Pain in the Heel of Foot: Diagnosing & Treatment Guide
People suffering with pain in and around the heel area of their foot shouldn’t ignore it and hope it will disappear. The reason is, whatever it is you’re doing; your heels will feel the impact first. Even if you’ve had a good night’s sleep, sat around on the couch all day or spend little time on your feet at work, you still have to deal with that first step – and it can be sheer torture. Our first instinct is to massage our feet or, soak them in warm water and that’s a good way to start in ruling out the cause of the problem, but don’t be surprised if you still have painful heel strikes as the root causes are usually much more serious.
Causes and Conditions Responsible for Plantar Heel Pain
Chronic heel pain is a common complaint with many causes to consider before any treatment can begin. The correct diagnosis is crucial as problems manifesting in heel pain range from mechanical to nerve damage. Pinpointing the precise location of the pain can also be a useful guide in making the correct diagnosis. Plantar fasciitis is a pain that runs down the middle of the heel and is the most common condition diagnosed. Symptoms include extreme heel pain when taking the first steps in the morning and after sitting for long periods of time. Additional causes of plantar heel pain include fracturing of the calcaneus (heel) which results in pain that gets increasingly worse over time and with strenuous activities. Trapped nerves are extremely painful and may be accompanied by numbness, burning, and tingling. A deep and painful, bruise-like condition called heel pad syndrome will radiate pain down the middle of the heel. And of course, there are neuromas (tumors), and plantar warts which are also the cause of great pain and discomfort as they grow. Plantar heel pain may also be caused by conditions affecting the tendon. Tendinopathy, (disease of the tendon), tendinitis, (inflammation of the tendon), and tendinosis (small tears in the tissue caused by overuse) Achilles tendinopathy is a commonly diagnosed condition that results in heel pain towards the rear of the foot. Tendon damage and inflammation will manifest in pain at the insertion site of the specific tendon.
Making and Communicating the Correct Diagnosis
Medical terminology is a fascinating conglomeration of words with origins deeply rooted in Greek and Latin. Even though the words can be long, confusing and hard to articulate, the wonderful thing about medical terminology is the fact that the basic language used in describing the human anatomy is referred to the same way by the entire medical field. If a doctor makes a diagnosis using the word calcaneus, rest assured everybody from your x-ray tech to your pharmacist will know it’s your heel they are talking about. The following steps have all been made in diagnosing and communicating some of the various causes of plantar heel pain, as well as the recommended treatment(s) for each:
Step #1: Haglund’s Deformity
- Heel pain towards the rear of the foot may be attributed to a Haglund deformity. This condition results in a prominence of the calcaneus that may cause inflammation of the bursa (a fluid-filled sac or cavity to offset friction at a joint), between the heel bone and Achilles tendon.
- Changes in foot wear
- Anti-inflammatory medication
- Application of ice
- Steroid injection exactly in the bursa
- Surgery is done when all the above methods have failed
Step #2: Sever Disease
- A calcaneal apophysitis is most common in children and adolescents. Symptoms include a painful inflammation of the growth plate where the Achilles tendon inserts towards the rear of the foot.
- Exercising the foot and leg specifically to strengthen while stretching the leg muscles and tendons
- Elevating and applying ice for 20 minutes. Use ice that has been wrapped in a towel, never directly to the skin two or three times per day, and on days when there is minimal pain to help reduce swelling
- Use an elastic bandage or compression stocking specifically designed to help decrease pain and swelling
- Take an over-the-counter medicine for the reduction of pain and swelling, such as acetaminophen (Tylenol) or ibuprofen (Advil, Motrin)
- Note: Children should not be given aspirin for pain due to the risk of a very serious illness called Reye syndrome.
Step #3: Medial Mid-foot Heel Pain due to Tarsal Tunnel Disease (compression of the posterior tibial nerve).
- Causes may include tight ligaments, cysts, tumors and varicose veins on the inner side of the foot and ankle.
- Inflammation of the ankle tendon or injury to the ankle itself as well as flat feet
- Particularly painful when continued weight bearing on the foot is exercised. May be associated with tarsal tunnel syndrome, which is a result of compression of the posterior tibia nerve.
- Anti-inflammatories such as Tylenol, Motrin and ibuprofen to reduce swelling and inflammation.
- Specially designed orthotics or braces for supporting a flatfoot if present.
- Treat underlying metabolic disorders such as diabetes mellitus, hyperthyroidism, and hypothyroidism if present.
- Immobilizing the foot and ankle by wearing a cast or brace to rest the foot and ankle.
- Daily to weekly physical therapy for muscle restoration and strengthening the ankle, and in reducing inflammation in the area.
- EMG studies and nerve conduction to further assess and diagnose the injury.
- MRIs may be recommended to evaluate the presence of space-occupying problems such as tumors.
- Surgery may be recommended to decompress the nerve. It may also be necessary to remove a space-occupying varicosity, tumor or lesion that might be the cause of the problem.
