Heel Pain

Plymouth Orthopaedic and Sports Injury Clinic

Heel pain is a very common complaint, and fortunately in the majority of cases resolves by itself but may take up to a year to do so!

There are many potential causes, but in the absence of trauma the overwhelming majority of cases will be caused by Plantar Fasciitis or Achilles Tendonopathy. It is however important to consider other potential causes, and this can usually be achieved with careful history and examination. A plain XRay is often indicated and ultrasound scanning is the most useful special investigation. Occasionally more sophisticated scans such as MRI are indicated.

Plantar Fasciitis

This typically causes pain underneath the heel. It is often worst on mobilising (start up pain) and gets better as day goes on although a persistent ache is common. Then following rest or overnight, there is further start up pain. Sometimes both heels are affected!

Achilles Tendonopathy

Pain can be felt in the body of the tendon, often associated with swelling of the tendon, or where the tendon inserts on to the heel (insertional tendonopathy). The start up nature of the pain is similar in many respects to plantar fasciitis.

Xrays may reveal bony spurs or prominences associated with these conditions. Occasionally these can cause insertionat Achilles tendon pain, but usually the spurs are not thought to be a direct cause of the condition

Whilst the underlying pathology in Achilles Tendonopathy and Plantar Fasciitis is poorly understood, many surgeons feel that the symptoms are related. It is therefore no surprise that treatment for both conditions follows a similar pattern.

 

Treatment

  1. In many patients, a spontaneous improvement will occur but may take many months.
  2. Simple pain relief is appropriate.
  3. Modified footwear (Rocker soled shoes) or padded inserts may well help.
  4. The Achilles tendon is often tight, and regular stretching exercises are critical. It is important that these are performed prior to load bearing. “Eccentric strengthening” (loading muscle and tendon as it lengthens) is particularly important, and instruction from an experience physiotherapist in this technique is invaluable. To be effective, an exercise regime must be maintained for many weeks or months if necessary.
  5. Injections of steroid and local anaesthetic may be appropriate, but must be used with caution particularly around the Achilles Tendon. We would usually advise that these are done at the same time as an ultrasound scan (performed by an experienced Radiologist) firstly to confirm the diagnosis and secondly to ensure the greatest possible accuracy of the injection. This maximises therapeutic benefit and minimises risk.
  6. Shockwave Therapy (Lithotripsy), is a technique that has become popular in recent years. We advocate this if guided injections and physiotherapy have failed. It usually involves three treatment sessions at weekly intervals in the XRay department, supervised by a Radiologist (XRay doctor).
  7. Surgery is a possibility for these conditions, but the overwhelming majority of patients with heel pain or Achilles tendonopathy do not require it, and symptoms can be resolved using the treatments above. Surgery always involves a relatively long period of rehabilitation, and most patients will take at least three months to fully recover