Whether you’re a runner, have just started exercising, or simply want to manage things like casual walks to work or household chores, heel pain is one problem that can stand in your way. Heel pain is a common problem that affects up to 10% of adults at any one time. There are various causes of heel pain that our physiotherapists see and treat across our Hong Kong Central and Wong Chuk Hang clinics, which include:
- An Achilles injury: your cord-like Achilles tendon is the strongest and largest tendon in your body, attaching to the back of your heel bone. When the Achilles is overloaded, overused or strained, damage can occur either at the mid-portion of the tendon or at its insertion. This can produce pain at the back of the heel during walking, running, and movements like standing on tip-toes.
- Calcaneal stress fracture: a stress fracture is a type of bone fracture that occurs gradually over time, starting as tiny, asymptomatic micro-cracks in the bone that grow and worsen to become painful and limiting. They are caused by overloading the heel and exposing the heel bone to excess forces over time, causing damage. As the pain associated with a calcaneal stress fracture comes on gradually and worsens, many people aren’t sure what has caused their pain as there isn’t a notable traumatic incident like there is with a regular fracture.
- Heel pad syndrome: we all have fat pads at the bottoms of our heels that play an important role in helping us absorb the pressure, shock and weight from every step we take. Whether it occurs naturally with age, or as a result of an injury or medical condition, our heel pads can wear down and no longer support and cushion our heels effectively. This can expose our heels to more pressure and stress, resulting in heel pain.
- Bursitis: bursitis means the inflammation of a bursa – a small, fluid-filled sac that sits between structures in the body to help prevent painful friction and rubbing while promoting lubrication and healthy movement. When a bursa is overloaded, like from excess pressure from tendons or other structures, it can become swollen and painful. This is known as bursitis. There are two bursae positioned at the back of the heel that can cause your heel pain – retrocalcaneal bursitis (the bursa between the Achilles tendon and the heel bone) and superficial calcaneal bursitis (sits just beneath the skin, at the back of the heel where the Achilles tendon inserts).
- Growing pains: Sever’s disease is a type of growing pain that only presents in children, often between ages 7-15 years, that affects the heel. It is not actually a disease, but a growth-related condition occurring when the growth plate at the back of the heel is irritated or damaged. This irritation is most often from tension from the Achilles tendon, resulting in pain at the back of the heel. Growth plates are softer and more vulnerable areas to which new bone is added, meaning that they’re more vulnerable to injury. Children will typically experience pain during or after exercise which can range from mild to severe, and may limp as a result.
Of all the causes of heel pain, one of the most common ones we see is called plantar fasciitis.
Plantar Fasciitis Heel Pain
Plantar fasciitis describes damage to the plantar fascia, a thick band of connective tissue that attaches to the bottom of your heel and then fans out across your arch and foot to connect to the toes. It helps to maintain the shape of the arch by supporting the bones, joints and muscles. When the fascia is strained, it becomes damaged and inflamed. This is known as plantar fasciitis.
Common symptoms of plantar fasciitis include:
- Pain at the bottom or inside of the heel that may radiate into the arch
- Swelling, redness or warmth at the bottom of the heel
- Worst pain when taking the first few steps in the morning, or when standing after rest
- The pain may come and go throughout the day
Damage to the plantar fascia can worsen over time if it is not effectively managed. An inflamed fascia may progress to a partial tear in the fascia, which will require a longer recovery. When identified and managed early, our physio team can help prevent your injury from worsening. Your physio will also ensure that you have a correct diagnosis at your first appointment, as other conditions may mimic the symptoms of plantar fasciitis, like Abductor Hallucis Tendinopathy.
What Causes Plantar Fasciitis?
If you picture the way that the plantar fascia spans the arch, every step does place some tension on the fascia – and even more so when running or jumping. While our body is used to the way that we normally use plantar fascia, when we place significantly higher loads on the fascia or increase the intensity of our activities, microtears can develop that cause damage and inflammation.
Increased loads on the fascia may result from:
- Increasing the amount of physical activity you’re doing
- Increasing the intensity of the activity that you’re doing
- Having tight calf muscles
- Wearing unsupportive footwear
- Having flat feet, or a foot type that puts more tension on the fascia
- Increased weight (including during pregnancy)
- Having a job where you’re on your feet all day, walking over hard surfaces
Plantar fasciitis can also be caused by a traumatic event, such as landing your heel or arch on a prominent stone that damages the area and fascia.
It is important to not only look at the symptoms of plantar fasciitis but also the cause so that you don’t struggle with a recurring injury in the future. This often happens when the cause isn’t a one-off activity but is associated with the biomechanics of your lower limbs.
Plantar Fasciitis Treatment
Plantar fasciitis can be successfully treated in most cases without surgery or invasive methods. Your physiotherapist will determine the best course of treatment for you based on the results of your assessment. Best practice guidelines published in 2021 show that a combined, multi-factorial approach to managing plantar fasciitis helps yield the best results. This includes:
- Education about all the aspects of plantar fasciitis, care, prevention, treatment and pain management
- Plantar fascia stretching
- Static and dynamic load management
- Addressing related conditions e.g. diabetes or a high BMI
- Footwear assessment
Our team at PhysioCentral offers a comprehensive approach to plantar fasciitis treatment that addresses all of these factors, which may include:
- Dry needling to the calf muscles and the plantar fascia
- Soft tissue massage
- Mobilisations of the foot and ankle joint
- Supportive taping to relieve strain on the plantar fascia, which may extend to bracing or splinting as needed
- Activity modification technique
- Stretching and strengthening programme, including foot stabilisation exercises, intrinsic foot muscle strengthening and calf strengthening
- A strong focus on tailored education about plantar fasciitis causes, management and prevention
- Ensuring your shoes are supporting your recovery and not adding to the problem
- Referral to a podiatrist to discuss the benefits of orthotics if required
You may take non-steroidal anti-inflammatories to help you manage pain in the interim, along with ice baths to support the reduction of inflammation and therefore pain. Your physio will track your progress, and if we do not see sufficient results, we may refer you for a corticosteroid injection.
At Home Care: Plantar Fascia Stretch & Ice Massage
The following plantar fascia-specific stretch is easy to perform at home. Take one hand and stretch your toes (of the affected foot) up towards the sky. Using your other hand, feel along the plantar fascia to ensure that it is taut. Hold for 30 seconds and repeat three times in each session. This should be done daily, especially before taking the first step in the morning and before standing following a period of prolonged sitting. Ice massage can also help to reduce plantar fascia pain. One method involves rolling a frozen can under the foot with moderate pressure for five to ten minutes at the end of each day.
- Plantar fasciitis can be a serious and debilitating condition, but in most cases can be resolved with the help of physiotherapy
- Overloading the plantar fascia is the most common cause of plantar fasciitis, so to reduce the likelihood of plantar fasciitis recurring in the future, you must address the factors that may be overloading the fascia
- You can get temporary relief from taping the foot, using NSAIDs and ice baths
- Physiotherapists may use a range of manual therapies as well as strengthening and stretching plans that are proven to support your recovery