Heel Pain – its not always plantar fasciitis, there is more to it than you think!

Scott Wilson  APAM, ESSAM, AEP, CSCS
APA Sports Physiotherapist
APA Musculoskeletal Physiotherapist
ESSA Accredited Exercise Physiologist

Practice Principal – Bounce Physiotherapy | Bounce Exercise Clinic
Haberfield  NSW


Heel pain is a very common problem in the community and a frequent reason for seeking treatment from your GP, physiotherapist or other health professional. Heel pain is a vague description of a condition that covers quite a large area of the rear foot.  While heel pain is rarely a sign of something more serious, it can still impact massively on your life and significantly alter your usual activities.

Rear view shot of the highlighted joints in a runner's foot

Most of the time, the source of pain will be due to pathology in a soft tissue structure (usually your tendons, fascia or nerves).  Having a thorough assessment is critical as there are many structures in your heel that can cause pain – each of these needs a specific treatment.

So – who typically gets heel pain then?

The majority of people presenting with heel pain are:

  • Middle aged men and women
  • People who are regular exercisers
  • Overweight people with are on their feet a lot
  • Children, usually aged 8-13 as they become more active or have rapid growth spurts

 

Table 1 Common presentations of heel pain by age
Age Possible conditions
Young Common: Sever’s disease (calcaneal apophysitis)
Uncommon: Calcaneal stress fracture

 

Middle – aged Common: Achilles insertion tendinopathy, plantar fascia pain

 

Older Common: Tibialis posterior tendinopathy and lengthening

How complex is the foot and ankle?

The foot and ankle complex is made up of 26 bones, 33 joints and more than 100 muscles, ligaments and tendons.  The calcaneus (or your heel bone) is the single largest bone in your foot.  Simply pushing on a structure is a poor way to diagnose a problem – lots of structures are painful to push on without being the cause of your pain or symptoms.

The human foot is a highly complex structure
The human foot is a highly complex structure

Other possible causes of heel pain

The most common causes of heel pain are plantar fasciitis and achilles tendinopathy, and often are due to mechanical factors, however below are some of the other causes of heel pain.

  • Referred pain from you lower back
  • Haglund’s Deformity
  • Peripheral Neuropathy
  • Rheumatoid Arthritis
  • Achilles Tendon Rupture
  • Heel Spur
  • Local nerve entrapment
  • Sarcoidosis
  • Bone Tumor
  • Osteomyelitis
  • Reactive Arthritis
  • Stress Fractures
  • Bursitis Paget’s Disease of Bone
  • Retrocalcaneal Bursitis
  • Tarsal Tunnel Syndrome
  • Flexor Hallucis Longus Tenosynovitis
  • Posterior Impingement
  • Tibialis Posterior Tendinopathy
  • Stress Fracture

Referred pain from your lower back

You would be very surprised at the number of patients we have referred to us for plantar fasciitis, that in fact have referred pain from their lower back.  The history, presentation and clinical examination looks and sounds like it could be plantar fasciitis.

Your back doesn't need to actually be painful to refer pain elsewhere
Your back doesn’t need to actually be painful to refer pain elsewhere

The surprise on people’s faces when they see their pain and symptoms change significantly is really obvious.

Think of the nerves running through your legs as electrical wiring.  The “junction box” where these nerves come from, is in your lower back.  So, while the “signal” being sent to your heel is where you are feeling your pain and symptoms, it is actually coming from your back.

Don’t self diagnose and treat

As you can see from the list above, heel pain can be due to a variety of factors and needs a comprehensive assessment to get your diagnosis right and the appropriate treatment for your issue.  For example, if you have done “Dr Google” and decided that your pain and symptoms were plantar fasciitis and commenced stretching to try and help this. If in fact you have flexor hallucis longus tenosynovitis, stretching will actually make your symptoms worse.  Other times, your treatment of choice may not be making any difference at all, even after many months.

What sort of treatments work then?

It sounds like I am being difficult, but it really depends on what is causing your heel pain.  As I outlined before, in some cases a treatment that helps one condition can make another worse.