Step #4: Sinus Tarsi Syndrome
- Occurring between the calcaneus and surrounding joints, this syndrome manifests laterally as a midfoot heel pain.
- Rest is essential and may require using crutches or wearing a brace as well as refraining from any activities that trigger the pain.
- Taking non-steroidal, anti-inflammatories, NSAIDS
- Applying ice which has been wrapped in a towel for relief from pain and inflammation. Ice massage may also be recommended. Note: Find effective methods of ice massage and treatments online.
- Various methods of physiotherapy may be indicated: joint mobilization to reduce stiffness around the ankle, taping to limit joint movement, and ultrasound to reduce inflammation.
- Wear footwear that will restrict extreme rear foot movement and support your foot is highly recommended. Shoe inserts might be recommended for flat feet No open back shoes, please.
- Exercises of the leg muscles are okay once there is no more pain. Avoid ankle exercises unless they are pain-free.
- Exercises which focus on stability and balance are vital for joint support.
- A gradual return to work is recommended. Pacing yourself will do more good than harm.
- Surgery is rarely called for but certain conditions like scar tissue, reconstructions of the ligaments, or fusion of certain joints may warrant surgical procedures.
First of all, you should know there are no guarantees when it comes to healing. Most surgeries are performed when nothing else has worked. The causes of heel pain can be diverse, stemming from a wide array of internal and external problems. There are so many diseases that can be transmitted through the generations, that knowing your family history may just confirm certain suspicions your doctor may have about your condition. MRI’s and X-rays could also prove invaluable in diagnosing your particular ailment.
When Surgery is Not an Option:
Alternative Methods to Alleviate Plantar Heel Pain
Just make it stop! Pain can be viewed as a gift, it’s true. We want to know when there’s something wrong with us. But, in most cases, once the pain has revealed the underlying problem, you just want it to stop – at any cost. Long-term drugs are not a good idea because of the dependency factor, side effects and contra-indications noted in the insert. After all, your liver can only take so much, and you can’t live without a liver. Fortunately, there are many treatments with excellent results for people with heel pain. Here are a few steps you can take when considering non-surgical relief:
Step #1: Injecting Medication and Externally Applied Treatments
- Injections of corticosteroid and platelet-rich plasma can reduce the pain caused from plantar fasciitis.
- Guidance from an ultrasound device has proven successful.
- Achilles tendinopathy and chronic recalcitrant plantar fasciitis have been treated using extracorporeal shock wave therapy.
- Corticosteroid or platelet-rich plasma injections are not recommended in treating Achilles tendinopathy.
Step #2: Orthotics, and Splints
- An orthotic is defined as an artificial means of support for the weakened or painful part of the body. Orthotics for heel pain will include shoe inserts which are specifically designed for taking pressure off the heel.
- There are also full-length orthotics. They will fit every type of shoe that laces-up, work boots or Velcro banded shoes. This orthotic will also work in running, walking and cross-training shoes.
- Orthotics are made to address the specific causes of certain medical foot conditions, whereas most other treatments focus on relieving the symptoms, resulting in short-term relief.
- Night splints are worn at night for heel support. Night splints will support the foot at 90 degrees while keeping the calf muscles in a stretched position throughout the night.
- The sock night splint is recommended for heel pain caused by plantar fasciitis or heel spurs and addresses the severe heel or foot pain that is experienced when first stepping out of bed in the morning.
Which Doctor Does What?
Care and treatment of the feet is a specific field of medicine requiring years of additional education and training. Let’s take a look at the various fields of practice included in the care, diagnoses and healing of the foot. There are many trained physicians and therapists in the field of foot care. Perhaps this is your first encounter with the podiatric world and you’d like to familiarize yourself with the education, residency and training they go through before they care for you. Here are the various fields and the necessary steps your future foot doctor must take in becoming a licensed care provider:
Step #1: The Podiatrist
A doctor of podiatric medicine (DPM), is a physician who performs surgery, diagnoses and treats diseases of the foot, ankle and structures of the leg related to the problem. The DPM after their name signifies a completed curriculum in foot and ankle training in podiatric med school and residency training within a hospital.
- Podiatrists must complete 4 years of training in a podiatric medical school.
- 3 years hospital residency training.
- Areas of practice include: surgery of the foot, sports medicine, care and treatment of wounds and injuries.
- Additional field of practice are pediatrics and metabolic disorders such as diabetes.
- Podiatrists become certified by taking an exam administered by the American Board of Foot and Ankle Surgery and the American Board of Podiatric Medicine.
Step #2: The Physiatrist
A licensed physiatrist must complete med school along with four years of residency in physical medicine and rehabilitation.
- Often work in association with physical therapists.
- Specializing in non-surgical methods of pain relief for conditions such as heel pain caused by plantar fasciitis and sprained ankles.
Step #3: Orthopedic Surgeons
Medical doctors who have completed 5 years of residency in general and orthopedic operations specializing in the ailments of the musculoskeletal system:
- Club feet, conditions affecting the tendons and bone fractures are all maladies you would want to consult an orthopedic surgeon about.
