Causes of Heel Pain

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Plantar Fasciitis

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Plantar fasciitis is the inflammation of the plantar fascia which causes pain in the bottom of the heel. The plantar fascia is a thick, web like fascial structure ( band) that connects your heel to the front of your foot. It supports the arch of your foot and helps you walk.

Plantar fasciitis is one of the most common orthopedic complaints. The plantar fascia experience a lot of wear and tear in your daily life. Normally, this fascia act as shock absorbers, supporting the arch of the foot. Excessive pressure on your feet can damage or tear the plantar fascia and it becomes inflamed eventually the inflammation causes heel pain and stiffness.

EPIDEMIOLOGY AND CAUSES

10% of people in the United States may present with heel pain over the course of their lives, with 83% of these patients being active working adults between the ages of 25 and 65 years old. Two large national data sets of ambulatory care data from the Centers for Disease Control and Prevention’s National Center for Health Statistics found that plantar fasciitis accounts for an average of one million patient visits per year to medical doctors.

A recent survey of members of the American Podiatric Medical Association revealed that plantar fasciitis/heel pain was the most prevalent condition being treated in podiatric clinics. According to the current literature, prevalence rates of plantar fasciitis among a population of runners have been shown to be between 4% and 22%.

Increased body weight10 and increased body mass index (BMI) have been shown to be significant risk factors for plantar fasciitis, with a BMI of more than 30 kg/m2 having an odds ratio of 5.6 compared with a BMI of less than 25 kg/m2.

CAUSES

Plantar fasciitis is most commonly caused by repetitive strain injury to the ligament of the sole of the foot. Such strain injury can be from excessive running or walking, inadequate foot wear, and jumping injury from landing. Plantar fasciitis can also be caused by certain diseases, including Reactive arthritis and Ankylosing Spondylitis

RISK FACTORS INCLUDE

Age.

Plantar fasciitis is most common between the ages of 40 and 60.

Certain types of exercise.

Activities that place a lot of stress on your heel and attached tissue — such as long-distance running, ballistic jumping activities etc can cause plantar fasciitis.

Foot mechanics.

Being flat-footed, having a high arch or even having an abnormal pattern of walking can put additional stress on the plantar fascia.

Obesity.

Excess pounds put extra stress on your plantar fascia.

Occupations that keep you on your feet.

Factory workers, teachers and others who spend most of their work hours walking or standing on hard surfaces can damage their plantar fascia.

CLINICAL FEATURES AND PATHOPHYSIOLOGY

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Plantar fasciitis typically causes a stabbing pain in the bottom of your foot near the heel. The pain is usually the worst with the first few steps after awakening, although it can also be triggered by long periods of standing or rising from sitting. The pain is usually worse after exercise, not during it.

Heel pain with first steps in the morning or after long periods of non-weight bearing.

Tenderness to the anterior medial heel.

Limited dorsiflexion and tight achilles tendon.

A limp may be present or may have a preference to toe walking.

Pain is usually worse when barefoot on hard surfaces and with stair climbing.

PATHOPHYSIOLOGY

Biomechanical dysfunction of the foot is the most common etiology of plantar fasciitis, however infectious, neoplastic, arthritic, neurologic, traumatic, and other systemic conditions can prove causative. The pathology is traditionally believed to be secondary to the development of microtrauma (microtears), with resulting damage at the calcaneal-fascial interface secondary to repetitive stressing of the arch with weight bearing.

Excessive stretching of the plantar fascia can result in microtrauma of this structure either along its course or where it inserts onto the medial calcaneal tuberosity. This microtrauma, if repetitive, can result in chronic degeneration of the plantar fascia fibers. The loading of the degenerative and healing tissue at the plantar fascia may cause significant plantar pain, particularly with the first few steps after sleep or other periods of inactivity.

PHYSICAL EXAMINATION AND DIAGNOSIS

Physical evaluation of plantar fasciitis is given below ( video link).

https://youtu.be/sLzhrMPKr9k

The pain of plantar fasciitis can usually be reproduced by palpating the plantar-medial calcaneal tubercle at the site of plantar fascial insertion to the heel bone.

