Heel Pain

Heel pain is a symptom caused by overload, biomechanical alterations, trauma, or other osteoarticular diseases.

Symptoms and Causes

Pain in the heel, whose medical term is talalgia, is one of the most common symptoms of overload, although it may also indicate that an injury has occurred or that there is an underlying pathology.

Talalgia manifests differently depending on the reasons for which it occurs:

Pain when stepping: appears on getting up, immediately when bearing weight on the foot after remaining at rest for some time.
Pain at rest: continues even when the foot is not bearing weight.
Pain when walking: it is common for it to be felt during the first steps after a period of rest and for it to decrease in intensity with movement.

Although it does not usually arise from a serious disease, heel pain negatively affects quality of life, as it prevents everyday activities from being carried out normally. The prognosis is usually favourable, as the pain tends to disappear on its own or with conservative treatments within a relatively short period of time, which, on some occasions, may be one year.

Symptoms

Heel pain may occur on the lateral side, internal or external, on the sole, or at the back. Its intensity is variable:

Dull pain: a mild and generalised discomfort.
Stabbing pain: an acute sharp pain felt when bearing body weight on the heel.

The symptoms associated with talalgia, usually derived from the underlying disease, are generally:

Inflammation.
Stiffness: difficulty flexing the ankle.
Numbness and tingling sensation.
Changes in gait walking on tiptoe or limping to avoid pain.

Causes

The most common causes of heel pain are:

Chronic diseases of the bones or joints:
- Plantar fasciitis: inflammation of the fascia, which is the tissue that connects the heel bone to the toes. It is the most common cause.
- Achilles tendinitis: overload of the Achilles tendon, which connects the calf muscles to the heel.
- Foot or retrocalcaneal bursitis: inflammation of the bursa (a fluid-filled sac that reduces friction in the joints) located between the calcaneal bone and the Achilles tendon, at the back of the heel.
- Calcaneal spur: a protrusion that forms on the lower part of the calcaneal bone, on the underside of the heel, due to the accumulation of calcium deposits.
- Baxter’s syndrome: a peripheral neuropathy that causes damage to the nerves of the foot. It may be associated with diabetes.
- Plantar papilloma: benign warts that appear on the soles of the feet as a consequence of the human papillomavirus (HPV).
Trauma and injuries:
- Achilles tendon rupture.
- Fracture of the calcaneal bone.
- Stress fracture: the bone develops a fissure due to repetitive impacts.
- Contusions.
Other conditions that may cause heel pain:
- Ankylosing spondylitis: inflammation of the spine and the joints of the hands and feet.
- Arthritis: inflammation of the joints that is usually associated with degeneration of the tissues that form them.
- Nerve impingement: the tissues surrounding the nerve — bones, tendons, muscles — exert excessive pressure on a nerve.
- Osteomyelitis: infection of a bone, usually by a fungus or bacterium.
- Sarcoidosis: a disease in which granulomas formed by immune system cells accumulate in different parts of the body.
- Bone tumour.

Risk Factors

The risk of experiencing heel pain is higher in the following circumstances:

Overweight and obesity.
Alterations in foot biomechanics:
Flat feet: the medial arch of the foot flattens when pressure is applied to it, so it touches the ground when standing.
Pes cavus: the arch of the foot is excessively high.
Valgus foot: the heel deviates outwards and the plantar arch flattens, so body weight rests on the inner edge of the foot.
Age: over time, tissues lose elasticity and are more prone to damage due to day-to-day load. Therefore, talalgia is more common from the age of 40 onwards.
Intense physical activity.
Standing for long periods of time.
Inappropriate footwear: excessively flat shoes or shoes with very high heels cause damage to the heel.
Shortening of the calf muscles or the Achilles tendon, as ankle mobility becomes limited.
Systemic inflammatory diseases.

Complications

Untreated heel pain may lead to any of the following complications:

Chronic pain.
Altered gait.
Secondary pain: when the way of stepping is changed to compensate for talalgia, it frequently causes pain in the knees, ankles, hips, or lumbar region.
Tarsal tunnel syndrome: compression of the tibial nerve that produces severe pain, tingling, and numbness.
Shortening of muscles and tendons.
Chronic plantar fasciitis.
Haglund’s disease or insertional Achilles tendinopathy: bony overgrowth on the calcaneal bone.

Which specialist treats heel pain?

Heel pain may be treated in the specialties of Traumatology and Orthopedic surgery, Podiatry, and Physical medicine and Rehabilitation.

Diagnosis

To diagnose the causes of heel pain, the following tests are performed:

Medical history: the specialist studies the patient’s medical background, presenting symptoms, and lifestyle.
Physical examination: the area is palpated to identify pain points and assess whether there is inflammation or loss of sensitivity.
Gait analysis: analyses weight distribution on the sole of the foot, both during movement and in standing position, to check for imbalances.
X-ray: The bone structure is visualised to rule out calcaneal spur, osteoarthritis, or possible fractures.
Ultrasound: provides images of the soft tissues of the heel — muscles, tendons, nerves, fat, blood vessels — and detects possible structural alterations, inflammation, or tears.
Electromyography: evaluates the electrical activity of the muscles and the speed of nerve conduction, and therefore detects possible entrapments or damage to peripheral nerves and muscle fibres.

Treatment

Heel pain is relieved by following these recommendations:

Rest.
Local cold: applying ice to the painful area reduces inflammation and relieves pain.
Stretching exercises.
When it is persistent, taking analgesics or anti-inflammatory drugs is recommended.
Physiotherapy: shock waves and manual therapy are very effective.

In addition to addressing the main symptom, it is necessary to find the appropriate treatment for the disease causing talalgia. The most notable are:

Plantar fasciitis:
- Orthopaedic insoles to distribute weight evenly across the sole of the foot.
- Night splints to keep the fascia and Achilles tendon stretched.
- Manual physiotherapy and shock waves to reduce inflammation and promote the formation of new blood vessels.
- Surgery: as a last resort, part of the tendon is cut to reduce tension on the fascia.
Achilles tendinitis:
- Physiotherapy: stretching and strengthening exercises.
- Orthoses: wedges or customised insoles relieve tendon tension.
- Tendon repair surgery.
Retrocalcaneal bursitis:
- Manual physiotherapy and strengthening exercises.
- Physiotherapy with equipment: ultrasound or electrolysis is applied to reach deeper tissues and reduce inflammation.
- Corticosteroid injections.
- Bursectomy: removal of the bursa in a surgical procedure.
Calcaneal spur:
- Orthopaedic insoles or silicone heel cups to cushion impacts.
- Physiotherapy to relax the muscles and stretch the plantar fascia.
- Shock waves to promote tissue regeneration.
- Corticosteroid injection to reduce inflammation.
- When the other treatments do not work adequately, surgery to remove the spur.
Baxter’s syndrome:
- Orthopaedic insoles to correct biomechanical alterations.
- Stretching exercises.
- Shock waves to reduce inflammation and pain.
- Corticosteroid injection.
- Surgery to releasethe nerve.
Plantar papilloma:
- Cryotherapy: liquid nitrogen is used to freeze the wart so that it detaches from the skin.
- Laser treatment to destroy the damaged tissue.
- Surgery to remove the wart.
Achilles tendon rupture: surgery to repair the damage to the tendon.
Fractures:immobilisation with a cast or removable orthopaedic devices, depending on the severity of the injury.