The heel bone, referred to as the ‘calcaneus’ is the largest bone in the foot and serves as an attachment point to several muscles and tendons that help in walking, running and jumping.
Heel pain can be very disabling as most people suffering from it, complain of discomfort on weight bearing, which causes them to limit basic activities like standing and walking.
Heel pain can be categorized as pain under the heel or behind the heel. It can arise from a number of structures, but biomechanical faults or improper mechanics that load some areas in the foot more than others, tends to be a major contributor to heel pain.
In this article, we will explore the spectrum of causes that can be responsible for heel pain:-
Plantarfascitis
This is one of the most common causes of heel pain. The plantar fascia is a dense, fibrous connective tissue structure extending from the medial tuberosity of the calcaneus through the medial longitudinal arch inserting into the base of each of the toes. It is an important static support for the longitudinal arch of the foot.
Over pronation or flat foot, strains the longitudinal arch which causes the plantarfascia to stretch excessively. This exerts a pull on the plantar fascia, especially at its origin on the medial process of the calcaneal tuberosity, thereby putting strain on its attachment at the heel.Patients typically complain of pain that is worse in the mornings especially when they take the first few steps after long periods of rest or inactivity.
Fat pad syndrome/ Fat pad degeneration
There is a cushion of fat which is made up of elastic fibrous tissue that acts as a shock absorber and protects the heel. Fat pad syndrome may develop either suddenly after a fall onto the heels or gradually due to thinning out from excessive loading and poor cushioning. Patients often complain of heel pain that is particularly felt during weight- bearing, mainly in the outer portion of the heel.
Calcaneal (Heel) spur
Calcium deposits may accumulate and build up on the under surface of the heel. This happens over time and is often caused by strains of muscles and ligaments of the foot or excessive stretching of the plantar fascia. Running or jogging on hard surfaces, excess body weight or improper footwear can cause repeated tearing of the membrane that covers the heel bone. This places excessive stress on the heel. Heel spur with no other associated abnormality may not be symptomatic. However, excessive repeated wear and tear can result in inflammation which may then lead to pain.
Calcaneal Stress fracture
Although a rare occurrence, it can be seen in athletes or people with overuse history and repetitive high impact activity, like runners, dancers or jumpers. There is diffuse pain over the entire heel, which tends to aggravate with loading activities. An X-ray or MRI is needed to confirm diagnosis.
Achilles tendonitis, Haglund’s deformity and Retro calcaneal bursitis
Haglund’s deformity also known as ‘pump bump’ is characterised by a prominence or tenderness over the back of the heel, and often causes it to rub against the tendon.This may predispose the bursa or tendon to mechanical irritation. Constant irritation causes inflammation of the fluid-like sac situated behind the heel between the tendon and heel bone. Inflammation of this bursa is called Retro calcaneal bursitis.
The tendon connecting the calf muscles to the calcaneus also known as the Achilles tendon attaches to the back of the heel bone. Achilles tendonitis is commonly associated with repetitive impact loading due to running and jumping. Achilles dysfunction can also be related to postural problems (e.g.high arches, fallen arches), poor footwear, or tight calf muscles. These postural and biomechanical faults may alter the alignment of the tendon and cause rotation of the heel. This rotation of heel (inward or outward) may cause grinding or friction of the calcaneus against the tendon. Eventually, due to this constant irritation, a bony protrusion may develop and the bursa may become inflamed.
Since the Achilles tendon insertion, the retro calcaneal bursa and the calcaneus are so intimately related, dysfunction in one area, commonly affects the other.
Symptoms include pain, swelling, a noticeable bump and redness at the back of the heel which intensifies on walking, as the bony enlargement rubs against the heel counter of the shoe.
As discussed, heel pain is common and could be due to various reasons. But like every problem has a solution, this one is no exception and most individuals respond well to treatment. There are a few practice suggestions that have proven to be beneficial for those suffering from heel pain. Regardless of what is causing you the heel pain, the following recommended tips are likely to help:-
- Relative rest: A fairly logical pointer! Avoid activities that cause pain or aggravate it.
- Cryotherapy: Icing the affected painful area helps decrease pain and control inflammation if any.
- Stretching: Plantar fascia and calf muscle stretching helps address the tight structures that may be one of the causes of pain. This helps in pain- relief and prevents recurrence.
4. Shoe modifications: Foot wear that has good support for the arches or has adequate heel cushioning can act like a buffer and reduces stress on the heel and other pressure areas along the foot. Eg: silicone gel heel pad, heel cups.
5. Bodyweight: If you are overweight there is more stress on the heels when you walk or run. Shedding off those few extra kilos won’t hurt!