Heel pain is one of the most common presenting problems to any foot and ankle specialist. Commonly, the problem is related to plantar fascitis or irritation of the insertion of the plantar fascia on the bottom of the heel. Plantar fascitis is associated with pain on first steps of the morning when the fascia gets stretched. The pain resolves within a few steps to a few minutes of walking and does not get worse again unless the person walks for long periods of time, has a period of sitting or rest after which standing again stretches the fascia or with excess pressure.
Although over 70% of heel pain is plantar fascia related, there are multiple other causes that must be considered. At University Foot and Ankle Institute, we see a large number of second opinion patients and most of the heel pain cases that have failed previous care are associated with causes other than pure plantar fascitis.
Other common heel problems to consider include:
- Baxter’s nerve pain
- Tarsal tunnel nerve pain
- Heel bursitis
- Heel stress fracture
- Heel bone bruise
- Heel bone cyst
With every heel pain case, all of the problems listed above must be considered in order to have a complete working diagnosis list. Each of these can be ruled in or out with common examination and testing options. We will now explore each of the above potential causes of heel pain.
Tarsal Tunnel and Baxter’s Nerve Pain
These two conditions are somewhat considered together. Heel pain from nerve issues causes similar pain to plantar fascitis but it gets worse with extended periods of walking or standing. Furthermore, there is also some associated tingling and burning pain noted. One must also consider back problems and nerve issues from the lower back if there is nerve pain in the foot and ankle. On examination, tingling of the tarsal tunnel on the side of the ankle can be recalled with a tap on the nerve.
Baxter’s nerve pain is heel pain associated with a small branch of the tarsal tunnel nerve that runs on the inside of the heel and onto the bottom of the heel. This is the most common source of nerve pain in the heel. Pressure on the medial arch side of the heel over the muscle belly region will cause tingling in the heel area.
Furthermore, numbing of this small nerve branch will take away all heel pain. Treatment may include physical therapy, cortisone injection, casting or possible nerve release.
Tarsal tunnel syndrome is a more complicated and involved form of the Baxter’s nerve heel pain syndrome. Much like carpal tunnel in the hand, tarsal tunnel is associated with nerve pain in the foot and ankle due to compression of the nerve on the side of the ankle. A tingling of the nerve is noted with tapping on the ankle area on the arch side of the foot in most cases, but certain cases may not show tingling with tapping on the nerve and may require further testing.
Treatment of tarsal tunnel may also include injection therapy, physical therapy, orthotics, casting or surgical release. In most nerve cases, we will order an EMG/NCV nerve conduction test in order to check for the region of nerve problems from the back down to the foot and also to check for neuropathy or generalized nerve problems within the body and not just the foot.
Bursitis of the heel region is associated with inflammation of the bursa or a fluid filled sack on the bottom of the heel. This problem is one of the most commonly missed issues as the bursa is directly at the bottom of the heel and directly over the central plantar fascia area. The difference in bursa pain and plantar fascitis pain is that bursa pain gets worse with increased walking due to chronic pressure on the bursa and central heel while plantar fascitis gets better with walking as the fascia stretches out.
Diagnosis of bursitis is commonly done using an ultrasound, which can show an inflammation of the bursa while the underlying fascia looks fairly normal. In such cases, treatment may include cortisone injection and cushioning of the heel region. It should be noted that orthotics can often irritate the bursa region as they are harder in makeup while the bursa requires a little bit of the softer surface to decrease pressure on the area. It is rare for bursa problems to require surgery or any further treatment.
Heel Stress Fractures
Stress fractures of the heel are not fairly common without an associated injury and this is one of the main differentiating factors for stress fracture. Whether the problem is due to prolonged walking in a bad pair of shoes or landing hard on the heel, trauma is the main cause of stress fracture. Stress fractures are commonly painful with side-to-side squeeze of the heel and may be seen on x-ray. However, x-rays may not show a stress fracture and if further diagnosis is necessary, an MRI may be best for seeing swelling of the bone associated with a stress fracture. The most common treatment for heel stress fractures is rest. A boot or a cast is used to rest the area and the problem usually will resolve with 4-6 weeks of rest.
Heel Bone Bruise
A heel bone bruise is similar to a stress fracture but there is no fracture just inflammation and bruising of the bone. This is common with extended periods of activity and stress or a possible bone injury from trauma. Diagnosis is only made with an MRI as nothing will show on x-ray and exam findings can be somewhat varied. Treatment again is mainly rest. In a small number of cases, there can be a problem with inflammation of the internal bone structure that does not resolve and an injection of a bone material is placed in the bone to strengthen the bone and resolve the inflammation of the bone region.
Heel Bone Cyst
A heel bone cyst is the most rare problem associated with heel pain. This involves weakening of the bone due to an internal tumor or bone cyst. The weakness of the bone causes swelling and pain with motion and activity. In certain cases, the pain can increase with a stress fracture of the bone. Diagnosis can be made with x-ray as a preliminary check and a possible CT or MRI for further check. Treatment needs to be conclusive and rapid with a tumor diagnosis. We usually with perform an excision or at least a biopsy of the cyst as soon as possible to rule out a malignancy.
In conclusion, the treatment of heel pain can be varied and multi symptom related. It may seem that an examination alone is sufficient but this can result in a missed diagnosis. We begin our initial visit with x-rays of the heel to check for tumor, stress fracture and identify any bone spurs. Examination will then dictate if there is nerve issues or potential bursa issue to consider. If there is a nerve issue that is clear, further care is performed with rest, injection and/or physical therapy. If problem persists, nerve testing is done. If the bursa is considered involved, an ultrasound can show both the fascia and the bursa for further consideration.
Proper examination and a complete consideration of the causes of heel pain will help avoid prolonged incorrect care and speed up the treatment of heel pain syndrome.
The physicians at University Foot and Ankle Institute have decades of combined diagnosing and treating heel conditions. If you would like more information or would like to schedule a consultation, please call (877) 989-9110 or visit us at www.footankleinstitute.com.
Dr. Baravarian been involved in athletics his entire life and played competitive tennis in high school and college. He has an interest in sports medicine, arthritis therapy and trauma/reconstructive surgery of the foot and ankle. He servers as a consultant to the ATP (Association of Tennis Professionals) tour, multiple running organizations and several shoe manufacturers. He is also fluent in five languages (English, French, Spanish, Farsi and Hebrew),
Podiatrist Dr. Bob Baravarian is available for consultation at the Santa Monica, Sherman Oaks and UCLA Westwood offices.
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