Heel Pain

There are many causes of heel pain and it is the most common type of pain we see here at NK Active. There are many causes of heel pain with the most common being Plantar Fascia pain, below are a few common causes of heel pain.

Plantar Fasciitis / Plantar Fasiosis /Chronic Plantar heel pain
Is the most common cause of heel pain, though the term ‘Fasciitis’ is not technically correct as it implies the plantar fascia is inflamed, but 48 hours after the onset of pain, inflammation will have subsided. However a suitable replacement term has not been devised.

The term Plantar Fasciosis implies a chronic condition with possible thickening of the Plantar Fascia, although this is not always true. So to keep things simple we shall use the term Plantar Fasciitis for the rest of this section.

The Plantar Fascia is a band of tissue that originates from the heel and attaches to the base of the toes and is an integral part of how the foot and 1st metatarsophalangeal joint functions throughout gait. It is also worth noting that the plantar fascia is part of the Achilles Tendon and the calf muscle complex which consist of gastrocnemius, soleus and plantaris and can also be referred to as tricep surae. This helps to explain the importance of calf stretches in the treatment of plantar fasciitis.

Plantar Fasciitis typically presents with pain on the medial aspect of the heel which is normally tender to touch, however it can be tender along any point of the fascia. It is typically worse in the morning with the first few steps or after prolonged sitting. The pain tends to be an ache or burning sensation and normally has a gradual onset with no history of trauma though this is not always the case.

Plantar Fasciitis is typically an overuse injury and walking and sports can increase the pain. There are many things that can aggravate the plantar fascia some of them are; foot function and lower limb biomechanics, footwear, tightness in muscle and sport.

Key Points
What exactly is Plantar fasciitis is still unknown, however we do know that it is the single most common injury we see in clinic on a day to day basis.

Baxter’s nerve entrapment
Is an entrapment of the Baxter’s nerve (Lateral plantar nerve) which branches from the Tibial nerve and can sometimes be mistaken for a plantar fasciitis. The difference is the pain will be described as sharp with some possible areas of numbness in the medial aspect of the heel which can track laterally. There will be no first step pain in the morning and the pain tends to get worse as the day goes on. It can be sporadic in nature, as nerve entrapment pain is only present when the nerve is stretched or stressed.

Is heel pain which occurs in the posterior heel, where the Achilles tendon inserts into the heel and is only present in children. The technical name for Sever’s is Sever’s traction apophysitis which means as the bones are growing the muscles are not keeping up, so become tight and the muscle’s tendon pulls on it’s insertion and creates pain.

Sever’s is most common between the ages of 10 and 14 and is found mostly in boys. The pain will be a burning, an ache or both which becomes worse on sport, especially sports like football which is played on a hard surface in the winter in the UK. There will be pain on palpation of the posterior heel and the squeeze test on the heel will be painful.

There is nearly always tightness in the calf muscles. Rest will reduce the pain and will have what seems to be a sporadic nature, however the pain corresponds with growth spurts.

In nearly all cases, Sever’s is self-limiting which means the pain will resolve on its own because as the growth plates fuse the pain tends to resolve.

The treatment is always conservative.

This traction apphoysitis can also occur in the knee and is called Osgood Schlatters.

Muscle strains
Lying under the plantar fascia are muscles, some of which are intrinsic and others are extrinsic, which can be overused resulting in a strain, which tends to present with a burning pain and will follow the path of the muscle affected.

On examination palpation of the muscle under a load will be painful, you will tend to remember a particular activity that set the pain off in the first place. Any activity that uses the injured muscle will be painful.

Medial Calcaneal Nerve Entrapment
This is an entrapment of the Medial Calcaneal (heel bone) Nerve which is a branch of the Tibial nerve from the leg. The type of pain is similar to Baxter’s nerve entrapment, so there may be some numbness located within the heel and this may be sharp. There will be no 1st step pain in the morning.

The pain is located just on the medial aspect of the heel just near the origin of Abductor Hallucis (muscle located of the medial aspect of the heel which attaches and the big toe and is responsible for abducting the hallux (moving the big toe outwards). You may find that you cannot abduct the big toe if the medial calcaneal nerve is entrapped.

Hitting the nerve with two fingers may reproduce the symptoms (Tinnel’s test):

Plantar – Underneath of the foot
Posterior – Behind
Chronic – Long standing
Medial – Inside, the same side as your hallux (big toe)
Lateral – Outside, opposite to Medial
Lower Limb Biomechanics – How the lower limb functions and moves
Intrinsic Muscles – Muscles that start and end in the foot
Extrinsic Muscles – Muscles that start out side of the foot and in side the foot