There are many causes of pain directly under the heel. Perhaps the most common cause is called plantar fasciitis. This is also commonly known as a heel spur. Whatever name you call it, the evaluation and the treatment remains the same. This discussion will include the anatomy of heel pain the treatment alternatives and what you can expect during your recovery.
The plantar facial band is a tight ligamentous structure on the bottom of the foot, which helps to hold up the arch. It begins directly underneath the heel and is attached to the bone (calcaneus). At the origin under the heel it is about 2cm in width. It then travels out towards the toes and broadens out. Just before reaching the toes, it splits into 5 slips with each slip going into a toe. You can see that the weakest point of the entire structure is at its origin in the heel where it is so small.
The bony alignment of the foot serves as the structural framework, which supports your arch. If for any reason this framework begins to flatten out (pronation), then the plantar fascial band has to help by resisting this abnormal flattening. Since the origin of the fascial band under the heel is its weakest point, the greatest stress will be transmitted to this site.
As you walk or run there will be a repetitive mechanical stress applied to this attachment. This abnormal stress will eventually lead to an inflammatory reaction around the origin of the fascial band where it is being “pulled away” from the bone. A major component of any inflammatory reaction is swelling. In this situation the swapping is imperceptible on the surface, but it is present around the fascial band. There are many small nerves running through this area and the swelling increases the pressure on theses nerves resulting in the pain you feel.
In an attempt to strengthen the attachment of the plantar fascial band, your body will actually lay down bone as a response to this chronic irritation. The formation of this “heel spur” is the end result of plantar fasciitis and is often times asymptomatic.
The pain associated with plantar fasciitis is normally fairly specific. Most people describe the pain as an aching “tightness” with occasional sharp pain “like a nail” under the heel. The pain is the worst typically when they first get out of bed in the morning or after sitting for a long time. The first few steps are excruciatingly painful. The pain will decrease gradually as the foot “warms up” which may be anywhere from 4-5 steps to 45 minutes. Another common complaint is that the pain again increases after standing for a long time.
What makes plantar fasciitis suddenly flare up? As we discussed in the causes of fasciitis, anything which increases the stress on the plantar fascia. Increased stress may come from an increase in activities such as a runner increasing his / her mileage. It may come from a worn out pair of shoes, which no longer are able to support an abnormal structural deformity. It also may occur with an increase in weight and often times a patient will relate a recent weight gain of 5-10 pounds.
In order to accurately diagnose plantar fasciitis, a detailed medical history is obtained, as well as a comprehensive examination of your foot to see what areas and movements are sensitive. Many times your walk or gait is examined, and X-Rays are taken in the office to determine the bony structure of the foot, to examine for any heel spurs, fractures, bone tumors, arthritic changes, and any other pathology.
Any successful treatment must focus on decreasing the stress on the plantar fascial band and at the same time decreasing the swelling around it. Your treatment will focus on both of these areas simultaneously. First, the bony structure of your foot must be supported in order to decrease the stress on the plantar fascial band. Second, the inflammation, which causes the pressure and pain of the nerves, must be decreed in order to treat the pain.
The good news is that in most instances, heel pain can be successfully treated and eliminated with conservative non-surgical treatments. Surgical procedures are also available for those who do not respond to conservative treatments. Timely presentation for an examination following the first symptoms of heel pain typically results in a quick resolution to this condition.