Heel pain requires a specific diagnosis - there is no one treatment to fix everything
Heel pain requires a specific diagnosis – there is no one treatment to fix everything

Overall though, load management (watching how much you do), strengthening, taping and heel raises or inserts can all be very effective at the right time.  Most importantly though is getting your heel pain diagnosed and treated by your GP or physiotherapist, as they will be able to select the best treatment options for you.

How long before I am better?

clock
Patience is the key – a clear treatment plan will help manage your frustrations!

This is a great question!  Again though its going to sound like I am being difficult (Sorry!).  Your GP or physiotherapist should give you a good description of your diagnosis, treatment plan and how long they think it will take to get better.

Most of the time you should start to see a change in your pain and symptoms within a few weeks, sometimes it is quicker than this.

However, it can be many months before you are completely better – this is a really, really important point.  Tendons for example can take 6-9 months to resolve completely, in the case of tendinopathy it never actually goes away for good, it is a case of life long management.

Once you have started your rehab and treatment (and been very diligent of course!) – it is important to follow your treatment guidelines.  Don’t stop just because your pain and symptoms have gone away.  We will often see clients a few months down the track who have had a relapse of their pain, often this is because they have stopped their treatment.

Diagnosis – Treatment – Management

Heel pain is often plantar fasciitis or Achilles tendinopathy, but not always!  There are many other conditions that could be the cause of your heel pain, that’s why seeing your GP or physiotherapist is important to get on top of your issue.

have-a-plan
It’s important to have a clear treatment plan from your GP or physiotherapist to get you back on track

The table below outlines the process for getting your heel pain sorted

Table 3 Matrix for sorting out your heel pain
Diagnosis Thorough assessment, diagnosis and treatment plan
Treatment Tailored treatment and intervention to help get rid of pain and symptoms
Management Ongoing plan to look after yourself, so you don’t get heel pain again

Whatever you do, don’t sit there and suffer in silence, go see your GP, or you can book a time to come and see one our physiotherapists.

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References

Brukner, Peter, Karim Khan, and Peter Brukner. Brukner & Khan’s Clinical Sports Medicine. Sydney: McGraw-Hill, 2012. Print.

“Heel Pain Causes – Mayo Clinic”. Mayoclinic.org. N.p., 2016. Web. 20 Aug. 2016.

Rio, Ebonie, Sue Mayes, and Jill Cook. “RACGP – Heel Pain: A Practical Approach”. Racgp.org.au. N.p., 2016. Web. 20 Aug. 2016.

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About the Author

Scott is the practice principal and owns the clinic with his wife Sandy, who is an Accredited Exercise Physiologist.  The treatment and management of heel pain is a particular area of interest at the clinic.

Scott has over 18 years’ experience in both elite sport and with everyday people, he spent 2011 & 2102 as the Rehabilitation Coordinator and Sports Physiotherapist for the Adelaide Crows.  Prior to this Scott has worked with many teams and individuals including;

  • Adelaide Football Club
  • Australian Sevens Team
  • International Rugby Board
  • Australian Women’s Ice Hockey Team
  • ACT Brumbies

Both the physiotherapy and exercise physiology services are overseen by Scott.  In addition to teaching the private courses offered here at the clinic, Scott has taught on undergraduate and post graduate courses for physiotherapy and exercise and sports science.  He is also a regular presenter for Sports Physiotherapy Australia on the Level 2 Sports Physiotherapy Course.

In 2014 he was awarded the title of Clinical Fellow of Australian Catholic University for both physiotherapy and exercise physiology.

About the clinic

Bounce Physiotherapy | Bounce Exercise Clinic is  a physiotherapy and exercise physiology private practice based in Haberfield, Sydney.

Established in the Inner West of Sydney since 2003 our business has provided services across the spectrum from injury treatment and known pathology to improving your general health and wellbeing, or athletic & sports conditioning.  Whatever your needs are we can help you get there. Bounce Physiotherapy | Bounce Exercise Clinic offers both clinical services and fitness services for our clients.

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