Heel Pain Syndrome

Pain under or around the heel from several conditions. The commonest by far is plantar fasciopathy (plantar fasciitis), a degenerative overload condition of the plantar fascia at its origin on the medial calcaneal tuberosity, with collagen degeneration, thickening and little true inflammation.

• Lifetime prevalence of plantar heel pain is about 10%, and it accounts for about 11 to 15% of foot symptoms needing professional care. It peaks between 40 and 60 years, affects women more than men, and also occurs in runners and military recruits.
• Risk factors: obesity (body mass index above 30), reduced ankle dorsiflexion and tight calf, prolonged standing or walking on hard surfaces, pes planus or cavus, sudden increase in activity, unsupportive footwear, leg length difference, and diabetes.
• Other causes of heel pain:
  • Plantar fat pad atrophy or contusion (heel pad syndrome).
  • Calcaneal stress fracture.
  • Entrapment of the first branch of the lateral plantar nerve (Baxter nerve) and tarsal tunnel syndrome.
  • Achilles insertional tendinopathy and retrocalcaneal bursitis (posterior heel pain).
  • Sever disease (calcaneal apophysitis, children 8 to 14 years).
  • Enthesitis in spondyloarthritis, gout, infection, tumour, and referred S1 radiculopathy.
• About 80 to 90% of plantar fasciopathy resolves within 12 months with conservative treatment, though many take 6 to 12 months.

• Plantar fasciopathy: sharp stabbing pain at the medial plantar heel, worst with the first steps in the morning or after prolonged sitting (start up pain), easing within minutes of walking and returning late in the day after prolonged weight bearing. Tenderness is localised over the medial calcaneal tuberosity and along the proximal fascia, and pain increases with passive dorsiflexion of the toes and ankle (windlass test, tensioning the fascia).
• Heel pad syndrome: central heel pain, a bruise like pain worse on hard surfaces and barefoot walking, with a thin, mobile heel pad and tenderness in the middle of the heel.
• Calcaneal stress fracture: heel pain with weight bearing and at rest, worse with activity, with positive pain on medial and lateral calcaneal squeeze.
• Nerve entrapment: burning, tingling or numbness in the heel and sole, pain at rest and at night, tenderness over the abductor hallucis along the medial heel, and a positive Tinel sign over the tarsal tunnel.
• Differential diagnosis: Achilles insertional tendinopathy, retrocalcaneal bursitis, calcaneal stress fracture, tarsal tunnel syndrome, entrapment of the first branch of the lateral plantar nerve, heel pad syndrome, calcaneal apophysitis in children, spondyloarthritis enthesitis, gout, infection, tumour and S1 radiculopathy. Red flags: night and rest pain, fever, swelling, bilateral symptoms with other joint disease, weight loss, a history of cancer, and inability to bear weight.
• Complications: chronic pain and gait alteration, plantar fascia rupture (sudden pop, often after steroid injection), fat pad atrophy, secondary knee, hip and back pain, and reduced activity.

• Clinical in most patients. Assess calf flexibility and ankle dorsiflexion, foot posture, footwear, weight, activity and occupational load.
• X-ray of the heel (weight bearing) is not needed at presentation, but is requested for pain persisting beyond 6 to 8 weeks, trauma, or suspected stress fracture or bony lesion. A calcaneal spur is seen in about 50% of people with plantar heel pain but also in about 10 to 20% of people without pain, and is not the cause.
• Ultrasound shows plantar fascia thickening (above 4 mm) and hypoechoic change, tears and fat pad thickness, and guides injection. MRI shows fascial and marrow oedema, stress fracture, tumour, infection and nerve compression.
• Blood tests (CRP, ESR, HLA-B27, urate, HbA1c) when bilateral or systemic disease is suspected. Nerve conduction studies for suspected nerve entrapment.