In more severe cases, pain may be reproduced by palpation over the proximal portion of the plantar fascia.

A tight Achilles tendon is commonly a secondary finding and usually contributes to the pathology, ankle dorsiflexion may be limited as a result.

Other findings may include various deformities, skin changes, and flat-foot or pes planus foot type, overpronation, pes cavus or high-arched foot type, leg-length discrepancy, excessive lateral tibial torsion, and excessive femoral anteversion.

Other maneuvers that may reproduce the pain of plantar fasciitis include passive dorsiflexion of the toes, which is sometimes called the Windlass test, and having the patient stand on the tiptoes and toe-walk. In a study by De Garceau et al, having the patient bear weight during the windlass test increased the sensitivity of the test from 13.6% to 31.8%.

WINDLASS TEST

https://youtu.be/GasNbVVD_4w

The Foot and Ankle Ability Measure is a good outcome measure to give to patients that are diagnosed with plantar fasciitis.

Ultrasound can help diagnose and confirm plantar fasciitis through the measurement of the plantar fascia thickness.

PHYSIOTHERAPY MANAGEMENT

The most common treatments include stretching of the gastrocnemius/soleus/plantar fascia, orthotics, ultrasound, iontophoresis, night splints and joint mobilization or manipulation .

Stretching of plantar fascia

https://youtu.be/uR4dMC92mGg

Manipulation for plantar fasciitis

https://youtu.be/1IBB0OFWWgk

Taping for plantar fasciitis

https://youtu.be/MvY4rcF1ZXU

Rehabilitation Exercise for plantar fasciitis

https://youtu.be/WjkkdWPm_7c

Achilles Tendonitis

Inflammation of the Achilles tendon is called Achilles tendonitis.

Achilles tendinitis is an overuse injury of the Achilles tendon, the band of tissue that connects calf muscles at the back of the lower leg to your heel bone (calcaneus) .

Most commonly occurs in runners who have suddenly increased the intensity or duration of their runs or drills . It’s also common in middle aged group who play sports, such as tennis or basketball etc

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EPIDEMIOLOGY AND CAUSES

Achilles tendinopathy affects competitive and recreational athletes as well as non-sporting people . The incidence of Achilles tendon rupture in the general population is approximately 5 to 10 per 100,000, but may be higher in some regions and populations, and is increasing overall . Over 80 percent of ruptures occur during recreational sports. Approximately 10 percent of patients who sustain an Achilles tendon rupture had pre existing Achilles tendon problems.

Data suggest that competitive athletes have a lifetime incidence of Achilles tendinopathy of 24 percent, with 18 percent sustained by athletes younger than 45 years of age . Tendon rupture occurs in 8.3 percent of competitive athletes.

CAUSES

Over training 

A sudden change in training surface e.g. grass to tarred road surface

Flat feet

High foot arch with tight Achilles tendon

Tight hamstring and calf muscles

Long term use of High Heels

Poor footwear

Hill running.

Poor eccentric strength

CLINICAL FEATURES AND PATHOPHYSIOLOGY

Morning pain is a hallmark symptom because the achilles tendon must tolerate full range of movement including stretch immediately after getting up in the morning.

Pain associated with Achilles tendinitis typically begins as a mild ache in the back of the leg or above the heel after running or other sports activity.

Episodes of excruciating pain may occur after prolonged running, stair climbing or sprinting.

Tenderness or stiffness, especially in the morning, which usually improves with activity.

Loss of strength of Achilles tendon.

The area may be tender, red, warm, or swollen if there is inflammation.

PATHOPHYSIOLOGY

The Achilles tendon is the extension of the calf muscle and attaches to the heel bone. It causes the foot plantar flexion

The Achilles tendon does not have good blood supply or cell activity, so this injury can be slow to heal. The tendon receives nutrients from the tendon sheath . When an injury occurs to the tendon, cells from surrounding structures migrate into the tendon to assist in repair. Some of these cells come from blood vessels that enter the tendon to provide direct blood flow to increase healing.

