false positives in painless heels. Not routinely used clinically.

The Role of MRI

Can be useful to distinguish mechanical from inflammatory heel pain, but not routinely necessary.

The Role of Blood Tests

Occasionally heel pain is the presenting symptom of a seronegative arthropathy (eg ankylosing spondylitis), Lyme disease or an autoimmune disease. This is the setting in which blood tests may be helpful.

The Role of Electrodiagnostic Tests

Used to support a clinical diagnosis of nerve entrapment, therefore not indicated in the typical patient.

The Natural History

According to Graham et al, the majority of patients resolve spontaneously in 12 months – about 90%. Recurrent episodes are unusual.

Proposed Aetiology

The pain is thought to be caused by micro-tears of the plantar fascia at its insertion into the medial calcaneal tuberosity. This is based on surgical biopsy of patients and is an analagous condition to tennis elbow.

Treatment Plan

Most importantly, reassure the patient that the natural history is benign though often protracted.

Initial Therapy should consist of:

1. Stretching exercises
2. Weight loss.
3. Cushioning heel cup.
4. Anti-inflammatory tablets.

If this fails:

1. Physiotherapy/ice massages.
2. Night splints.
3. Custom orthotic device.
4. Injection of Marcain and steroid.
5. Cast.
6. Shock wave therapy.

If this fails and 12 months have elapsed, consider surgery, either:

• Open release of the medial plantar fascia. 71% good results, but average recovery time is 7 – 12 months (Kitaoka et al, 1992).
• Endoscopic release of the plantar fascia is experimental at present, and should be regarded with scepticism until proven.