Injuries to the Arch

The heel bone is the largest of the 26 major bones in the human foot.  But while it is a large, strong bone, it is often injured, and this pain can be quite disabling at times.  Heel pain can occur in the front, back, sides or bottom of the heel. 

That the heel is commonly injured is not surprising, perhaps, given the amazing amount of stress it must endure during a day.  Indeed, it is one of the most common injuries of the foot; we see some variation of heel pain in our offices an average of 5 or 6 times per day.     

There are many possible causes of heel pain.  Most commonly it is a chronic, long-term pain that results of some type of faulty biomechanics (abnormalities in the way you walk) that place too much stress on the heel bone and the soft tissues that attach to it.  Chronic pain is a common result of standing or walking too many hours in the course of a day, working on concrete, being overweight, wearing poorly-constructed shoes, having an overly-pronated foot type (where the arch collapses excessively) or the opposite--having too high an arch.   For more on this, see our web page on flat feet.  

Women seem to get this slightly more often than men, and while any age can be affected, it usually occurs between 30 and 50 years of age.    

The other type of heel pain is the sort you get from an acute injury--a bruise to the bone or soft tissue strain resulting from a strenuous activity, like walking, running, or jumping, or from some degree of trauma. 

While there are dozens of possible causes to heel pain, we will review some of the more common causes.

The pain usually diminishes after a few minutes of walking, sometimes even disappearing, but the pain is commonly felt again the longer you're on the foot. 

***Please note:  We are pleased to announce that as of January 2004, we have the newest in technology in the field of extra-corporeal shock wave therapy in our main Surrey office.    The Piezoson 100 machine, a German-made machine that has been used in Europe for several years has just been approved for use in Canada, and ours is the first and only machine in western Canada.  For the first time true extra-corporeal shock wave therapy can be offered without anesthesia with success rates of 83% reported in German medical journals on difficult-to-treat heel pain.  

Patients considering shock-save therapy should note that not all shock-wave machines are the same or have the same success rates.  For more information on this, please visit our partner, Shockwave Therapy - BC's website on extra-corporeal shock wave therapy.

Many patients, however, have a biomechanical cause to their complaint, such as excessively pronated feet.   This may mean many of the treatments listed above will only provide temporary relief of fasciitis symptoms.  When you stop the treatment, the pain often returns. This is why many cases of fasciitis respond well to orthoses--custom-made inserts that control the mechanical cause of the complaint.   

***Note regarding orthotics:  If you're considering orthoses, it's very important to have a podiatrist examine you.  Ideally it should be a podiatrist who specializes in the field of biomechanics.  There are many biomechanical factors to consider when assessing the need for literally dozens of types of devices available, so you need to have an expert to properly assess you.  

Unfortunately, as is the case in many jurisdictions, there is no minimum standard of training required in British Columbia to make orthoses, and there are many fly-by-night operations around that employ salesmen with little, if any, training in understanding anatomy or foot function.  The emphasis with these groups is on selling you some sort of device, rather than providing proper assessment, treatment and follow-up.  

Injuries to the Heel Bone

When the fascia is not the source of heel pain, the next most commonly injured tissue is the heel bone itself.  

Periostitis

One possible affliction is when the heel bone simply becomes bruised.  This is usually known as "periostitis."   This is more common in sudden, acute injuries.   Rest, ice, compression, and cushioning (with innersoles, heel cups, and gel materials) may be helpful.  In more severe cases, immobilization to fully rest the tissue may be necessary.

Stress fractures 

Stress fractures may also cause heel pain.  This is more common as a chronic, ongoing injury.  The good news is that with rest and conservative care, the heel bone is usually one of the quickest-healing bones in the foot.  

Heel Spurs                              

If chronic fascial strain occurs over a long-enough period of time, it may be a result of excessive growth of bone to develop where it attaches to the heel bone, something known as a "heel spur".  This growth usually develops on the underside of the heel bone. 

The chronic strain that results causes a repeated tearing away of the lining or membrane that covers the heel bone (a tissue known as "periosteum"), which causes bleeding and bone growth in the direction of the soft-tissue pull.  

The spur that develops is visible by X-ray, and appears as a protrusion of bone that can extend forward as much as half an inch. 

The notion of heel spurs can be a bit misleading, however, as the spurs, themselves, are not usually the thing that hurts.  This is because the heel bone has relatively few pain fibres compared to the soft tissues that attach to it.  This is why you may often have a heel spur with no pain.  What typically hurts are the soft tissues that attach to that spur.  Thus, you can have a tremendous amount of pain in the heel, yet have no spur show up on x-ray. 

Thus, treatment is usually aimed more at the painful soft tissues around the heel than it is at the heel spur itself.  

Posterior Heel Spurs

Heel spurs may also occur on the back of the heel.  This is known as a "Posterior Heel Spur," a "Haglund's Deformity," a "Pump Bump", or a  "Retrocalcaneal Exostosis. "   The term "Retrocalcaneal Exostosis" literally translates to a "bony bump on the back of the heel bone" and is discussed in more depth on a separate web page.  

