Heel pain, often confused with pain in the sole of the foot, can be a very complex symptom to manageThis is because of the large number of structures such as bones, tendons and nerves with which it is related. This is precisely why heel pain can result from many different problems, some of them serious, such as stress fractures and rheumatoid arthritis; we will discuss the main ones in a moment.

It is precisely because of this great variability that it is essential to rely on a professional, such as a specialised physiotherapist, who is able to first rule out more serious pathologies and then be able to understand the specific source of the symptoms through a thorough analysis of the pain's history, location, triggering activities, tests and, if necessary, instrumental examinations and further specialist examinations.

Anatomy of the foot

The heel, from which heel pain may originate, is the bone located at the most posterior part of the sole of the foot.
In order to understand how multifactorial the cause of pain can be, it is important to take a look at anatomy, so as to understand the large number of structures with which it relates:

• Superiorly, it articulates with the talus forming the subastragalic joint;
• Posteriorly via the calcaneal tuberosity it makes contact with the Achilles tendon;
• Inferiorly on the medial tubercle the plantar fascia is inserted; anteriorly it articulates with the cuboid bone;
• Inferiorly, it is covered by an adipose pad;
• It is also enveloped by several branches of the tibial and sural nerve;

Heel pain: causes

Let's take a look at some of the issues that can generate heel pain

Plantar fasciitis:

Heel pain due to plantar fasciitis occurs in the inferior anterior part, where the plantar fascia is inserted, and may spread along it. It is often intense in the early morning and tends to worsen after foot-loading activity such as

standing, walking, running. The cause of plantar fasciitis to date is unfortunately unknown and is probably multifactorial. It is very common among runners, so in these people but not only, it seems to be due to repeated microtraumas following a overload. An overload can occur when the stress to which I subject my foot exceeds the capacity of the foot too much, for example if I have increased the distance or intensity of my training too quickly, but also very simply used flip-flops all day long (greater load on the foot than normal shoes) without being used to it.

Achilles tendonitis:

In this case, the pain occurs in the back heelwhere the tendon fits. As in all tendinitis in most cases the cause is an overload, i.e. having done an activity that required the tendon to handle a load that was excessive compared to its capacity.

Pain will be present mainly during or after (even up to two days later) activities that stress the Achilles tendon such as walking, running and jumping.

Tibial nerve neuropathy:

The pain in the calcaneus may be due to a suffering of one of the Tibial and Sural nerve branches by which it is enveloped.

These are the possible symptoms:

- Pain in different parts of the calcaneus, which may also radiate upwards along the calf, often described as burning ;

-  Numbness e tingling ;

- Sensitivity alteration ;

- Reduction in the strength of the plant muscles.The causes can be many, including trauma, overloads and systemic diseases (Diabetic neuropathy).

A typical issue is the Tarsal Tunnel Syndrome.

Atrophy and heel fat pad syndrome:

The fat pad is a protective layer designed to reduce stress on the heel. The structure and properties of this tissue can change as a result of ageing, pathologies o repeated overload traumas. The atrophy mainly affects older people, whereas the syndrome mainly affects walkers and runners.The pain will be localised just under the heelin the case of atrophy often bilateral and described as a sensation of walking on pebbles or right on the bone, sometimes associated with the presence of a swollen heel.

Pain will be present by applying stress to the heel, therefore in all activities that lead us to stand, walk, run, worsening on hard surfaces, in hard shoes or barefoot.

Bone problem:

Among these, which can potentially generate heel pain and thus heel pain, are bone stress injuries that can progress with stress fractures of the calcaneus. These are problems related to intense sporting activity especially in the running but sometimes also in the trekking and other sports. Initially, the pain will only be present during sporting activity, but with the passage of time it will tend to progressively worsen until it also occurs at rest and during the night.

Heel pain: what to do

Plantar fasciitis:

When we talk about heel pain due to plantar fasciitis, treatment initially requires strategies for pain reduction, then reduction of the activities that most cause the symptomHowever, the patient will not have to give up these activities. gradual reintegration of these activities.

Other treatments that can help in the first phase are:

- Drugs ;
- Insoles ;
- More sustained and therefore less minimalist shoes ;
- Manual therapy and stretching of the calf and fascia ; 

- Shock waves.

As it is a problem that creates pain in load, i.e. when using the foot, it is essential to start active rehabilitation right awaywhich leads to restoring the foot's ability to stand, walk and run.
It is therefore important to have a specialised physiotherapist guiding the patient through a programme of exercises to strengthen the foot and ankle muscles and progressive loading of the fascia through an exercise called Modified Calf Raise and in the second phase a gradual exposure to the patient's daily activitiesall without producing a flare-up of symptoms.

