Heel Pain / Plantar Fasciitis

The most common cause of deep pain on the bottom surface of the heel is Plantar Fasciitis (inflammation of the plantar fascia).

The plantar fascia is a broad band of fibrous tissue which runs along the bottom surface of the foot, from the heel to the toes. It is just below the skin and subcutaneous fat.

It helps to secure the arch of the foot. Long standing inflammation causes the deposition of calcium at the point where the plantar facia inserts into the heel bone. This can result in the appearance of a bony heel spur on x-ray. The spur itself is not the source of the pain. Stubborn heel pain should be evaluated by a Podiatrist. Plantar fasciitis may also present as pain anywhere along the sole of the foot, particularly along the arch and just in front of the heel.

Symptoms

• Sharp pain often localized to the bottom and/or inside margin of the heel
• Pain often worse on arising in the morning and after rest
• Aggravated by prolonged weight bearing and ambulation
• May severely limit activities
• Most common in middle-aged and overweight adults

Causes

• Excessive flattening of the arch on weight bearing
• Tight plantar fascia
• Over-pronation of the foot (a complex motion including outward rotation of the heel and inward rotation of the ankle).
• Excessive load on the foot from increased body weight

What you can do

• Application of ice to the heel area after prolonged activity
• Wear supportive shoes with a stiff heal counter (the part of the shoe which wraps around the heel) and a good arch. A well made running or walking shoe is a good example
• Sometimes a shoe with a moderately high heel will relieve pressure on the fascia (you should try this unless directed to by a Podiatrist)
• Use over the Counter anti-inflammatory medications containing ibuprofen or aspirin when tolerated (please consult a Pharmacist prior to use)

What the Podiatrist may do

• Teach specific stretching and strengthening exercises to stretch plantar fascia and strengthen the small intrinsic muscles which stabilize the arch
• Control faulty foot function with orthotics
• Inject powerful anti-inflammatory medication to calm inflammation around the painful area
• Apply tape/ padding to relieve strain on the plantar fascia
• Administer physical therapy (ie ultrasound,)
• Prescribe special splints to help stretch the fascia
• In some cases surgical release of the plantar fascia and excision of the heel spur (rarely required).

Other causes of heel pain

• Various types of arthritis
• Trauma to the heel
• Inflammation of the tendons around the heel
• Heel Neuroma (benign tumors of the nerves around the heel)
• Abnormality in the shape of the heel bone
• Foreign body in the heel (eg. splinter)

X-rays of Heel Spurs

Plantar heel Spur

This is a side (lateral) view of the foot. This patient had a painful heel. The arrow identifies the spur on the inferior aspect of the heel bone (calcaneus)

Posterior heel spur

This is a side (lateral) view of the heel bone, and demonstrates a spur on the back (posterior) surface of the heel bone (calcaneus). This was asymptomatic (without pain or other symptoms). A tight Achilles tendon can cause this to form. It may be associated with pain at the point were the achilles tendon inserts into the calcaneus.

Below: Magnetic Resonance Image (MRI) of Plantar Fasciitis showing a calcaneal spur