Children’s Heel Pain

Heel pain can also occur in children, most commonly between ages 8 and 13, and in this age group the most common tissue to be injured isn't the fascia or a heel spur, but the growth plate of the heel.  This is known as  "Calcaneal apophysitis," or simply "apophysitis".

Often simply dismissed as "growing pains", pediatric heel pain is seen as children become increasingly active in sports activity in and out of school. This physical activity, particularly jumping, inflames the growth center of the heel (the apophysis.  The more active the child, the more likely the condition will occur.

If heel pain occurs in this 8 to 13 year old age group, there are a large number of treatments available, so podiatric care can do a lot to protect the growing bone and to provide pain relief.   When the heel bone matures, the "apophysitis" problem disappears, and the pain is not likely to recur in exactly the same location.  But at older ages, the pain may move more to the region of the fascia (slightly forward from the original location), or develop into a heel spur. 

Other Causes of Heel Pain

Rheumatoid arthritis and other forms of arthritis, including gout, which usually manifests itself in the big toe joint, can cause heel discomfort in some cases.

Heel pain may also be the result of an inflamed bursa (bursitis), a small, irritated sack of fluid behind the heel. 

A neuroma (or inflamed nerve, which may involve scar tissue) involving the so-called Baxter's Nerve, (a nerve that courses under the heel bone), may also cause heel pain that mimics the pain of a heel spur.  We have a separate web page on  neuromas that occur in the more common location in the ball of the foot and into the toes, but many of the symptoms and treatments discussed there are applicable to a neuroma involving Baxter's Nerve.  

Tarsal Tunnel Syndrome, a pinched nerve beneath the inside ankle bone, too, can cause pain in the heel.  Tarsal Tunnel Syndrome, analogous to carpal tunnel syndrome in the hand, is often associated with conditions like a pronated or flattened foot type, posterior tibial tendon dysfunction, and arthritis.  

Pain at the back of the heel is associated with inflammation of the Achilles tendon as it runs behind the ankle and inserts on the back surface of the heel bone. The inflammation is called Achilles tendinitis.  It is common among people who run and walk a lot and have tight tendons. The condition occurs when the tendon is strained over time, causing the fibbers to tear or stretch along its length, or at its insertion on to the heel bone. This leads to inflammation, pain, and the possible growth of a bone spur on the back of the heel bone. The inflammation is aggravated by the chronic irritation that sometimes accompanies an active lifestyle and certain activities that strain an already tight tendon.

On very rare occasions, there can be problems within the bone structure itself that cause heel pain.   Paget's disease, cysts, bone tumours, and other conditions can occur in the heel causing pain, so it is important to be examined thoroughly.  

Preventing Heel Pain

A variety of steps can be taken to avoid heel pain and accompanying afflictions:

• Wear shoes that fit well — front, back, and sides — and have shock-absorbent soles, rigid shanks, and supportive heel counters.
• Wear the proper shoes for each activity.
• Do not wear shoes with excessive wear on heels or soles.
• Prepare properly before exercising. Warm up and do stretching exercises before and after running.
• Pace yourself when you participate in athletic activities.
• Try to avoid standing on concrete for long periods.  
• Don’t underestimate your body's need for rest and good nutrition.
• If you're heavier than you should be, lose weight.

Treating Heel Pain

If pain and other symptoms of inflammation—redness, swelling, heat—persist, you should limit normal daily activities and contact a podiatrist.

Your foot would be examined, and an X-ray may be taken to rule out problems of the bone.

Early treatment might involve oral or injectable anti-inflammatory medication, taping, padding, massage, stretching, exercise, shoe recommendations, or physiotherapy.  Over-the-counter shoe inserts can provide cushioning and may help somewhat for support.  Foam or Gel heel cushions help more for bruising of the heel bone, less so than for a strained arch.  If the condition is chronic and there is a biomechanical basis to the complaint, orthoses (or orthotic devices) may be used to permanently take strain off the fascia.  

Chronic, non-responsive complaints may be able to be treated with a new form of therapy known as extracorporeal shockwave therapy, or ESWT for short.  Analogous to lithotripsy, the treatment where sound waves are used to break up kidney stones without surgery, ESWT uses similar shockwaves to promote healing of certain causes of painful heels.  For more on this, visit our partner Shockwave Therapy - BC's website, www.shockwavetherapy.ca.

Only rarely is surgery required for heel pain.  If necessary, however, surgery may be considered, and may involve treating the soft tissue structures, the bony structures, or both.  

Common soft tissues procedures employed to treat heel pain include releasing the plantar fascia or removing an abnormal soft tissue structure causing the pain--like a neuroma, bursa, or tumor, for example.  

When procedures to treat heel pain involve bone, common treatments include removing a heel spur or realigning the heel or other bones relative to each other to correct abnormal bone position.