Heel Pain Causes and Treatment

Courtesy: Prof Nabil Ebraheim, University of Toledo, Ohio, USA

Introduction

• Heel pain is an extremely common clinical complaint.

• It has several distinct and overlapping causes.

• Accurate identification of the underlying cause is essential to ensure appropriate and effective treatment.

• Overlapping pain locations often make diagnosis challenging and, at times, confusing.

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Common Causes of Heel Pain

The commonly encountered causes of heel pain include:

1. Plantar fasciitis

2. Baxter’s nerve compression

3. Fat pad atrophy

4. Achilles tendinitis

5. Haglund’s deformity

6. Stress fracture of the calcaneus

7. Tarsal tunnel syndrome

8. Lumbosacral spine radiculopathy

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Clinical Causes and Their Characteristics

1. Plantar Fasciitis

• Caused by irritation and inflammation of the thick fibrous tissue on the plantar aspect of the foot.

• Pain is most severe during the first steps taken in the morning, commonly referred to as start-up pain.

• Pain persists with activity throughout the day and intensifies with prolonged standing or exercise.

• Examination findings include:

  • Tenderness over the plantar medial aspect of the heel

  • Medial calcaneal tenderness

  • Negative Tinel’s sign

• Radiographs may demonstrate a plantar heel spur.

• Frequently associated with a tight Achilles tendon.

Treatment options include:

• Night splints

• Physical therapy

• Cushioned silicone heel inserts

• Corticosteroid therapy

• Achilles tendon stretching exercises

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2. Baxter’s Nerve Compression

• Baxter’s nerve is the first branch of the lateral plantar nerve.

• It accounts for approximately 20 percent of heel pain cases.

• This nerve provides motor innervation to the abductor digiti minimi muscle.

• Compression of this nerve often produces symptoms similar to plantar fasciitis.

• The nerve travels between the abductor hallucis and quadratus plantae muscles, then turns sharply laterally beneath the calcaneus.

• Pain is typically localized to the medial plantar aspect of the heel.

• This condition is frequently overlooked or misdiagnosed, particularly in athletes.

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3. Fat Pad Atrophy

• The heel fat pad normally cushions the calcaneus during weight bearing.

• In fat pad atrophy, thinning of this tissue leads to loss of cushioning and increased pain.

• Commonly seen in elderly patients.

• There is often a history of repeated corticosteroid injections for plantar fasciitis.

• Pain characteristics include:

  • Deep, central plantar heel pain

  • Non-radiating pain

  • Worsening when barefoot

  • Improvement when walking on toes

• Examination reveals tenderness at the central aspect of the heel pad.

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4. Achilles Tendinitis

• Typically presents as a chronic condition with symptoms lasting several months.

• Patients report pain and swelling at the posterior aspect of the ankle.

• Physical examination reveals:

  • Thickening of the Achilles tendon

  • Tenderness near its insertion on the calcaneus

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5. Haglund’s Deformity

• Characterized by insertional calcification and bony prominence at the Achilles tendon insertion.

• Initial management includes:

  • Physical therapy

  • Anti-inflammatory medication

• Injections should be administered around the tendon and not through the tendon substance.

• If symptoms persist beyond 6 months, surgical intervention may be required.

• Surgical procedures may include:

  • Excision of the posterosuperior calcaneal prominence

  • Removal of insertional calcification

• If more than 50 percent of the Achilles tendon is detached during surgery:

  • Tendon fixation to the calcaneus is required using suture anchors

  • Tendon transfer may be necessary

• Advanced degeneration may require Achilles tendon debridement, calcaneal exostectomy, and flexor hallucis longus tendon transfer.

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6. Stress Fracture of the Calcaneus

• Occurs due to repetitive overuse.

• Patients experience severe weight-bearing heel pain that worsens with walking and running.

• Pain does not improve during the day and is present with each step.

• Medial to lateral compression of the calcaneal tuberosity reproduces pain.

• Radiographs may appear normal in early stages.

• Magnetic resonance imaging is often required for definitive diagnosis.

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7. Tarsal Tunnel Syndrome

• Characterized by numbness and paresthesia in the plantar aspect of the foot.

• Symptoms worsen with activity and may awaken the patient at night.

• A ganglion cyst is a known cause of compression within the tarsal tunnel.

• Magnetic resonance imaging should be evaluated to identify space-occupying lesions.

• Surgical excision of the ganglion often leads to favorable outcomes and symptom resolution.

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8. Lumbosacral Spine Radiculopathy

• Lateral foot pain may originate from lumbosacral disc pathology.

• Herniation at the L5–S1 level commonly affects the S1 nerve root.

• S1 nerve root involvement results in:

  • Pain along the lateral aspect of the foot

  • Decreased sensation in the same distribution