PHYSICAL EXAMINATION AND DIAGNOSIS

Royal London Hospital Test

https://youtu.be/nM3yu_TR4H8

Positive Arc Sign

https://youtu.be/zhP0CAsQr7U

Observation, brief history, hallmark signs and symptoms should help in making diagnosis.

Range of motion testing, strength and flexibility are often limited on the side of the tendinopathy .

Palpation tends to elicit well-localized tenderness that is similar in quality and location to the pain experienced during activity.

Physical examinations of the Achilles tendon often reveal palpable nodules and thickening.

Anatomic deformities such as heel varus, excessive pes planus or foot pronation are often associated with this problem.

Physical performance measures includes hip hop and heel raise endurance tests, measurement of ankle dorsiflexion range of motion, sub talar joint range of motion, plantar flexion strength and endurance, static arch height, forefoot alignment, and pain with palpation.

Imaging studies are generally not necessary for achilles tendonitis diagnosis. However Ultrasound is the imaging modality of first choice as it provides a clear indication of the tendons width, changes of water content within the tendon and collagen integrity, as well as bursal swelling.  An MRI may be indicated if the diagnosis is unclear or if symptoms are atypical. The MRI may show an increased signal within the Achilles Tendon.

PHYSIOTHERAPY MANAGEMENT

Optimise biomechanics

Individuals presenting with achilles tendinopathy should have a full biomechanical assessment. Clinically consideration suggests using orthotics in chronic stage and using taping first, in the acute stage .

Controlled tendon loading

Low Intensity Activities should be encouraged so that the burden on the tendon decreases however complete immobilisation should be avoided, since it can cause atrophy. Eccentric exercise in particular is supported although some protocols use both concentric and eccentric exercise.

It has been shown that strength training, that is stimulated externally and is linked to a functional tasks, not only helps reduce tendon pain but modulate excitatory and inhibitory control of muscle, and thus potentially tendon load. A popular and effective option is the eccentric strength training. In the past decade eccentric exercises have been shown to have positive effects of Achilles tendinopathy and became the main non surgical choice of treatment for achilles tendinopathy.

ACHILLES TENDONITIS REHABILITATION EXERCISE

TOWEL STRETCH

STANDING CALF STRETCH

STANDING SOLEUS STRETCH

HEEL RAISES

PLANTAR FASCIA STRETCH

STATIC AND DYNAMIC BALANCE EXERCISES

Click below for details

https://youtu.be/qqAlt1k_-gs

In combination with approaches to optimise biomechanics and prescribe exercise therapy, adjunct therapies may be used, they are used more for symptom management.

Manual Therapy

It includes soft tissue manipulation techniques such as effleurage massage, Graston technique, IASTM.

Follow the link below for manual therapy of Achilles Tendonitis

Soft tissue Manipulation for Achilles Tendonitis

https://youtu.be/tdfrn8gNZTY

Graston technique

https://youtu.be/9hn8jPv2ofM

IASTM for Achilles Tendonitis

https://youtu.be/JpdpLMlgUbg

Electrotherapy Modalities

The use of Extracorporeal Shock Wave Therapy in the chronic stage is administered but has conflicting evidence. There is evidence suggesting that the outcomes are dependent upon the dosage of the shock wave energy. There is also evidence that the use of anaesthetic required in high energy protocols decreases the effectiveness of ESWT. Therefore, using low energy ESWT protocols without the need for anaesthetic are recommended as more practical, more tolerable, and less expensive with equivalent results. Low energy ESWT protocols can apply to both focused and radial ESWT.

Iontophoresis

The use of iontophoresis using dexamethasone in the acute stage is advisable but not in chronic stage .

Taping

Antipronation taping is often applied.  Clinicians should not use therapeutic elastic tape to reduce pain or improve functional performance in patients with Achilles tendinopathy. Clinicians may use rigid taping to decrease strain on the Achilles tendon and/or alter foot posture in patients with Achilles tendinopathy.

Night splints

It is advisable to use night splints and braces in acute stage but has low benefit in chronic stage and should nit be used in conjunction with exercise regime.

Dry Needling

Clinicians may use combined therapy of dry needling with injection under ultrasound guidance and eccentric exercise to decrease pain for individuals with symptoms greater than 3 months and increased tendon thickness.