Typical site of plantar fascitis pain
This QuickGuide is about pain under the heel. Pain posterior to the heel is usually due to problems with the insertion of the Achilles tendon. About 7% of patients with pain under the heel also have posterior pain.
What causes it?
- Plantar fasciitis is the commonest cause of pain under the heel. It is a degenerative condition of the attachment of the plantar fascia to the medial calcaneal tubercle. The pathology is similar to that of Achilles tendonopathy, tennis elbow and rotator cuff disease. In a few patients it represents part of a spondyloarthropathy with chronic inflammatory features.
- There is reasonable evidence that entrapment of the branches of the medial or lateral plantar nerve contribute to the pain inpatients with plantar fasciitis, and in some this is the main cause.
- About 10-15% of patients with pain under the heel have more diffuse pain in the heel pad. The pathology of this is less clear.
- A few patients have other causes such as referred pain from the subtalar joint, stress fractures or cysts of the calcaneum or tarsal tunnel syndrome.
- Heel “spurs” are commoner in patients with plantar fasciitis but are not the cause of heel pain
- Plantar fasciitis is commoner in people who walk a lot at work, especially on hard surfaces, and in the obese. It’s controversial whether it is associated with any particular foot shape.
- Achilles and hamstring tendons are often tight, which increases tension in the plantar fascia
What do people complain of?
- Pain under the heel, especially on the first step in the morning or after resting
- Pain sometimes gets worse toward the end of the day
- A few people complain of feeling like they have a pebble under the heel
Things to think about
- Where is the pain? – plantar fasciitis is under the distal, medial plantar surface of the heel; pain all over the heel is harder to treat
- Could it be inflammatory? – ask about psoriasis, iritis, bowel problems, urethritis, back pain
- Is work a factor? – long time on feet, hard surfaces may be worth discussion with occupational health
- Don’t think about the spur!
Principles of treatment
- It’s a self-limiting condition in many people – explanation and some advice about foot care, shoewear, weight and the work environment may be enough
- Simple first-line treatment includes Achilles and plantar fascial stretching (the MSK physio can help), soft heel pads and simple analgesia. NSAIDs probably aren’t much better than paracetamol
- For people who comply with first-line treatment and advice but still have pain, a night splint maintains the stretch overnight and reduces first-step pain but many people find it very awkward
- Patients with marked flatfoot or high-arched feet, or who fail initial treatment, may benefit from a biomechanical assessment and orthotics from the MSK podiatrist
- Feel and tap along the medial side and under the medial border of the heel for a sensitive entrapped nerve, possibly with radiating “shock” pain under the heel
- If all that fails, reassess for compliance, occupational factors, weight and inflammatory disease
- Only now think of a steroid injection! It’s less painful to give it from the medial approach. Ultrasound guidance may increase the effectiveness.
- Shockwave therapy is controversial and the evidence conflicting, but there is probably a small treatment effect for patients who fail other simple treatment.
- Splintage in a cast or walker boot may be worth trying in resistant pain
- Very rarely, surgical release of part of the fascial attachment, often with neurolysis of branches of the medial or lateral plantar nerve, is indicated. Referral would usually be via MSK
- Generalised heel pad pain may respond to advice, weight reduction, soft heel pads or pain management
- Patients with diffuse pain often have nonspecific musculoskeletal pain conditions such as fibromyalgia, or more complex pain issues. If the pain is atypical a pain management approach is worth considering early.
- And ignore the spur!