Heel Pain

Heel pain is common and can be due to a number of conditions. The calcaneus (heel bone) is the largest bone in the foot and is the first to hit the ground when walking.

The anatomy of heel pain:

The heel bone is designed to be the first contact the foot has with the ground. The achilles tendon inserts into the back of the heel bone (calcaneus) and a very strong ligament along the bottom of the foot attaches to the bottom of the heel bone (the plantar fascia). Several small muscles also attach to the heel bone above the insertion of the plantar fascia.

Given the forces of walking that the heel bone is subjected to and the pull of all these ligaments and muscles, then it is not surprising that heel pain is so common.

The causes of heel pain:

There is no one cause of heel pain. Whole text books have been written on Disorders of the Heel. Some of the types of problems that can be seen in the heel include:

Heel spurs – these are small bony spurs that often develop on the bottom of the heel. They do not really cause any problems. It is only mentioned here as it is a common myth that they are a problem – almost always the pain associated with heel spurs is really plantar fasciitis.

Plantar fasciitis is the most common cause of heel pain and is due to a strain of the long ligament along the bottom of the foot. The most symptom is pain when getting out of bed first thing in the morning (‘post-static dyskinesia’)

A number of disease processes can uncommonly cause heel pain, such as rheumatoid arthritis, ankylosing spondylitis and gout.

Stress fractures, which is an abnormal reaction of bone to stress can occur in those that are very active (eg athletes) or have weaker bones (eg osteoporosis)

Pain at the back of the heel could be due to a number of problems – there could be a bursitis at the back of the heel bone (sometimes called ‘Haglund’s); there could be problems with the insertion of the achilles tendon, such as tendonitis or calcification.

A ‘stone’ bruise is sometimes considered to be a cause of heel pain – its is simply a bruise of the bone.

Another cause of heel pain is problems in the calf muscles that refer pain to the heel (myofascial trigger points) or pain referred from the lower back via the nerves from the back to the heel.

Heel pain in children is usually due to severs disease or calcaneal apophysitis.

 

What is heel pain in children (Severs disease or Calcaneal apophysitis):

Heel pain, unlike the heel spurs, that occur in adults is very uncommon in children. Of those children who do get heel pain, by far the most common cause is a disturbance to the growing area at the back of the heel bone (calcaneus) where the strong achilles tendon attaches to it. This is known as Sever’s disease or calcaneal apophysitis (inflammation of the growth plate). It is most common between the ages of 10 to 14 years of age. These are one of several different ‘osteochondroses’ that can occur in other parts of the body, such as at the knee (Osgood-Schlatters Disease).

The anatomy of heel pain in the child (Severs disease or Calcaneal apophysitis):

When a baby is born, most of the bones are still cartilage with only some starting to develop into bone. When the heel (calcaneus) starts to develop bone, there is generally one large area of development that starts in the center of the cartilage heel. This area of bone spreads to ‘fill up’ the cartilage. Another area of bone development (ossification) occurs at the back of the heel bone – see the x-ray to the right. These two areas of developing bone will have an area of cartilage between them – this is how the bone grows in size. At around age 16, when growth is nearly complete, these two bony areas fuse together. Sever’s disease or calcaneal apophysitis is usually considered to be due to damage or a disturbance in this area of growth.

The two growth areas of the calcaneus can be seen on this x-ray. The smaller area to the back of the heel is normal. Notice the small cartilage joint between the two.

What are the symptoms of heel pain in the child (Severs disease or Calcaneal apophysitis):

Pain is usually felt at the back and side of the heel bone. Sometimes there may be pain at the bottom of the heel. The pain is usually relieved when the child is not active and becomes painful with sport. Squeezing the sides of the heel bone is often painful. Running and jumping make the symptoms worse. One or both heels can be affected. In more severe cases, the child may be limping.

