The Various Aetiologies of Heel Pain

A detailed assessment of patient history, physical examination of the lower extremity and radiographic adjuncts are crucial in gaining a better understanding of the true pathophysiology behind heel pain.

Diagnosing heel disorders can be challenging due to anatomic complexity and a plethora of aetiologies which include but are not limited to neurologic, rheumatologic or traumatic factors. 

Although plantar fasciitis is often cited as the most common cause of plantar heel pain, it is beneficial to acknowledge some of the differential diagnoses of the condition to devise appropriate conservative or operative treatment modalities.

Neurologic heel pain is caused by entrapment or irritation of the nerves that innervate the heel region – lateral plantar, medial plantar, posterior tibial or medial calcaneal; this pain is characterised as sharp, burning or radiating.

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Post-static dyskinesia occurs frequently in patients experiencing plantar heel pain of neural origin; this is caused by fluid retention around the affected nerve during a period of rest.

Sensory disturbances in the form of tingling or numbness around the medial and plantar aspects of the heel, are also a secondary effect of nerve entrapment.

Various systemic diseases such as rheumatoid arthritis, psoriatic arthritis or Reiter’s disease can be responsible for subcalcaneal heel pain; these patients are likely to present other joint symptoms and would require careful radiographic evaluation to detect erosions or proliferative changes that are associated with any of the diseases mentioned.

Stress fractures to the calcaneus are commonly observed in athletes participating in sports that entail jumping or running activities because of the repetitive load to the heel; this pain is aggravated upon posterosuperior compression of the calcaneus with warmth and swelling observed in the region.

Conditions such as diabetes or any other abnormalities of the endocrine system can lead to the possibility of neuropathic fractures, which should be considered at the time of diagnosis.

Plantar heel pain is most often responsive to conservative measures such as physical therapy and customised orthotics because of the optimisation of muscle functioning in addition to the positioning of the foot in a biomechanically efficient manner.

This reduces stress to the static and dynamic soft tissues of the lower limbs whilst promoting the healthy alignment of the musculoskeletal system, allowing the affected region to heal and helping prevent recurrences.

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References:

1. Rosenbaum J. A., DiPreta J., Misener D. (2013) Plantar heel pain. Medical Clinics of North America: December 2013, http://dx.doi.org/10.1016/j.mcna.2013.10.009
2. Thomas L. J., Christensen C. J., Kravitz R. S., Mendicino W. R., Schuberth M. J., Vanore V. J., Weil Sr. S. L., Zlotoff J. H., Bouché R., Baker J. (2010) The Diagnosis and Treatment of Heel Pain: A Clinical Practice Guideline–Revision 2010. The Journal of Foot and Ankle Surgery: Official Publication of the American College of Foot and Ankle Surgeons: May 2010, Vol. 49, 3 Suppl., S1-S19
3. Alshami M. A., Souvlis T., Coppieters W. M. (2008) A review of plantar heel pain of neural origin: Differential diagnosis and management. Manual therapy 13: May 2008, pp. 103-111

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