Heel Disorders

Heel Pain in Adults
By Robert H. Sheinberg, D.P.M., F.A.C.F.A.S., D.A.B.F.A.S.

The most common cause of pain in the heel is inflammation of the ligament that attaches the heel bone to the ball of the foot. This ligament may become inflamed by excessive pulling and stress that may take place in the ligament. Pain and inflammation where the ligament is most firmly attached to the heel bone, then develops.

Commonly Asked Questions About Heel Pain In Adults:

What causes the inflammation and pain?

An injury to this ligament at its main point of attachment to the heel can be caused by many things. Many foot types may predispose a person to this injury. People who are excessively flatfooted have weak arches causing excessive pulling of the ligament in the heel. People with high arches have a lot of tension on the arch, causing the arch to become inflamed. A recent weight gain or an increased activity level may begin an inflammatory condition in the heel. Poor shoe gear or walking barefoot for prolonged periods of time do not allow any support to the foot, causing excessive pressure on the ligament in the arch. Tight leg muscles may cause or aggravate the condition.

Why is the pain worse when I get out of bed in the morning or when I get up after sitting for a short period of time?

While in bed or sitting the arch ligaments and muscles relax and contract (shorten). When they contract they are in a restful state. When the person puts weight on their foot the arch has to stretch out, causing a lot of pulling on the ligament, and pain at the connection of the ligament to the bone develops.

How successful is treatment?

Conservative treatment for painful heel conditions are successful in more than 98% of the cases. It is rare for people to continue to suffer from disabling heel pain. It is important for the treatment plan to be followed. Compliance with regards to proper shoe gear and stretching exercises is important to adhere to.

Treatment Plan

A combination of treatments is necessary to eliminate heel pain in the shortest time possible. The treatment includes:

  1. Mechanical support.
    Mechanical support is necessary to decrease the pulling of the ligament (plantar fascia) on the heel.
    1. Foot strapping – A good temporary means to decrease the pulling of the ligament on the heel is taping the heel and arch.
    2. Orthotics – Custom molded orthotics are the only effective permanent way to avoid reinjuring the heel.
    3. Shoes – The correct choice of shoes alone can be very helpful in lessening the discomfort in the heel.
  2. Anti-inflammatories.
    1. Oral anti-inflammatory medication – Medications like Motrin and Aleve are very helpful in reducing the inflammation.
    2. Cortisone injections – A small amount of cortisone with a local anesthetic from the side of the heel into the inflamed ligament may be helpful in reducing the inflammation.
  3. Bracing.
    Bracing may be necessary to decrease the pulling of the ligament in the arch, especially when every step causes pain in the heel region.
    1. Boot – A walking boot allows the patient to resume walking without putting pressure on the heel. This causes an almost immediate lessening of the pain in the heel, thus allowing healing to take place.
    2. Night splint – Night splinting is often necessary to increase flexibility of the muscle behind the leg and to the ligaments and muscles in the arch region. These are worn at night to allow the patient to wake up in the morning and be free of that immediate pain they experience when getting out of bed in the morning.
  4. Physical Therapy.
    A number of modalities may be necessary to reduce the inflammation that is causing heel pain. These may include ultrasound, electrical stimulation, deep massage and laser or light therapy.
  5. Stretching.
    Stretching tight muscles is very important in achieving long lasting correction of this problem. Once the tight muscles in the back and lower extremity are identified an exercise program to restore their proper length will be helpful in not only keeping this condition away but also preventing injuries to other parts of the extremity and spine.
  6. Casts.
    Casting the extremity can be indispensable in healing a chronically inflamed heel and ligament. While placing the foot in a cast the foot portion is correctly molded to the foot to prevent stress on the plantar fascia. At the same time the calf muscle is stretched to lessen some of the pulling on the heel. Casting has proven to be extremely effective for this problem. Casts may be necessary for 2-6 weeks. Surgery should not be contemplated until casting is performed first.
  7. Shockwave Therapy.
    Shockwave therapy may be needed to heal the injured area if all forms of conservative treatment have failed. It is a nonsurgical method used to lessen the affects of scar tissue in the healed ligament. The success rate is approximately 70%.
  8. Surgery (Endoscopic Plantar Fasciotomy).
    Surgery is rarely necessary but if needed is done endoscopically with two small incisions on an outpatient basis. Postoperatively the patient is temporarily placed in a walking cast for 2-4 weeks. Long-term results are excellent.