- Treatment of the bones, nerves, muscles and joints.
- Sports injuries such as torn ligaments in the knee.
- Diabetic foot treatments: resulting from excessive sugar in the bloodstream causing nerve damage.
- Numbness, pain when walking, development of scaly skin on the foot and lower leg.
- Usually non-surgical treatment for joint problems associated with arthritis.
- Treating chronic pain associated with fibromyalgia resulting in muscle spasms, muscle pain, overall stiffness making it hard to stand and/or walk.
- Diagnoses and treatment of sciatica (pain, tingling and numbness in the back and hips) resulting from a pressed nerve. Treatment may include prescription medication and physical therapy.
- Diagnoses and treatment of the pain brought on by bone cancer. Bones containing tumors are susceptible to fractures and breakage thusly, an orthopedic surgeon will prescribe meds and methods to help prevent damage to the fragile bones.
The more you know about your condition, the more effective you’ll be in obtaining the best results. Since nearly every condition has pain associated with it, it would benefit you to learn as much as you can about your family history, document any accidents regardless of how incidental they may seem at the time, and keep track of the most painful times of the day. The types of activities you’re into also have a lot to do with the pain in your heel. Are you a runner, chef or working on your feet all day? Are you diabetic, experiencing fatigue or numbness in various extremities? Everything you’re experiencing will be of great use to the doctor trying to diagnose the problem so, keep track.
How to Choose the Right Foot Doctor or Surgeon
Important Considerations and Concerns
The process of finding the right doctor to see regarding your heel pain shouldn’t be too hard. Talk to friends, family, and co-workers if you’re comfortable sharing your situation. If not, there are usually reviews posted online which can help you get a feel for the care others have received. Any qualified M.D. can have MRI’s or X-rays taken to start the ball rolling, however, once the problem has been diagnosed, can you be assured of receiving the quality visits and follow-up care you deserve? The list of steps below may help you recall some of your top priorities in choosing a physician:
Step#1: Good Communication
You cannot know if your doctor understands your concerns unless you communicate with them. They may be supremely qualified, but they will not ever be able to read your mind. You’ll know if you’re at the right office when the doctor takes time to listen and respond. This can only happen when you’ve done your part in being as accurate and detailed as possible in describing your symptoms.
- Have all your questions been answered?
- Do you understand the information you’ve been given?
- Are you comfortable speaking directly to the doctor?
- Are your phone calls taken seriously and returned promptly?
- Is your doctor or surgeon experienced in the forthcoming treatments and procedures?
Step #2: Research Your Candidate
In most cases, you’ll be looking for a doctor in your area. Think of it as an interview because you are actually considering hiring them to work for you.
- Get all the insurance questions out of the way including deductibles, post-op therapy coverage and payment plans.
- Check your candidate’s credentials, background and local affiliations in the community.
- Meet face to face. Even if it is a brief handshake, it’s an opportunity to gain some personal insight into your doctor’s demeanor.
To start checking the background of your potential doctor you’ll need to have their full name as well as the counties and states they practiced in. You can also conduct a national criminal check to see if there are any convictions on their record. Your state’s medical board will be able to inform you that your doctor’s license is good standing, and can provide you with information on their schooling, license history, specialties, locations and any disciplinary actions. Also, know that many states automatically run background checks on physicians, however, there are 14 states that currently do not. If you live in one of these you’ll need to run a county, state (or national) check and sex offender registries yourself.
The importance of looking into the causes and treatment of heel pain cannot be overstated. Look at the multitude of injuries and diseases that can all manifest in your feet! Diagnosis of heel pain could involve your history of the symptoms, getting a complete physical exam, x-rays, ultrasound or MRI. An image produced by x-ray will reveal heel spurs, stress fractures, and calcium deposits all which are very painful. There are many treatments when it comes to getting relief from heel pain. Some natural remedies are available and work by learning stretching exercises whereas, other more serious conditions may require surgery. In any case, do your part in finding the right doctor. There are approximately 3,000 doctors who are disciplined every year for offenses like incompetence, negligence and sexual misconduct. There are 70 medical/osteopathic boards in the USA each with different rules, so do your homework. You can check screening procedures for your state online at the Federation of State Medical Boards.
https://www.apma.org/Patients/content.cfm?ItemNumber=992 what is a podiatrist
https://www.aafp.org/afp/2011/1015/p909.html diagnosis of heel pain 10-15-11 PRISCILLA TU Jeffrey Bytomski
http://www.joint-pain-expert.net/haglund-deformity.html Haglund Deformity: Causes, Diagnosis and Treatment
http://footlogics-shop.com.au/page/24/orthotics-for-plantar-fasciitis What is Plantar Fasciitis?
https://www.washingtonpost.com/national/health-science/some-common-causes-for-aching-feet-and-how-to-treat-them/2017/10/20/ad4a4d26-93e5-11e7-aace-04b862b2b3f3_story.html?utm_term=.3fea40ffe3fb Some common causes for aching feet and how to treat them article 10-21-17