…and why you should be evaluated by a foot doctor!
There are many causes of heel pain and the most common diagnosis is plantar fasciitis. The plantar fascia is a very strong ligament on the bottom of the foot that attaches from the heel to the toes.
For many reason, such as wearing the wrong type of shoes, change in work environment, change in activities, body weight or other medical conditions, the fascia can become inflamed and can turn into a painful process known at plantar fasciitis.
Plantar fasciitis is typically characterized as pain experienced in the bottom of the heel. Pain can be quite significant after a period of rest. The classic example would be taking those first few steps after getting out of bed. As the foot starts to warm up, pain can subside but as you become increasingly active throughout the day pain can return to significant levels.
Plantar fasciitis can be extremely debilitating and the process can worsen significantly without formal treatment. This condition usually puts people out of commission with athletics due to disability and with lack of exercise, body weight can potentially increase, further amplifying one of the potential reason for plantar fasciitis to develop in the first place.
As plantar fasciitis progresses without appropriate treatment, the plantar fascia ligament will get larger, thicker and start to degenerate.
The good news is that with prompt diagnoses, early implementation of a good treatment plan can lead to rapid resolution of your symptoms.
Sometimes heel pain is not caused by plantar fasciitis. It is recommended that you seek evaluation by a qualified foot and ankle specialist for accurate diagnosis.
1. Stress Fracture
A stress fracture is a small break in the heel bone (medically known as the “calcaneus”).
A stress fracture is very different from a regular break in the bone. The best way to think of a conventional fracture or broken bone is through obvious injury or trauma to the bone. Examples include a twisting injury of the ankle that leads to an ankle fracture, or falling from a height leading to a heel bone fracture, or being involved in a high speed motor vehicle accident causing broken bones in the foot from slamming the breaks.
A stress fracture does not occur through an obvious injury. A stress fracture typically occurs due to overuse of the foot but there are some risk factors that can increase the risk of a stress fracture. The major risks factors include a history of stress fracture, low level of regular fitness, female gender and menstrual irregularity, lower body mass index (BMI), poor bone health, low calcium/vitamin D intake, and poor biomechanics.
A stress fracture of the heel bone can potentially mimic plantar fasciitis but there are some characteristic features that may suggest it is not plantar fasciitis. A stress fracture could potentially have a corresponding increase in swelling, warmth and redness in the heel. Stress fractures will also hurt even in the non-active position (like sitting on the couch watching TV).
An x-ray is a great place to start but it may take a few weeks after pain develops for the stress fracture to show up on an x-ray. In fact, a heel bone stress fracture may NEVER show up on a regular x-ray. Other imaging studies may be required like a CT scan, MRI or bone scan.
Treatment is different because a stress fracture requires immobilization (like with a fracture boot) to heal. If the patient remains active with a stress fracture it will either take much longer to heal or may not heal.
2. Bone Infection
This is a very rare diagnosis but sometimes heel pain can be due to an infection of the heel bone. Typically this is more likely in the younger/pediatric age group and there may be other symptoms of infection like fevers, chills, muscle and joint aches, and other flu-like symptoms. Bone infection is extremely rare but if caught must be treated aggressively with antibiotics.
Tumors around the heel bone or inside the heel bone can be another cause of heel pain. A soft tissue mass (not hard like bone) will occur outside the bone and a bone tumor will occur inside the heel bone itself. These can be relatively straightforward to diagnose and will require imaging like an x-ray, ultrasound or MRI.
4. Nerve Problem
Heel pain can also be due to a nerve problem in the back or leg. The nerve problem can occur at different levels in the nervous system but still manifest as pain in the heel. One example would be a pinched nerve in the back like with sciatica. Unfortunately, treatment directed towards the foot will typically not work because the underlying nerve issue needs to be addressed directly in order to attain relief. You may need evaluation by a back doctor or orthopedist and they may recommend imaging, physical therapy, injections or surgery.
Other nerve problems can occur lower down in the ankle and foot region and cause heel pain. An example of this would be a condition called “tarsal tunnel syndrome” which is similar to carpal tunnel syndrome of the wrist.
Another example of a nerve issue would be entrapment of one of the tiny nerves around the heel called “Baxter’s Nerve”. Baxter’s nerve is also known as the “1st branch of the lateral calcaneal nerve”. Nerve like symptoms will be experienced on the bottom of the heel including numbness, burning, tingling and pain. This can usually be diagnosed in person with a good physical examination and treatment is normally the same as traditional plantar fasciitis. If further imaging is needed an MRI is usually the best choice because entrapment of this nerve will lead to characteristic findings on the MRI. One interesting feature with Baxter’s nerve entrapment is that the patient usually cannot move the baby toe in the outward direction (called abduction).
5. Loss of fat pad under the heel bone
The fat pad under the heel is normal anatomy and serves to cushion the bone from the stresses of standing, walking, running and other activities.
When the fat pad gets thin there is less cushioning which can make it painful to walk on the heel bone.
There are a variety of reasons why this can occur. A few examples would be general loss of the fat pad due to age, certain medical conditions like scleroderma, or unfortunately the result of multiple cortisone injections into the heel which can lead to loss of the fat pad.
Treatment for this include cushioning the heel bone either with gel cushions, orthotics or by injecting a fat pad supplement like Leneva under the heel bone as a fat graft.