Mark Reed, DPM DABFAS

714-528-3668

Below the Heel Pain

PLANTAR FASCIITIS, CALCANEAL BURSITIS, SEVER'S DISEASE, SCIATICA REFERRED PAIN AND TARSAL TUNNEL SYNDROME

When foot pain and tenderness occurs in the bottom of the heel, most commonly the podiatry problem is related to an inflammation of the Plantar Fascia.  This discussion will focus on pain to the bottom of the heel and not to the ankle joint or the rear of the heel.
Besides plantar fasciitis, there are a few other conditions that need to be considered in diagnosing heel pain. These conditions include ruling out the presence of a calcaneal stress fracture, an entrapment of the nerve going to the inside or outside of the heel, radiating pain from sciatica from the hip or back and / or an nerve compression in the ankle called tarsal tunnel syndrome.  In teenagers, there is also a common condition with the growth plate causing bottom of the heel pain called Sever's Disease.

PLANTAR FASCIITIS AND HEEL SPUR SYNDROME

The Plantar Fascia is a strong inelastic band of fibers which begins at the heel and
extend into the toes.  When the Plantar Fascia becomes inflamed, the pain is mainly in the arch of the foot.  Medically, this condition is called Plantar Fasciitis.  When the Plantar fascia becomes inflamed and the pain is mainly in the heel, medically this condition is called Heel Spur Syndrome.  The usual cause of Plantar Fasciitis or Heel Spur Syndrome is excessive pulling on the Plantar Fascia from either excessive exercise, poor fitting shoe gear or poor foot alignment while running or standing.
Plantar fascia pain usually begins as a mild pain to either the arch area or the bottom of the heel.  The discomfort in the foot is usually most noticeable with the first step in the morning and seems to improve after a period of "warming up" the foot.  If untreated, the pain can become intolerable.  In some individuals, actual heel spur formation can occur at the site of where the Plantar Fascia is connected to the heel.  The heel spur is actually a ridge of bone that forms to reinforce where the plantar fascia attaches to the heel.  The ridge of bone is not the main problem unless a small nerve under the plantar fascia becomes entrapped.  The Plantar Fascia is the primary pathological anatomical structure that is causing pain to the patient.  If the pulling on the plantar fascia is corrected, it is important to understand that the heel spur that formed from the pulling is not important and does not need to be removed with surgery.  There are many doctors who get the heel spur confused and tell the patient that a heel spur is causing their pain when in fact it is the injury to the Plantar Fascia that needs to be medically treated.
Home care for either Plantar Fasciitis or Heel Spur Syndrome primarily consists of resting the foot, applying ice to the affected area three times a day for ten minutes, and using a supportive athletic shoe for most activities during the day. Sometimes stretching the arch by rolling the foot on an empty soft drink bottle in the morning helps relieve some of the pain. In addition, using a heel pad or a padded insole can be helpful in relieving the pain in the heel. If these home treatments do not relieve the pain, treatment by a foot and ankle specialist is warranted.
In treating heel and arch related foot pain, an X-ray of the foot is usually obtained to rule out a rare heel stress fracture and to document if a heel spur has occurred. Once a diagnosis is made of either Heel Spur Syndrome or Plantar Fasciitis, initial treatment usually consists of anti-inflammatory medications, the use of a night splint and functional foot orthotics. A night splint is required to hold the foot in the correct position during sleep to allow the Plantar Fascia to heal in the correct length as when standing and walking. A functional orthotic is required to control the amount of pulling that is occurring in the Plantar Fascia with weight bearing by controlling the position of the foot in the shoe. In some cases a cortisone shot is placed into the area of the origin of the Plantar Fascia to rapidly reduce the amount of pain that is present. However, in many cases, a cortisone shot results in only a couple of weeks of pain relief and the problem is back with the same intensity of pain or even worse than before the cortisone shot.
Surgical intervention of either Heel Spur Syndrome or Plantar Fasciitis is rarely indicated and should be considered only after use of the night splint and / or the functional foot orthotic has failed. The surgery is warranted if the Plantar Fascia band has become too short due to repeated injury to where the Plantar Fascia or the nerve under the Plantar Fascia has become entrapped. An experienced surgeon should only performed this type of surgery. The primary purpose of the operation is to lengthen the Plantar Fascia and remove the excessive bone formation where the Plantar Fascia is anchored to the heel bone. In many surgical cases, there is also an adventitious bursa that must be excised. Over the last five years, a procedure has been advertised for heel spur surgery using a scope with claims to have a better recovery time and less associated pain compared to traditional procedures. However, to date this procedure has not demonstrated any better advancement over traditional methods and has actually been associated with a higher rate of complications than traditional procedures.
Because Heel Spur Syndrome and Plantar Fasciitis is an inflammatory condition, early intervention is essential to stop the repeated scarring of the Plantar Fascia that can lead to irreversible shortening of the Plantar Fascia, nerve entrapment and the formation of a painful adventitious bursa.

CALCANEAL BURSA AND CORTISONE INJECTIONS

A calcaneal adventitious bursa is an enlargement of inflammatory tissue under the heel bone that feels like a nail going into the bone when standing on a hard surface. This condition is most commonly associated with long standing plantar fasciitis or heel spur syndrome where swelling and inflammation leads to the additional problem of the formation of the calcaneal adventitious bursa. Treatment usually involves an injection of cortisone directly into the bursa to reduce the size of the bursa and the associated pain to the heel bone. Because adventitious bursa formation is associated plantar fasciitis or heel spur syndrome, there are some patients that will need a cortisone injection to the bursa but not to the where the plantar fascia is connected to the heel bone. The concept here is that the plantar fascia that has been injured causing the plantar fasciitis or heel spur syndrome must scar in and heel to stop hurting and if cortisone is placed in this area early in the healing process, then the plantar fascia will not heal. The heel will feel better for two to four weeks but when the cortisone is subsequently absorbed by the body the heel pain will return because the injury to the plantar fascia was never resolved. For many patients who have had only cortisone injections treat their plantar fasciitis or heel spur syndrome and not to treat an adventitious bursa, the experience has been frustrating with no resolution to their plantar fasciitis or heel spur syndrome.