What causes heel pain in children (Severs disease or Calcaneal apophysitis):

The cause of Sever’s disease is not entirely clear. It is most likely due to overuse or repeated minor trauma that happens in a lot of sporting activities – the cartilage join between the two parts of the bone can not take all the shear stress of the activities. Some children seem to be just more prone to it for an unknown reason – combine this with sport, especially if its on a hard surface and the risk of getting it increases. It can be almost epidemic at the start of some sports seasons, especially winter. At the start of winter, the grounds are often harder, but soften later. Children who are heavier are also at greater risk for developing calcaneal apophysitis.

A tight calf muscle is also common in those who develop calcaneal apophysitis, you can imagine how much pull there is from the calf muscles via the achilles tendon on the small growth plate at the back and the strain that this will place on the cartilage join between them. A pronated foot (a foot rolled in at the ankle) is also more common – it is assumed that this may cause an uneven weight bearing on the back part of the heel bone.

Self management of heel pain in the child (Severs disease or Calcaneal apophysitis):

If your child have Sever’s disease, the following is suggested:

* cut back on sporting activities – don’t stop, just reduce the amount until symptoms improve (if the condition has been present for a while, a total break from sport may be needed later)
* avoid going barefoot
* a soft cushioning heel raise is really important (this reduces the pull from the calf muscles on the growth plate and increases the shock absorption, so the growth plate is not knocked around as much).
* stretch the calf muscles, provided the stretch does not cause pain in the area of the growth plate)
* the use of an ice pack after activity for 20mins is often useful for calcaneal apophysitis – this should be repeated 2 to 3 times a day.

Podiatric management of heel pain in children (Severs disease or Calcaneal apophysitis):

Management by a health professional of Sever’s disease is often wise. There are a few very rare problems that may be causing the pain, so a correct diagnosis is extremely important.

Advice should be given on all of what is mentioned above – appropriate activity levels, the use of ice, always wearing shoes, heel raises and stretching … follow this advice!!!

As a pronated foot is common in children with this problem, a discussion regarding the use of foot orthotics long term may be important.

Strapping or tape is sometimes used during activity to limit the ankle joint range of motion.

If the symptoms are bad enough and not responding to these measures, medication to help with anti-inflammatory may be needed. In some cases the lower limb may need to be put in a cast for 2-6 weeks to give it a good chance to heal.

After the calcaneal apophysitis resolves, prevention with the use of stretching, good supportive shock absorbing shoe and heel raises are important to prevent it happening again.

What are the long term consequences of heel pain in the child (Severs disease or Calcaneal apophysitis):

This condition is self limiting – it will go away when the two parts of bony growth join together – this is natural. Unfortunately, Sever’s disease can be very painful and limit sport activity of the child while waiting for it to go away, so treatment is often advised to help relieve it. In a few cases of Sever’s disease, the treatment is not successful and these children will be restricted in their activity levels until the two growth areas join – usually around the age of 16 years. There are no known long term complications associated with Sever’s disease.

 

Cracked Heels

What are cracked heels:

Cracked heels are a common foot problem that are often referred to as heel fissures. Cracked heels are commonly caused by dry skin (xerosis), and made more complicated if the skin around the rim of the heel is thick (callus). For most people this is a nuisance and a cosmetic problem but when the fissures or cracks are deep, they are painful to stand on and the skin can bleed – in severe cases this can become infected.

What does a cracked heel look like:

The skin is normally dry and may have a thick callus which appears as yellow or dark brown discolored area of skin, especially along the inside border of the heel. Cracks in the skin are usually obvious.

What are the symptoms of cracked heels:

If the cracks are bad enough there will be pain on weight bearing, that is not there when weight is off the heel. The edges or rim around the heel will generally have a thicker area of skin (callus). Wearing open or thin soled shoes usually make the symptoms worse.

What causes cracked heels:

Some people tend to have a naturally dry skin that predisposes them to the cracks. The thickened dry skin (callus) around the heel that is more likely to crack is often due to mechanical factors that increase pressures in that area (eg the way you walk).

