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ARROYO FOOT & ANKLE CLINIC

Heel Pain

Description

People of all age groups and physical activity levels can experience heel pain. The pain can occur suddenly and severely, as in cases of trauma. It can also occur gradually, insidiously over several weeks or months. In gradual cases, the pain may be dull, becoming noticeable only at certain times of the day, such as the first thing upon rising in the morning, or when getting up from the dinner table. Pain may be more severe the day following a day of strenuous or protracted activities on the feet. The pain may incrementally increase over time until it's present almost all of the time, and become so strong that walking even short distances is difficult. Depending upon the cause of the pain, your feet may feel better in boots, in athletic shoes or sandals, or they may feel better without shoes altogether.

Heel pain can be sharp, dull, aching, tender, throbbing, burning, electric, like a bruise, and may radiate from one area on your foot to another. It can be located on the bottoms, sides, or back of your heels, or may feel as though it's coming from the joint deep within the heel.

Common causes of heel pain

As we age, the fat pad on the bottom of the heel thins out. This causes the heel bone (the calcaneus) to lose its normal cushioning. The resultant shock encountered in walking, not to mention running, causes pain. This pain is more pronounced with any weight-bearing activities on the feet, but as it becomes more severe, there can also be residual pain with sitting or when you're in bed.

 Tearing and consequent inflammation of the fibrous band which courses from the bottom of the heel to the ball of the foot is called plantar fasciitis ('plantar' means the bottom of the foot; the band is called a 'fascia'). A foot that rolls down towards the inside, or flattens too much, or that is high arched can pull too much on this band, tearing it. If the Achilles' tendon is tight due to contracted musculature, it can precipitate plantar fasciitis. At first, this pain tends to be worse upon arising in the morning, or when walking after having been off your feet during the day. As the problem becomes more chronic, a marked limp may occur. Getting off your feet will usually lessen or eliminate the pain. Climbing stairs (or using a StairMaster for aerobic exercise) sharply worsens this pain.

Nerve entrapments can occur at a number of sites on your foot. The nerve becomes pinched by one, or between two bones, by a muscle, by an inflamed bursa or within a restraining fibrous band. These elicit pain that can be burning, sharp, electric throbbing or tingling. In fact, any sensation that a nerve can carry under normal circumstances can be reproduced with a nerve entrapment (one patient had a foot that felt wet all the time, even though it was not; another patient's forefoot felt as though there was a piece of cardboard stuck to the bottom of it.)

There are several tendons that pass by the heel. Through overuse, trauma, genetic factors, or abnormal foot mechanics, they may become torn, inflamed and painful. This process is called a tendinitis. The pain tends to become worse during walking or athletic activities. The tendinitis, if chronic and left untreated, can progress to complete rupture of the tendon.

Ankle sprains which have not been properly treated can heal poorly. These cases, as well as cases of repeated ankle sprains can result in chronic or recurrent ankle sprains. The parts of the heel just below your ankle may may be tender and feel unstable, especially with activities which require side-to-side motions. Swelling may accompany the pain. Ankle sprains may also be acute, at which time the pain tends to be sharp, prohibiting normal ambulation. Substantial swelling and bruising usually accompanies an acute ankle sprain.

Heel spurs can occur at the back or the bottom of the heel. These are bony outgrowths which occur in response to arthritic processes or abnormally high tension on a fascia or tendon which is connected to the bone at that site. A spur at the back of the calcaneus is invested within the Achilles tendon, and may cause direct irritation and pain in that tendon. Athletic activities tend to worsen this pain. Spurs on the bottom of the calcaneus, if of arthritic origin, may be painful; if caused by high tension by the plantar fascia, these spurs do not cause pain (unless they become traumatically fractured). However, the high tension on the plantar fascia which causes the spur to form, may also cause the plantar fascia to tear and become painful. Looked at in another way, there are many people who have a spur on the bottom of the calcaneus, but who have no heel pain.

A Haglund's deformity is bony prominence at the back of the calcaneus. The skin over this prominence can become irritated with being rubbed between the prominence of bone and the inside of the shoe. High heeled shoes are particularly prone to this process, hence the common name of 'pump bump'. In response to friction, your body may form a swollen, fluid-filled sack called a bursa within the skin. The bursa can become red, swollen and very tender in shoes.

Arthritis of various sorts (there are about 130 different sorts of arthritis!) can cause heel pain. Some, such as gout, can cause pain due to the deposition of sharp crystals. Other arthritic problems, such as rheumatoid arthritis, cause pain through inflammatory processes and subsequent soft tissue and bony destruction. Osteoarthritis, the wear-and-tear arthritis that almost everyone eventually gets, causes pain as the cartilage (the slick shock absorbers of the joints) wears out and bone spurs arise around the joints.

Sever's Disease is a tearing that occurs at the back of the calcaneus where the bone hasn't yet finished forming. The tearing occurs in cartilage that will eventually fuse adjacent bone pieces into one big bone. Swelling and warmth may be present along the sides and back of the heel. Classically, the typical person who got this was described as being a boy between the ages of 8 and 14, large for his age and engaged in athletic activities. With girls participating in athletic activities (such as soccer) to a greater extent that in prior years, they are being diagnosed with this problems in increasing frequency.

Fractures can manifest in the calcaneus. They can be due to acute trauma, or repetitive microtrauma (a stress fracture). Pain is present with almost any weight bearing activity, ranging from mild to severe. There may be warmth, swelling and bruising in the surrounding skin. In severe trauma, the skin may be broken and the shape of the rearfoot obviously distorted.

Back problems, such as a herniated disc, arthritis, and fracture or dislocation of a vertebra may pinch the sciatic nerve. This can cause burning or stabbing pain, or numbness to be felt in the foot. Shooting pain may be felt down the buttock, into the thigh or leg. Nerve damage may lead to loss of use of muscles, and changes in skin color or texture.

Diagnosis

Diagnostic tests may be used in conjunction with a detailed history and physical examination. Blood tests or crystal studies may be ordered. X-rays, ultrasound, MRI (magnetic resonance imaging), and C-T scans are frequently useful in diagnosis. If a neurological cause is suspected, nerve conduction velocity or electromyography may be indicated.

Treatment

Treatments are at least as varied at the causes of heel pain. Oral, topical or injected medications are frequently used. Custom fabricated shoe inserts (orthoses) may be used to control a biomechanical cause of pain. Heel inserts, strapping, bracing or casting may be primary or adjunctive treatments. Physical therapy can often provide assistance with the reduction of pain and rehabilitation. Rest is almost always required, with restricted or modified athletic activities. Changes in shoe gear can be helpful. Surgery can be the treatment of choice, or that of last resort.

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