SEVER'S DISEASE OR CALCANEAL APOPHYSITIS

Sever's Disease is a common condition in early teenagers due to the blood supply
to the growing plate is not keeping up with the demands of growing.  The pain that occurs is a deep ache or soreness to the corner of the heel and tends to be aggravated with running activities.  The pain can be debilitating for a youth.  Treatment consists of ultrasound to the heels with message therapy two to three times a week for two to three weeks, decreasing athletic activities for two weeks and the use of custom made foot orthotics to help improve foot biomechanics.  Prior to treatment, x-rays should be obtained to rule out any problem with the growth plates in the foot and ankle.

CALCANEAL STRESS FRACTURE

Calcaneal stress fractures would present with a sharp pain to the heel that would increase with weight bearing but would not be any more painful with the first step in the morning such as is seen with plantar fasciitis.  X-rays are the standard test that is performed but a CT may be indicated do to the square shape of the calcaneus.  Treatment is non-weight bearing in a cast for at least 6 to 8 week depending on the severity of the stress fracture.  Early treatment is essential to prevent a further fracture of the calcaneus.

CALCANEAL NERVE ENTRAPMENT

There is a nerve called the Medial Recurrent Calcaneal Nerve off the Posterior Tibial Nerve from the ankle that goes under the inside of the heel.  This nerve can become entrapped and cause a burning pain to the underside of the heel.  The pain can mimic plantar fasciitis but does not increase with the first step in the morning.  The symptoms for this nerve entrapment would include a burning type pain, tends to be worse at night and has a point of maximal tenderness where the nerve is entrapped.  Diagnosis is made by numbing the point of maximal tenderness and determining if the pain disappears while the local anesthetic is working.  Treatment would include removing whatever is pressurizing the nerve such as changing shoes, trying the use of a pad over the area to reduce the pressure on the nerve, cortisone injections to calm down the inflamed nerve and /or surgical decompression if necessary.  There is also a rare entrapment of the nerve to the under side of the heel from the outside of the foot.  This nerve is called the Lateral Recurrent Calcaneal Nerve from the Sural Nerve in that the pain would radiate toward the outside of the foot.  Entrapment of the Lateral Recurrent Calcaneal Nerve is associated with a large calcaneal spur at the beginning of the Plantar Fascia on the heel bone.

SCIATICA REFERRED PAIN

The sciatic nerve is a nerve that is prone to being entrapped as the nerve turns and
moves down the leg.   There is a condition where the nerve becomes compressed as it passes under a muscle in the hip that results in the nerve sending pain messages to the brain that in many cases are phantom pains.  Phantom pains from sciatica will give the impression that the only place where pain is occurring is in the heels of the feet and there is no pain in the knee or lower leg area.  Sciatica is associated with a feeling of numbness in the heel and may be associated with a burning pain at night.  Getting treatment for the Sciatica in many cases is the cure for the heel pain.  Sometimes a herniated disk is the cause of the heel pain but usually there is back pain and muscle spasms from the disk pressing on the root that is exiting the spine.   Sciatica in many cases is successfully treated with anti-inflammatory medications such as Celebrex and physical therapy including manipulation of the back and the Illiopsoas muscle that is usually the muscle that is compressing the Sciatic nerve.  Prior to any physical therapy, evaluation is essential to insure that the herniation of the disk will not increase with physical therapy. 

TARSAL TUNNEL SYNDROME

Tarsal Tunnel Syndrome is a rare condition in the ankle that is commonly
misdiagnosed because the symptoms can mimic different conditions in the foot.  The nerve that is being compressed in the tarsal tunnel innervates the entire bottom of the foot and all of the muscles in the bottom of the foot.  Because the Posterior Tibial Nerve is such an important nerve and because it innervates most of the foot, when the nerve becomes injured from excessive pressure in the tarsal tunnel, the nerve can give off many different types of pains.  The key to making the correct diagnosis is obtaining a good history of the patient and having the experience to suspect that the tarsal tunnel is the problem to the patient's pain.  Tarsal tunnel syndrome is usually associated with a radiation of pain either up or down the leg or foot.  Diagnosis is based on clinical judgment and performing a local anesthetic block to determine if all of the pain is resolved with numbing of the tarsal tunnel.  Nerve conduction studies are performed but only are positive after the Posterior Tibial Nerve has lost half of its function.  Diagnosis of Tarsal Tunnel Syndrome should be made prior to and not after the nerve has lost half of its function. 
Treatment for Tarsal Tunnel Syndrome consists of resting the nerve by either using a night splint or a cast for a month.  In addition, cortisone injection therapy, anti-inflammatory medicines and physical therapy can all be used singularly or in combination.  When the pain is severe and treatment is failing, it is the judgment of the patient and the doctor to go forth with decompression surgery.  The surgery involves releasing the strong fascia sheets overlying the nerve and carefully freeing up the nerve along the entire distance where the Posterior Tibial Nerve moves from the back of the ankle to the bottom of the foot.  Depending on how the nerve is entrapped, the surgeon will determine how extensive of a decompression is required.  The prognosis after surgery is excellent with typically a couple of months will be required to allow the nerve to heal completely.  
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