Contrary to their widespread use, scientific evidence does not seem to support cortisone infiltrations as a first line of treatment due to the only temporary and variable pain reduction and potential risks to the patient.

Achilles tendonitis:

In order to be healthy, the tendon must have the ability to handle the significant loads it is subjected to during various activities. In the presence of tendonitis, as in the knee tendinitisthese abilities are reduced, the tendon is no longer able to walk, run and jump as before. Unfortunately the longer we keep the tendon at rest, the more these capacities will tend to decreaseThis is precisely why basing treatment, as is often the case, exclusively on rest and passive therapies such as medication, massage and physical therapy, rarely leads to a resolution of the problem.

In the first phase of acute pain, present even after a few steps, it is essential to reduce the symptom through:

• Reducing more provocative activities ;
• Exercise even in the acute phase is the key to treatment. Initially, we can use a isometric exercise high load, which is often well tolerated by the tendon, resulting in a inhibitory effect on pain and an immediate safe load on the tendon.
• Drug therapy should be used with much cautiona reduction in pain not associated with a real improvement in tendon capacity can expose the person to overloading again, leading to a worsening of the tendon condition.
• Use of heel lifts to reduce stress on the tendon.
• Avoid stretching in the acute phase.

Once the pain has disappeared in the basic activities of daily life, it is essential to restore tendon capacity and the only way to do this is expose it to progressive loads This can be achieved with a programme developed and managed by a specialised physiotherapist who, through the use of specific exercises, trains the resilience, strength and power of the tendon in a progressive manner.

Another key aspect is the gradual return to activities required by the person, in fact there is no exercise or passive treatment that can restore the tendon's ability to run for 10-20 km, for example. Unfortunately, this part of rehabilitation is often left to the patient and it is at this stage that major relapses that risk creating a kind of vicious circle. It is therefore essential, even in this phase, to be followed by a specialised physiotherapist or athletic trainer who can guide you in a progressive and safe return to sporting activities.

Even if the cortisone infiltrations are often among the first therapies proposed their use as a first line of treatment should be not recommended this because of the only short-term reduction of pain and the potential risks to which the tendon is exposed as an inhibition of load adaptation and collagen synthesis, potentially increasing the risk of tendon rupture. The guidelines indicateprogressive load exercise as the first line of treatmentIf this does not achieve results or is impossible to apply, infiltration may be a valuable tool to combine with treatment.

Tibial nerve neuropathy:

Treatment will differ depending on the cause of the nerve irritation. Conservative treatment is often possible, which may consist of:

• - Drugs ;
• - Insoles ;
• - Specific exercises to improve the nerve's ability to handle compression and stretching stimuli;
• - Exercises to improve foot and ankle function ;
• - Manual therapy. If the patient does not respond, one option is the use of cortisone infiltrations.Atrophy and heel fat pad syndrome:Initially, it will be necessary to reduce provocative activities, in some cases with the help of heel cushions, orthotics and particularly cushioned shoes. Once the acute phase is over, it will be essential, as always, to progressively burden the heel through a very gradual resumption of previously painful activities of daily living.

CONCLUSION

As you will have realised, heel pain can be a difficult challenge to deal with due to the large number of different possible causes, which is precisely why a correct heel injury is essential in the first session.

Conservative treatment is often the trump card and this must be guided by a specialised physiotherapist who takes care of the correct education, load management and the progressive load exercise programme.

If after a period of 6-12 months conservative treatment is not effective, the surgical option is considered.

Source

Ebonie Rio , Sue Mayes, Jill Cook - Heel pain: a practical approach - Aust Fam Physician - 2015.

Karin Grävare Silbernagel , Shawn Hanlon , Andrew Sprague - Current Clinical Concepts: Conservative Management of Achilles Tendinopathy - J Athl Train - 2020.

Dr. Vincenzo Bellante

I have been working for 15 years in Varese in the field of orthopaedic and sports rehabilitation. I deal with problems such as, back pain, neck pain, tendinopathies, arthrosis, sports injuries of various kinds with particular interest in the rehabilitation of runner's problems. I work both in the office and via telerehabilitation.
I use mainly active physiotherapy, based on patient education and exercise. The goal is to give you the means to heal, to teach you how to use your body's incredible resources to solve the problem.