Other factors that can be involved in the cause of cracked heels include:

prolonged standing (at work or home, especially on hard floors)
being overweight (this increases the pressure on the normal fat pad under the heel, causing it to expand sideways – if the skin is not supple and flexible, the pressures to ‘crack’ are high)
open back on the shoes (this allows the fat under the heel to expand sideways and increases the pressure to ‘crack’)
some medical conditions predispose to a drying skin (eg autonomic neuropathy in those with diabetes leads to less sweating; an underactive thyroid lowers the body’s metabolic rate and there is a reduction in sweating, leading to a dryness of the skin)
skin conditions (eg psoriasis and eczema)

Another way to look at it:

Consider a tomato on the bench … when you push on it from above, it wants to expand out sideways … eventually the skin cracks. This is what happens to the normal fat pad under your heel … as your body weight pushes down, the fat wants to expand sideways and the pressure on the skin to crack is increased. If the weight is excessive (eg prolonged standing) and the skin is not supple (eg callus and/or dry) and nothing is helping hold the the fat pad under the foot (eg open backed shoes) … do you get the picture?

Self treatment for cracked heels:

Applying an oil based moisturizing cream twice daily is really important to get on top of this problem. A pumice stone can be used to reduce the thickness of the hard skin. After looking at the ‘tomato’ analogy above it should be obvious why it is important to avoid open backed shoes or thin soled shoes.

Never try to reduce the hard skin your self with a razor blade or a pair of scissors. There is a risk of an infection developing and taking too much off.

Podiatric management of cracked heels:

The podiatric treatment of cracked heels may involve the following:

investigating the cause of the problem, so this can be addressed
removing the hard thick skin by debriding it (often the splits will not heal if the skin is not removed). This may need to be done on a regular basis. Regular maintenance may be the best way to prevent the problem.
if very painful, strapping may be used to ‘hold’ the cracks together while they heal (a maintenance program after this to prevent recurrence is very important).
prescription and advice regarding the most appropriate moisturizer or emollient.
advice about footwear and self care of the problem.
insoles may be used to alter the way you walk to prevent the thick skin from developing (these are indicated in cases of heel callus and are not suitable for all cases).
a heel cup may be used to keep the fat pad from expanding sideways. This is worn in the shoe and can be very effective at prevention if used regularly.
on rare occasions some Podiatrists and Dermatologists have used a tissue ‘glue’ to hold the edges of the skin together, so the cracks can heal.

 

Heel Pain in Children

What is heel pain in children (Severs disease or Calcaneal apophysitis):

Heel pain, unlike the heel spurs, that occur in adults is very uncommon in children. Of those children who do get heel pain, by far the most common cause is a disturbance to the growing area at the back of the heel bone (calcaneus) where the strong achilles tendon attaches to it. This is known as Sever’s disease or calcaneal apophysitis (inflammation of the growth plate). It is most common between the ages of 10 to 14 years of age. These are one of several different ‘osteochondroses’ that can occur in other parts of the body, such as at the knee (Osgood-Schlatters Disease).

The anatomy of heel pain in the child (Severs disease or Calcaneal apophysitis):

When a baby is born, most of the bones are still cartilage with only some starting to develop into bone. When the heel (calcaneus) starts to develop bone, there is generally one large area of development that starts in the center of the cartilage heel. This area of bone spreads to ‘fill up’ the cartilage. Another area of bone development (ossification) occurs at the back of the heel bone – see the x-ray to the right. These two areas of developing bone will have an area of cartilage between them – this is how the bone grows in size. At around age 16, when growth is nearly complete, these two bony areas fuse together. Sever’s disease or calcaneal apophysitis is usually considered to be due to damage or a disturbance in this area of growth.

The two growth areas of the calcaneus can be seen on this x-ray. The smaller area to the back of the heel is normal. Notice the small cartilage joint between the two.

What are the symptoms of heel pain in the child (Severs disease or Calcaneal apophysitis):

Pain is usually felt at the back and side of the heel bone. Sometimes there may be pain at the bottom of the heel. The pain is usually relieved when the child is not active and becomes painful with sport. Squeezing the sides of the heel bone is often painful. Running and jumping make the symptoms worse. One or both heels can be affected. In more severe cases, the child may be limping.

