Pain under the heel is a common complaint that has multiple presentations and causes.
Unfortunately the assumption is often made that the person is suffering from plantar fasciitis when the plantar fascia is only one of the possible sources of symptoms. Multiple sources of symptoms can be present simultaneously, some of which may be a long way from your foot. Having a thorough assessment of all possible sources of symptoms is critical to determining the source of your heel pain, as the treatment and advice to avoid recurrence will vary significantly.
The plantar fascia is a made up of two broad bands of connective tissue spanning from the heel bone to the toes which assists in support of the arches of the foot with weight bearing and walking. This tissue is a continuation of the Achilles tendon and is attached to the underneath of heel bone. The commonly used term plantar fasciitis can be misleading as “itis” implies inflammation is present and research studies have shown this not to be the case. A more accurate term is plantar fasciosis which indicates a degenerative change in the tissue as a result of abnormal loading. Cortisone injections are not warranted and increase the risk of rupture of the plantar fascia. The typical signs of plantar fasciosis include start up pain on rising in the morning and after sitting, which eases with activity. Calf tightness if often a feature leading to restriction in ankle movement and effective treatments include calf stretching and a night splint if symptoms are not resolving with calf stretching alone. Off the shelf cushioned orthotics and taping of the plantar fascia can also be of benefit to relieve symptoms. Due to interconnections in the myofascial system the source of the calf tightness may be a long way from the foot and may even emanate from dysfunction as high up as the upper rib cage or neck.
Plantar fascia tear
A partial tear or rupture of the plantar fascia presents as a severe pain under the heel with swelling often visible with careful examination. It is exquisitely tender to direct pressure and can be diagnosed with expert ultrasound imaging or MRI. An incident is not always recalled and pain may be present for months or years before a diagnosis is made. Immobilisation in a walking boot for 6-8 + weeks is required to allow the tissue to heal followed by a graduated return to activity over 3 months with cushioned orthotics to support and protect the new tissue.
Fat pad bruising
The thick fat pad under the heel protects the heel bone from impact but may become traumatised with increased walking on hard surfaces or direct trauma such as stepping on a stone. Deflective padding of the heel, cushioned heel inserts, cushioned footwear, anti-inflammatory medication, reduced weight bearing and gait retraining may be required to alleviate symptoms.
Trigger point referred pain
Trigger points are sensitised nerve endings within taut bands of muscle and can refer pain to areas remote to the trigger point. Two muscles that can refer pain directly to the under surface of the heel are the Soleus, the deeper of the two main calf muscles, and the Quadrates plantae muscle that attaches to and acts with the long toe flexor muscle. The flexor digitorum muscle also refers pain into the arch of the foot and is often mistaken for plantar fascia pain. Deactivation of trigger points can be achieved with various methods including low level laser and/or dry needling (a form of acupuncture) although dry needling is not advisable in the sole of the foot. Specific stretching as well as identification of the cause of the overuse is important to prevent recurrence. For example, overuse of the toe flexor muscles may occur with prolonged wearing of loose footwear such as thongs or ballet flats or from postural faults, loss of balance, inefficient walking strategies or repeated jumping.
There are two nerves, the Medial Calcaneal and First branch of the Lateral Plantar Nerve, which may cause pain under the heel. Both these nerves may become irritated by tightening of the abductor hallucis muscle and its fascia along the inside of the foot through which they pass. The large abductor hallucis muscle is an important stabiliser of the big toe and assists in propulsion and is loaded with pivoting activities. The pain from irritated nerves is often described as burning or sharp and shooting and the nerves are tender to direct pressure. Low level laser and specific soft tissue release are often effective in alleviating symptoms and surgery is rarely indicated.
Referred pain from the lower back
The nerve root from the S1 segment at the base of the lower back may be a source of referred pain to the heel and sole of the foot. This is often described as burning or sharp pain and may be accompanied by pins and needles. The site of the pain may shift and may also be felt in the lower calf. Performing a straight leg raise test may elicit the pain and treatment is directed to the lumbosacral region and improving joint and nerve mobility in this area.
To ensure you are receiving the right care come and see us at Joint Health for a thorough approach to helping you overcome your heel pain and get back on track.
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