• Education and load management: reduce prolonged standing, hard surfaces and running, avoid barefoot walking and unsupportive footwear, and lose weight when overweight. Avoid complete rest.
• Stretching, the most effective simple treatment:
  • Plantar fascia specific stretch: sit with the affected foot crossed over the opposite knee, pull the toes back toward the shin until a stretch is felt in the arch, hold for 10 seconds, repeat 10 times, 3 times daily (including before the first step in the morning).
  • Calf stretching (gastrocnemius with the knee straight, soleus with the knee bent), 30 seconds, 3 times each side, twice daily.
• Strengthening: heavy slow resistance calf raises with a towel under the toes (to tension the fascia), 3 sets of 12 repetitions every second day, and foot intrinsic strengthening, for 12 weeks. This programme is as good or better than cushioning alone.
• Support: well cushioned supportive shoes, prefabricated or custom orthoses (arch support for flat feet, cushioned heel cup), silicone heel cups for fat pad atrophy, low-Dye or plantar fascia taping for 1 to 2 weeks for short term relief, and a night splint (holding the ankle in dorsiflexion) for 1 to 3 months in persistent morning pain.
• Analgesia: ice (frozen water bottle rolled under the foot) for 10 to 15 minutes after activity. Paracetamol 1 g orally 6 hourly. Ibuprofen 400 mg orally 8 hourly with food (or naproxen 500 mg 12 hourly) for 1 to 2 weeks if needed. Topical diclofenac 1% gel 2 to 4 g 3 to 4 times daily.
• Corticosteroid injection for pain that is disabling after 6 to 12 weeks of conservative care: triamcinolone acetonide 20 to 40 mg (or methylprednisolone acetate 20 to 40 mg) with lidocaine 1% 2 mL, using a medial approach into the proximal fascia origin under ultrasound guidance. About 70% have relief for 4 to 12 weeks, with no benefit beyond 3 to 6 months. Risks: plantar fat pad atrophy, fascia rupture, infection, and a rise in glucose for 3 to 5 days in diabetes. Limit to 1 to 2 injections.
• Extracorporeal shock wave therapy: 3 to 5 weekly sessions, for chronic disease after 6 months of failed care, with success in about 60 to 70%.
• Other options with limited evidence: platelet rich plasma (a single injection of 3 to 5 mL under ultrasound guidance, comparable to steroid at 3 to 6 months), botulinum toxin type A (about 50 to 100 units into the medial gastrocnemius or the fascia), and dry needling.
• Surgery for failure of 6 to 12 months of correct treatment: partial (medial one third to one half) plantar fascia release, open or endoscopic, with about 70 to 90% success, and gastrocnemius recession for a documented tight gastrocnemius. Complications include arch flattening, lateral column pain, nerve injury, and persistent pain. Rehabilitation takes 6 to 12 weeks.
• Specific conditions:
  • Heel pad syndrome: soft heel cups, cushioned insoles, avoidance of barefoot walking, and no steroid injection.
  • Calcaneal stress fracture: protected weight bearing in a pneumatic boot for 6 to 8 weeks, with correction of vitamin D deficiency (cholecalciferol 1000 to 2000 IU daily) and review of bone health.
  • Nerve entrapment: footwear and orthosis changes, a neuropathic agent (gabapentin 300 mg at night increasing to 900 to 1800 mg daily), a local anaesthetic and steroid injection, and surgical decompression for failure.
  • Sever disease: activity modification for 2 to 6 weeks, heel cups, calf stretching and ice, and resolution at skeletal maturity.
  • Spondyloarthritis: NSAIDs and biologic therapy under rheumatology.
• Special groups:
  • Pregnancy: supportive footwear, stretching, ice and paracetamol. Avoid NSAIDs after 20 weeks.
  • Diabetes: monitor glucose after injection, and examine the feet for neuropathy and ulcer risk.
  • Elderly: check for fat pad atrophy and osteoporotic stress fracture.
  • Runners and military recruits: gradual load progression and footwear change.
  • Renal impairment and gastrointestinal disease: avoid oral NSAIDs.
• Follow up: review at 6 weeks and again at 3 months. Refer to orthopaedics, podiatry or sports medicine for no improvement at 3 to 6 months, suspected fracture, nerve entrapment, or consideration of injection or surgery.