Heel pain is one of the most common musculoskeletal conditions that podiatrists treat and it is fair to say that even if you are lucky enough not to have experienced it yourself, chances are you have a friend or relative who has told you all about a debilitating pain in their heel that is ruining their day! There are many causes of plantar heel pain, which is a generic term given to pain on the underside of the heel, but below we will break down the most common cause, which is Plantar Fasciopathy.
What is Plantar Fasciopathy?
Plantar Fasciopathy is the name that has replaced Plantar Fasciitis, which was the term given to the condition when it was believed to be inflammatory in nature and therefore the suffix -itis was used. However research into the condition over recent years has found there is typically little to no inflammation or inflammatory markers within the plantar fascia and that it tends to behave more in line with a tendinopathy. This has lead to changes in the way we treat and manage the condition, but more about that later.
Common presenting symptoms:
When talking about Plantar Fasciopathy, we usually see a very familiar set of symptoms and circumstances. These mayinclude:
– pain on the plantar (under) surface of the heel- sometimes around the middle side of the heel
- pain in the arch region
- first step pain in the morning and when first standing after prolonged sitting
- pain typically settling after a few steps in the morning and increasing again with activity throughout the day.
What causes it:
Plantar Fasciopathy arises when the load through the plantar fascia is greater than the tissue’s ability to repair and recover. There can be many reasons why the load may increase, but some common factors include:
- an increase in the volume of exercise (two walks a day rather than one or increasing the number of training sessions for a particular sport)
- new activity (for example running for the first time)
- foot posture
- tight calf muscles
- poor footwear or old footwear that needs replacing
- poor pelvic stability/gluteal weakness
- weight gain/obesity.
Treating Plantar Fasciopathy:
Given that the cause is due to increased load through the plantar fascia, our treatment needs to focus on reducing this load to a level where by the plantar fascia can start to repair, but also needs to focus on increasing the capacity of the tissue moving forward.
Some of the common initial treatment methods are:
- strapping the foot to offload the plantar fascia
- calf stretching
- activity modification
- replacing footwear to ensure adequate stability
- rolling a tennis/spiky ball under the arch
Another important element of treatment is increasing the strength of the plantar fascia, almost like a long term insurance policy to prevent the recurrence of the issue down the track. Working on gluteal strengthening to improve your pelvic stability and also calf raises with the toes elevated on a towel to load up the plantar fascia and increase it’s tolerance to load, are both key components of treatment.
Plantar Fasciopathy definitely responds more effectively to treatment the earlier you address the pain, but if the pain has been around for many months, or in some cases many years, all is not lost and there may be a need for longer term options such as orthotics to provide longer term offloading of the tissue.
A quick word on imaging:
People with heel pain often become caught up in whether there may be a heel spur present and quite often seek x-ray imaging to confirm this. The fact is that whether there is a heel spur present or not, the treatment does not change. Over the years I have seen people with heel pain both with and without heel spurs and quite often they may have a heel spur in the non symptomatic foot.
The typical view of imaging in the podiatry, is that it is only necessary if the information found may change the course of treatment. So in terms of cases that present with very typical Plantar Fasciopathy symptoms, it is not something we would usually pursue. However if the pain is not responding to regular treatment measures, then this is a time to look to x-ray or ultrasound to see what else may be happening.
Other causes of heel pain:
Whilst Plantar Fasciopathy is the most common cause of heel pain, it is important to be aware that there can be other lesser known causes. This includes calcaneal stress fracture, fad pad inflammation or atrophy, calcaneal bone oedema or even due to an underlying systemic condition such as rheumatoid arthritis, gout or fibromyalgia. These are certainly much less common, but should there be no change to the pain with the treatment measures outlined above, then further investigation is required to determine if one of these conditions may be the cause.
Wrapping it all up:
The fundamental things to remember with heel pain is to treat it as early as possible to ensure a swift and pain free return to activity, but as mentioned above, if the pain has been present for months or years, all is not lost and a treatment program can certainly be tailored to move you towards recovery. Visiting a podiatrist to assess the contributing factors such as foot posture, activity levels, footwear and strength is an important component in quickly isolating the cause and moving towards resolution of the pain.