Plantar Heel Pain

Pain in the heel on the underside (the plantar aspect) of the foot is quite common and can have several causes, but the most common of those by far is the one that you are most likely to have heard of: plantar fasciitis. Other possible causes are fat pad syndrome, fracture of the calcaneus (heel bone), neurological problems and rheumatoid arthritis. The correct diagnosis of plantar heel pain depends on several factors, including whether the onset was sudden or gradual; whether pain is felt under the heel on weight bearing; whether it hurts when there is no weight on that foot; whether there are any other associated symptoms, such as weakness or numbness; what makes it worse and what makes it better.

Plantar Fasciitis

Plantar fasciitis is inflammation of the plantar fascia, which is the connective tissue that connects the heel to the toes. The plantar fascia is between a ligament and a tendon in character; it connects bones, but behaves like a tendon. Plantar fasciitis is caused by a strain on the tissue, often from a recent increase in volume of walking or running or from spending more time than usual standing. It can also result from inadequate cushioning for the sole of the foot. One in ten of the population in the Western World develop plantar fasciitis at some point in their lifetime and it is the most common cause of heel pain.

The pain of plantar fasciitis tends to be felt more on the inside of the heel than in the middle of it and it tends to be worse on the first few steps of the day, walking off during the day and returning after sitting rest. If the condition persists for more than three months, it changes from being an inflammatory condition to a failure to heal and is then known as plantar fasciopathy.

Initial management of plantar fasciitis may include:

  • Wearing firm, low-heeled footwear with cushioned soles, which can help relieve the discomfort by taking some of the pressure off the plantar fascia.

  • Applying an ice pack to the area and/or taking non-steroidal anti-inflammatory drugs (NSAIDs) to reduce the inflammation.

  • The use of strapping or taping to support the area.

  • Firm, off-the-shelf orthotics.

  • Stretching the calf and plantar fascia.

  • Massage to relieve tension in the plantar fascia and to promote healing.

  • Steroid injection is another option and is about 50% successful.

Longer term management options include:

  • Stretching as above.

  • Gait retraining (because the pain may have caused changes to the way that someone walks or runs, which could lead to other problems).

  • Warmth over the affected area to stimulate the circulation and healing, rather than to reduce inflammation at this stage.

  • Custom orthotics if the arches of the feet are particularly flat (pes planus) or high (pes cavus).

  • Massage as above.

  • Shockwave therapy, which can be provided by a physiotherapist or osteopath.

  • Ultrasound guided steroid injection, performed by a medical professional (ideally one experienced in treating plantar fasciitis).

  • Platelet rich plasma (PRP) treatment, which is now also available on the NHS.

Fat Pad Syndrome

One in ten people with heel pain have fat pad syndrome, so it is the next most common cause of heel pain after plantar fasciitis. Fat pad syndrome is experienced as a dull ache in the centre of the heel. The pain is only and always felt on weight bearing, is worse barefoot, is usually only in one heel and doesn’t walk off. It is due to age-related atrophy of the cushioning (fat pad) under the heel and so is most common over the age of forty. It can also occur in people with high arches because the pad may be displaced by the one-sided pressure on it. The pad can also be damaged by traumatic injury. A heel spur (a bony lump also known as an osteocyte) can aggravate an irritable fat pad.

Calcaneal Fracture

If the heel pain is caused by a fracture in the calcaneus (heel bone) it may have come on suddenly after a fall or an unusually long walk or run. Being underweight can cause bones to weaken and so will make calcaneal fracture more likely, as can being overweight, which puts the bone under more strain. A stress fracture can also occur in the calcaneus from increased load of impact exercise. Calcaneal fracture results in heel pain even when not weight bearing and there can be pain at night. Heat may make it worse.

Neurological Causes

A problem in the lumbar spine can cause sciatica, referring pain down the leg to the heel. Tarsal tunnel syndrome in the foot (similar to carpal tunnel syndrome in the hand) can cause heel pain because of the restriction of nerves around the ankle. Usually if there is a neurological cause there will be pain elsewhere in the body and associated neurological phenomena (e.g. shooting pains, pins and needles).

Rheumatological Causes

If heel pain is caused by a rheumatological condition, it will usually be in both heels, with stiffness as well as pain. There will usually be a family history of rheumatoid arthritis or other enthesopathies (pain where a tendon inserts into a bone), so those over the age of thirty will usually have been screened for the condition or diagnosed already.

If you experience heel pain, no matter the possible cause, it is advisable to consult with your GP as soon as possible for a diagnosis and for advice on the most appropriate treatment for your condition. They will also be able to refer you on if necessary for the most suitable ongoing support. And if you are heel-pain free, I hope that you have learnt something here to help you stay that way.