What causes heel pain in children (Severs disease or Calcaneal apophysitis):

The cause of Sever’s disease is not entirely clear. It is most likely due to overuse or repeated minor trauma that happens in a lot of sporting activities – the cartilage join between the two parts of the bone can not take all the shear stress of the activities. Some children seem to be just more prone to it for an unknown reason – combine this with sport, especially if its on a hard surface and the risk of getting it increases. It can be almost epidemic at the start of some sports seasons, especially winter. At the start of winter, the grounds are often harder, but soften later. Children who are heavier are also at greater risk for developing calcaneal apophysitis.

A tight calf muscle is also common in those who develop calcaneal apophysitis, you can imagine how much pull there is from the calf muscles via the achilles tendon on the small growth plate at the back and the strain that this will place on the cartilage join between them. A pronated foot (a foot rolled in at the ankle) is also more common – it is assumed that this may cause an uneven weight bearing on the back part of the heel bone.

Self management of heel pain in the child (Severs disease or Calcaneal apophysitis):

If your child have Sever’s disease, the following is suggested:

* cut back on sporting activities – don’t stop, just reduce the amount until symptoms improve (if the condition has been present for a while, a total break from sport may be needed later)
* avoid going barefoot
* a soft cushioning heel raise is really important (this reduces the pull from the calf muscles on the growth plate and increases the shock absorption, so the growth plate is not knocked around as much).
* stretch the calf muscles, provided the stretch does not cause pain in the area of the growth plate)
* the use of an ice pack after activity for 20mins is often useful for calcaneal apophysitis – this should be repeated 2 to 3 times a day.

Podiatric management of heel pain in children (Severs disease or Calcaneal apophysitis):

Management by a health professional of Sever’s disease is often wise. There are a few very rare problems that may be causing the pain, so a correct diagnosis is extremely important.

Advice should be given on all of what is mentioned above – appropriate activity levels, the use of ice, always wearing shoes, heel raises and stretching … follow this advice!!!

As a pronated foot is common in children with this problem, a discussion regarding the use of foot orthotics long term may be important.

Strapping or tape is sometimes used during activity to limit the ankle joint range of motion.

If the symptoms are bad enough and not responding to these measures, medication to help with anti-inflammatory may be needed. In some cases the lower limb may need to be put in a cast for 2-6 weeks to give it a good chance to heal.

After the calcaneal apophysitis resolves, prevention with the use of stretching, good supportive shock absorbing shoe and heel raises are important to prevent it happening again.

What are the long term consequences of heel pain in the child (Severs disease or Calcaneal apophysitis):

This condition is self limiting – it will go away when the two parts of bony growth join together – this is natural. Unfortunately, Sever’s disease can be very painful and limit sport activity of the child while waiting for it to go away, so treatment is often advised to help relieve it. In a few cases of Sever’s disease, the treatment is not successful and these children will be restricted in their activity levels until the two growth areas join – usually around the age of 16 years. There are no known long term complications associated with Sever’s disease.

 

Heel Spurs

A heel spur is a calcium deposit on the underside of the heel bone. On an X-ray, a heel spur protrusion can extend forward by as much as a half-inch. Without visible X-ray evidence, the condition is sometimes known as “heel spur syndrome.”

Although heel spurs are often painless, they can cause heel pain. They are frequently associated with plantar fasciitis, a painful inflammation of the fibrous band of connective tissue (plantar fascia) that runs along the bottom of the foot and connects the heel bone to the ball of the foot.

Treatments for heel spurs and associated conditions include exercise, custom-made orthotics, anti-inflammatory medications, and cortisone injections. If conservative treatments fail, surgery may be necessary.

Causes of Heel Spurs

Heel spurs occur when calcium deposits build up on the underside of the heel bone, a process that usually occurs over a period of many months. Heel spurs are often caused by strains on foot muscles and ligaments, stretching of the plantar fascia, and repeated tearing of the membrane that covers the heel bone. Heel spurs are especially common among athletes whose activities include large amounts of running and jumping.

