Heel pain is a common presenting symptom to primary care physicians and has an extensive differential diagnosis. Many reasons can cause heel pain; however, the differential diagnosis of heel pain is very important. Osteoarthritis, infection, trauma, tumor, nerve entrapment, lumbar radiculopathy, Achilles tendinopathy, heel pad syndrome, neuroma, and plantar fasciitis are the most common reasons for heel pain; however, a mechanical etiology is the most common cause. A thorough patient history, physical examination of the foot and ankle, and appropriate imaging studies are essential in diagnosis process and initiating proper treatment (2). The history should provide information about the onset and characteristics of the pain, alleviating or exacerbating factors, changes in activity, and other related conditions.
The most common mechanical cause of heel pain is plantar fasciitis, which leads to medial plantar heel pain, especially with the first weight-bearing steps in the morning or after rest.Plantar fasciitis is causing heel pain in more than 2 million people every year(1).
The primary symptom of plantar fasciitis is a throbbing pain in medial plantar aspect of heel, especially first steps in the morning raising from sleep or walking following a period of rest. The pain often decreases after further ambulation, but can return with continued weight bearing. Palpation of the medial heals and along the bottom of foot typically causes sharp, stabbing pain. Heel spurs are present in approximately 50% of patients with plantar fasciitis, but researches are showing that they do not correlate well with symptoms and can also be found in persons without plantar fasciitis(3).
Neuropathic heel pain
Heel pain that is including burning, tingling, or numbness may suggest a neuropathic etiology, either with nerve entrapment or the development of a neuroma. Nerve entrapment can be caused by overuse, trauma, or injury from a previous surgery (4,5). Neuropathic plantar heel pain usually involves branches of the posterior tibial nerve, the lateral plantar nerve, or the nerve to the little toe (1). Lumbar radiculopathy at the L4-S2 levels should also be considered regardless of the presence of associated low back pain. Neuropathic heel pain is usually unilateral, and underlying systemic disease should be ruled out in patients with bilateral pain.
Heel pad syndrome
This syndrome is typically caused by inflammation but can also be due to damage to or atrophy of the heel pad. Pain from heel pad syndrome is described as a deep, bruise-like pain, usually in the middle of the heel, and can be reproduced with firm palpation. Pain may be elicited by walking barefoot, on hard surfaces, or for prolonged periods of standing (6). Decreased heel pad elasticity from aging, prior corticosteroid injections, or increased body weight may also be the reason (1,6). Rest, ice, taping, and the use of anti-inflammatory or analgesic medications, heel cups, and proper footwear are treatments that are aimed to decrease pain.
Achilies Tendinopathy (Posterior Heel Pain)
The Achilles tendon is formed from the blending of the calf muscles, and it inserts into the heel bone (7). Excessive mechanical load such as increased running can cause tendinopathy that leads to posterior heel pain. The pain associated with Achilles tendinopathy is achy, occasionally sharp, and worsens with increased activity or pressure to the area (7, 8).
Despite plantar fasciitis being a frequently occurring musculoskeletal condition, only close to % 8 of patients was evaluated by physical therapists and was primarily seen in private or hospital-based outpatient clinics. If you have heel pain, evidence suggests that physical therapy will help you recover faster and cost you less than if you do not receive this treatment. The 2017 guidelines from American Association of Physical Therapy (APTA) present evidence that strongly suggests a combination of manual therapy and rehabilitative exercises to help patients to reduce their pain.
As a profession, there is a substantial need for physical therapists to engage and educate the public, primary care providers, sports medicine physicians, and orthopedic surgeons on the scope of physical therapist practice and value added in the care of patients with PF.
- Tu P, Bytomski JR. Diagnosis of heel pain. Am Fam Physician. 2011;84(8):909-916.
- Papaliodis DN, Vanushkina MA, Richardson NG, DiPreta JA. The foot and ankle examination. Med Clin North Am. 2014;98(2):181-204.
- Goff JD, Crawford R. Diagnosis and treatment of plantar fasciitis. Am Fam Physician. 2011;84(6):676-682.
- Ferkel E, Davis WH, Ellington JK. Entrapment neuropathies of the foot and ankle. Clin Sports Med. 2015;34(4):791-801.
- Peck E, Finnoff JT, Smith J. Neuropathies in runners. Clin Sports Med. 2010;29(3):437-457.
- Lin CY, Lin CC, Chou YC, Chen PY, Wang CL. Heel pad stiffness in plantar heel pain by shear wave elastography. Ultrasound Med Biol. 2015;41(11):2890-2898.
- Li HY, Hua YH. Achilles tendinopathy: current concepts about the basic science and clinical treatments. Biomed Res Int. 2016;2016:6492597.
- Thomas JL, Christensen JC, Kravitz SR, et al.; American College of Foot and Ankle Surgeons heel pain committee. The diagnosis and treatment of heel pain: a clinical practice guideline-revision 2010. J Foot Ankle Surg. 2010;49(3 suppl):S1-S19.