Heel pain is one of the commonest complaints an orthopedic surgeon in his outpatient department. I would go ahead and say that almost all of us experience heel pain at least once in our life time. Let us see what causes this heel pain. Looking at the anatomy in the picture below one can see a white sheet like structure called “plantar fascia” extending from the heel bone (calcaneum) to the base of the toes. The next picture shows the

Though there are multiple causes of heel pain the most common refers to this important structure i.e. “plantar fascia”. We orthopedic surgeons describe this condition as “Plantar Fascitis”. The first picture shows the foot in the “heel off or push off” position of our gait cycle. The next step would be “foot off the ground” and then “heel strike “followed by “foot flat” on the ground. During this entire cycle the plantar fascia which is

One may wonder why some people get heel pain and some do not even though all of us walk! There are few predisposing factors which put some individuals at higher risk of developing heel pain. If one has a very high arch of the foot or has no arch (flat foot) at all then the fascia is under higher tension and develops tears easily. Obesity is another risk factor for obvious reasons. Faulty footwear with rigid soles is another cause. We therefore see a sudden increase in heel pain patients during the month of June and July because many patients start wearing plastic chappal and shoes for the rainy season! This plastic footwear is rigid and causes the fascia to stretch more. People spending too much time on their feet, especially on hard surfaces, can overstress the fascia. This would apply to certain occupational groups such as teachers or department store clerks. Certain sports (excessive running, basketball, and aerobics, especially stair-stepping) can also, over time, put undue strain on the plantar fascia.

A sudden increase in activity, as in lunging after shots in a game of squash after a long period of inaction or attempting to push heavy objects can overstress the fascia. This is especially true if some of the other contributing factors, to be discussed below, are present.

Age. As we age, the fascia loses elasticity. One source suggests that 90% of people with plantar fasciitis (heel spurs) are more than 30 years old.

Weight-bearing activities (standing for long periods of time, jogging, lifting heavy weights)

Inflexible calf muscles

Weak foot muscles

There are other causes of heel pain and therefore a proper clinical examination is very important. A herniated lumbar disc can cause heel pain and hence history of backache and sciatica like symptoms should be always asked for. A positive straight leg raise is a give way sign indicating the problem is higher up and not at the heel. Another rare disorder is the “Tarsal tunnel syndrome”, where a nerve gets trapped below the flexor retinaculum at the medial malleolus level. In this condition the patient sometimes complains of tingling numbness around the heel in addition to pain. A gentle tap just below the medial malleolus elicits a positive Tinel sign in a few cases.

X-Rays of the heel may reveal a bony spur but frequently they are not associated with pain and need not be treated. This is the most important aspect which a family physician needs to understand. Most of the patients get an X-ray done for heel pain and are told that there is a spur! There are a few patients who then want this growth to be removed! Spurs indicate chronic traction force on the attachment of the plantar fascia and nothing else!

It is important to realize that the plantar fascia tears heal with time if patient gets enough rest and the provocative factors are removed. To reduce the impact on heel while walking I prescribe heel cushions which are freely available in medical shops. All patients need to wear them for 3 months and in some high risk cases like a traffic policeman I recommend a constant use. Hot water fomentation helps. In addition I do prescribe anti-inflammatory drugs. Eliminating the causative factors like faulty footwear is also essential. Those who do not recover need a cortisone injection at the painful site. Once the pain settles all patients are taught exercises shown below. These exercises make the foot muscles strong and stretch the heel cord if it’s too tight. Research has shown that a tight tendo Achilles (heel cord) is the commonest factor for recurrence of heel pain. Obese patients are asked to lose weight. Conservative treatment almost always works in these cases and I have so far not operated a single case! There are however surgeries described for chronic recalcitrant plantar Fascitis.

This is one of the commonest problems easily dealt with by conservative treatment. One should carefully identify any risk factors mentioned above and eliminate them. A chronic heel pain patient definitely needs a orthopedic referral to eliminate other causes.

Dr. Shreedhar Archik is a consultant Orhtopedic Surgeon attached to Lilavati and Shushrusha Hospitals, Mumbai.

Please exercise after consulting a qualified physiotherapist or an Orthopedic surgeon. These are general guidelines and your specific condition may require certain precautions. This website does not take the responsibility if you damage your tissues exercising without supervision.