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Conditions that cause heel pain

  • Plantar fasciitis

  • Achilles tendinopathy

  • Baxter's nerve entrapment

  • Tarsal tunnel syndrome

  • Medial calcaneal nerve entrapment

  • Plantar fat pad injury

  • Plantar calcaneal bursitis

Plantar fasciitis

This is the most common condition we treat, simply  because it is the most common cause of heel pain. Plantar fasciitis is a painful foot condition located mostly at the heel. Although originally thought of as an inflammatory process, plantar fasciitis is a disorder of degenerative changes in the plantar fascia leading to thickening of the fibres and may be more accurately termed plantar fasciopathy. Plantar means the bottom of the foot, and fascia is the fibrous tissues that connects the heel bone to the heads of the metatarsal bones found at the base of your toes. It is an overuse injury where the plantar fascia becomes strained due to levels of stress that exceed how much the plantar fascia can tolerate. The level of stress the plantar fascia can tolerate varies from person to person.  Plantar fasciitis is the most common cause of heel pain affecting up to 10% of the population. Approximately 80% of heel pain is caused by plantar fasciitis. It is most often seen in middle-aged men and women (between the ages 40-60), but can be found in all age groups and is also common in the athletic population due to  the repetitive nature of the some sports which can cause damage to the plantar fascia.  

Achilles tendinopathy

Achilles tendinopathy is another very common cause of heel pain which affects the back of the heel, usually around 5cm from the attachment site of the achilles tendon to the heel bone. It can be considered a similar condition to plantar fasciitis in terms of disease process, causes, and the patient types it most commonly affects. It is an overuse injury where the achilles tendon becomes strained due to levels of stress that exceed how much the tendon can tolerate.

Baxter's nerve entrapment

Baxter's nerve entrapment is often misdiagnosed as the symptoms mimic plantar fasciitis and the difficulty in confirming diagnosis as it is not easy to detect with diagnostic tests. Baxter was one of the first doctors to report this condition hence the name. The specific nerve this condition relates to is known as the inferior calcaneal nerve or the first branch of the lateral plantar nerve. This small nerve supplies sensation to the plantar fascia and the bottom of the heel bone. The nerve can be become entrapped, irritated or compressed for a wide number of reasons which often presents as a burning, sharp or shooting type of pain.

Tarsal tunnel syndrome

This is another condition that is often misdiagnosed and can cause heel pain. The tarsal tunnel is a specific part of the foot and ankle anatomy where many structures pass through including blood vessels, tendons and nerves. In tarsal tunnel syndrome the tibial nerve becomes either entrapped, compressed or irritated. This can be a result of trauma or anatomical abnormalities such as a cyst compressing the nerve. The tibial nerve is relatively large and divides into smaller branches of nerves as it passes through the tarsal tunnel and into the sole of the foot. A few of the branches extend to the heel and supply sensation and muscle function. When the tibial nerve becomes injured it typically presents as a sharp shooting pain and can be described as tingly, like pins and needles. Patients also report numbness or a cold sensation in the affected foot. As other branches of the tibial nerve supply sensation along the sole of the foot extending to the toes, it is common for patients to report symptoms radiating along the sole of the foot and into the toes which may be additional to heel pain. Click here to learn about our preferred treatment for tarsal tunnel syndrome

medial calcaneal nerve entrapment

This is another neural cause of heel pain. The medial calcananeal nerve is a branch of the tibial nerve. This nerve usually branches off the tibial nerve within the tarsal tunnel. It extends along the inside of the ankle and heel and terminates under the heel bone. This nerve supplies sensation to the skin on the heel and the plantar fat pad. Medial calcaneal nerve entrapment mimics plantar fasciitis and is often misdiagnosed as such.

Plantar fat pad injury

Plantar fat pad injuries are not as common as other causes of heel pain, additionally plantar fat pad injuries are not well documented in the medical literature. The plantar fat pad is found directly below the skin. It has a spongy property and is designed to aid in shock absorption during heel contact with the ground. The plantar fat pad can become injured such as a tear or rupture in the fat cells which can lead to pain. An example of this would be stepping on a relatively blunt object under a lot of force such as a stone which may not puncture the skin but has the potential to damage the fat pad directly below the skin. This is another condition that can mimic plantar fasciitis as both conditions are exacerbated by weightbearing.

Plantar calcaneal bursitis

A bursa is a small sac of fluid that reduces friction of moving body parts. We have bursa in many different parts of our bodies and there is a small bursa located on the bottom of the heel. This bursa can become inflamed as a result of injury. This is known as bursitis. Bursitis is often very painful and can cause patients to walk with a limp. It is difficult to confirm diagnosis from a clinical examination alone as there isn't necessarily visible swelling of the heel even though the bursa is inflamed however can be detected with diagnostic ultrasound or an MRI.

Retrocalcaneal bursitis

This is a common cause of posterior heel pain which means pain at the back of the heel. Between the achilles tendon and the back of the heel bone there is a bursa. A bursa is a small sac of fluid designed to reduce friction when we flex the ankle back and forth during normal activities such as walking. In this condition the bursa becomes inflamed, usually as a result of repetitive mechanical overloading or a bony abnormality such as a calcaneal exostosis (benign growth of the heel bone).

Superficial calcaneal bursitis

This is another type of bursitis located between the achilles tendon and the skin. The bursa is located just under the skin hence the name superficial which means shallow. This condition is often diagnosed clinically as this type of bursitis is easy to visualise, characterised by localised redness, and swelling. This condition is most commonly cause by poor fitted footwear where the back of the shoe rubs on the back of the heel pain repetitively causing the bursa to become irritated and inflamed. Similar to retrocalcaneal bursitis, it can also be caused by a bony abnormality such as calcaneal exostosis (benign growth of the heel bone).

Flexor hallucis longus tendinopathy

The flexor hallucis longus tendon is a long tendon that runs along the back of the ankle and heel and extends along the sole of the foot to connect to the bottom of the big toe. This tendon is responsible for flexing the big toe downwards and helps with toe push off during walking. The tendon can become strained or torn anywhere along its course from the ankle to the big toe. When an injury occurs behind the ankle, it may present as pain in the back of the heel but can be difficult to pin point as it is a relatively deep structure. Flexor hallucis tendinopathy is considered an uncommon cause of posterior heel pain and is often misdiagnosed as achilles tendinopathy which is much more common.

Heel stress fracture

Stress fractures occur when the level of stress placed on a bone is greater than what the bone can tolerate. Heel stress fractures are not uncommon and are often linked to a sudden increase in activity levels over a short period of time where the bone hasn't had an opportunity to adapt to the increased stress placed on it. This condition is more common in middle aged and elderly post-menopausal women because oestrogen deficiency causes accelerated bone resorption. Calcaneal stress fractures are often very painful. Patients typically present with swelling around the heel and inability to fully weightbear on the heel.  

Sever's disease (calcaneal apophysitis)

This is a very common condition typically seen in boys and girls aged between 10-12 however some may be a bit younger or older.  Overall it is more common in boys and people that play sports. It is a type of bone injury in which the growth plate in the lower back of the heel, where the Achilles tendon attaches, becomes inflamed and causes pain. This condition eventually self resolves once the growth plate matures as ossifies into bone however this can take a number of years to take place. Fortunately symptoms are often very manageable with treatment and activity modification.

  • Retrocalcaneal bursitis

  • Superficial calcaneal bursitis

  • Flexor hallucis longus tendinopathy

  • Heel stress fracture

  • Sever's disease

  • Plantar fibromatosis

  • Systemic causes of heel pain

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