Risk factors for heel spurs include:

Walking gait abnormalities,which place excessive stress on the heel bone, ligaments, and nerves near the heel
Running or jogging, especially on hard surfaces
Poorly fitted or badly worn shoes, especially those lacking appropriate arch support
Excess weight and obesity

Other risk factors associated with plantar fasciitis include:

Increasing age, which decreases plantar fascia flexibility and thins the heel’s protective fat pad
Diabetes
Spending most of the day on one’s feet
Frequent short bursts of physical activity
Having either flat feet or high arches

Symptoms of Heel Spurs

Heel spurs often cause no symptoms. But heel spurs can be associated with intermittent or chronic pain — especially while walking, jogging, or running — if inflammation develops at the point of the spur formation. In general, the cause of the pain is not the heel spur itself but the soft-tissue injury associated with it.

Many people describe the pain of heel spurs and plantar fasciitis as a knife or pin sticking into the bottom of their feet when they first stand up in the morning — a pain that later turns into a dull ache. They often complain that the sharp pain returns after they stand up after sitting for a prolonged period of time.

 

Calcaneal apophysitis

What is heel pain in children (Severs disease or Calcaneal apophysitis):

Heel pain, unlike the heel spurs, that occur in adults is very uncommon in children. Of those children who do get heel pain, by far the most common cause is a disturbance to the growing area at the back of the heel bone (calcaneus) where the strong achilles tendon attaches to it. This is known as Sever’s disease or calcaneal apophysitis (inflammation of the growth plate). It is most common between the ages of 10 to 14 years of age. These are one of several different ‘osteochondroses’ that can occur in other parts of the body, such as at the knee (Osgood-Schlatters Disease).

The anatomy of heel pain in the child (Severs disease or Calcaneal apophysitis):

When a baby is born, most of the bones are still cartilage with only some starting to develop into bone. When the heel (calcaneus) starts to develop bone, there is generally one large area of development that starts in the center of the cartilage heel. This area of bone spreads to ‘fill up’ the cartilage. Another area of bone development (ossification) occurs at the back of the heel bone – see the x-ray to the right. These two areas of developing bone will have an area of cartilage between them – this is how the bone grows in size. At around age 16, when growth is nearly complete, these two bony areas fuse together. Sever’s disease or calcaneal apophysitis is usually considered to be due to damage or a disturbance in this area of growth.

The two growth areas of the calcaneus can be seen on this x-ray. The smaller area to the back of the heel is normal. Notice the small cartilage joint between the two.

What are the symptoms of heel pain in the child (Severs disease or Calcaneal apophysitis):

Pain is usually felt at the back and side of the heel bone. Sometimes there may be pain at the bottom of the heel. The pain is usually relieved when the child is not active and becomes painful with sport. Squeezing the sides of the heel bone is often painful. Running and jumping make the symptoms worse. One or both heels can be affected. In more severe cases, the child may be limping.

What causes heel pain in children (Severs disease or Calcaneal apophysitis):

The cause of Sever’s disease is not entirely clear. It is most likely due to overuse or repeated minor trauma that happens in a lot of sporting activities – the cartilage join between the two parts of the bone can not take all the shear stress of the activities. Some children seem to be just more prone to it for an unknown reason – combine this with sport, especially if its on a hard surface and the risk of getting it increases. It can be almost epidemic at the start of some sports seasons, especially winter. At the start of winter, the grounds are often harder, but soften later. Children who are heavier are also at greater risk for developing calcaneal apophysitis.

A tight calf muscle is also common in those who develop calcaneal apophysitis, you can imagine how much pull there is from the calf muscles via the achilles tendon on the small growth plate at the back and the strain that this will place on the cartilage join between them. A pronated foot (a foot rolled in at the ankle) is also more common – it is assumed that this may cause an uneven weight bearing on the back part of the heel bone.

Self management of heel pain in the child (Severs disease or Calcaneal apophysitis):

If your child have Sever’s disease, the following is suggested:

* cut back on sporting activities – don’t stop, just reduce the amount until symptoms improve (if the condition has been present for a while, a total break from sport may be needed later)
* avoid going barefoot
* a soft cushioning heel raise is really important (this reduces the pull from the calf muscles on the growth plate and increases the shock absorption, so the growth plate is not knocked around as much).
* stretch the calf muscles, provided the stretch does not cause pain in the area of the growth plate)
* the use of an ice pack after activity for 20mins is often useful for calcaneal apophysitis – this should be repeated 2 to 3 times a day.

Podiatric management of heel pain in children (Severs disease or Calcaneal apophysitis):

Management by a health professional of Sever’s disease is often wise. There are a few very rare problems that may be causing the pain, so a correct diagnosis is extremely important.

Advice should be given on all of what is mentioned above – appropriate activity levels, the use of ice, always wearing shoes, heel raises and stretching … follow this advice!!!

As a pronated foot is common in children with this problem, a discussion regarding the use of foot orthotics long term may be important.

Strapping or tape is sometimes used during activity to limit the ankle joint range of motion.

If the symptoms are bad enough and not responding to these measures, medication to help with anti-inflammatory may be needed. In some cases the lower limb may need to be put in a cast for 2-6 weeks to give it a good chance to heal.

After the calcaneal apophysitis resolves, prevention with the use of stretching, good supportive shock absorbing shoe and heel raises are important to prevent it happening again.

What are the long term consequences of heel pain in the child (Severs disease or Calcaneal apophysitis):

This condition is self limiting – it will go away when the two parts of bony growth join together – this is natural. Unfortunately, Sever’s disease can be very painful and limit sport activity of the child while waiting for it to go away, so treatment is often advised to help relieve it. In a few cases of Sever’s disease, the treatment is not successful and these children will be restricted in their activity levels until the two growth areas join – usually around the age of 16 years. There are no known long term complications associated with Sever’s disease.

Plantar Fasciitis

What is plantar fasciitis?

Plantar fasciitis (say “PLAN-ter fash-ee-EYE-tus”) is the most common cause of heel pain. The plantar fascia is the flat band of tissue (ligament) that connects your heel bone to your toes. It supports the arch of your foot. If you strain your plantar fascia, it gets weak, swollen, and irritated (inflamed). Then your heel or the bottom of your foot hurts when you stand or walk.

What causes plantar fasciitis?

Plantar fasciitis is caused by straining the ligament that supports your arch. Repeated strain can cause tiny tears in the ligament. These can lead to pain and swelling. This is more likely to happen if:

Your feet roll inward too much when you walk (excessive pronation).
You have high arches or flat feet.
You walk, stand, or run for long periods of time, especially on hard surfaces.
You are overweight.
You wear shoes that don’t fit well or are worn out.
You have tight Achilles tendons or calf muscles.

What are the symptoms?

Most people with plantar fasciitis have pain when they take their first steps after they get out of bed or sit for a long time. You may have less stiffness and pain after you take a few steps. But your foot may hurt more as the day goes on. It may hurt the most when you climb stairs or after you stand for a long time.

If you have foot pain at night, you may have a different problem, such as arthritis, or a nerve problem such as tarsal tunnel syndrome.

How is plantar fasciitis diagnosed?

Your doctor will check your feet and watch you stand and walk. He or she will also ask questions about:

Your past health, including what illnesses or injuries you have had.
Your symptoms, such as where the pain is and what time of day your foot hurts most.
How active you are and what types of physical activity you do.

Your doctor may take an X-ray of your foot if he or she suspects a problem with the bones of your foot, such as a stress fracture.

How is it treated?

No single treatment works best for everyone with plantar fasciitis. But there are many things you can try to help your foot get better:

Give your feet a rest. Cut back on activities that make your foot hurt. Try not to walk or run on hard surfaces.
To reduce pain and swelling, try putting ice on your heel. Or take an over-the-counter pain reliever like ibuprofen (such as Advil or Motrin), naproxen (such as Aleve), or aspirin.
Do toe stretches, calf stretches and towel stretches several times a day, especially when you first get up in the morning.
Get a new pair of shoes. Pick shoes with good arch support and a cushioned sole. Or try heel cups or shoe inserts (orthotics). Use them in both shoes, even if only one foot hurts.