Heel pain including plantar fasciitis and bone spurs are one of the most common complaints seen in the foot. Plantar fasciitis is an inflammation of the large ligament on the bottom of the foot. Although most cases of plantar fasciitis occur near the heel, often described as sharp pain, this condition can be evident anywhere from the heel all the way to the ball of the foot.
In order to feel the plantar fascial ligament, with one hand bend the big toe upwards, run your finger from your other hand along the bottom of the foot, you will feel a large cord like structure that runs from the ball of your foot to your heel. The purpose of this structure is to act like a bowstring in order to support the structure of your arch.
In the picture below, the yellow band represents the plantar fascial ligament. Notices how it attaches from the heel to the ball of the foot.
Many authors consider the plantar fascial ligament to actually be a direct extension of the Achilles tendon. Once again refer to the diagram above.
People who exhibit an equinus or lack of dorsiflexion in the foot (the inability to bend the foot upwards beyond a 90 degree angle to the leg with their knee in a locked position) will be more inclined to suffer from plantar fasciitis. People who have a tight Achilles tendon are generally inclined to pronate more, to compensate for the Achilles tightness and this puts an added strain on the plantar fascial ligament.
Many women who suffer from plantar fasciitis will tell me that their heel feels better when they are in high heels. Why, because wearing a high heel reduces the tension on the Achilles tendon and thus reduces the tension on the plantar fascial ligament. If an equinus does exist, it must be addressed in the overall treatment plan because no matter what type of therapy your doctor may recommend, the tendency to overstretch the plantar fascial ligament will continue and so will the pain.
The problem with most foot symptoms unlike a hand injury for example, is that it is very hard to “rest” a foot in order to allow it to get better. So every time you take a step you are re-injuring an injured area and for that reason foot injuries can take a long time to heal, especially heel pain because every time you take a step you are putting pressure on the heel.
Most people relate a similar story:
When there is excessive inflammation particularly at the insertion of the ligament into the heel bone, calcification can occur and you end up with what is routinely known as a heel spur which is the classic bone spur in the foot. One could argue that this is simply an exacerbation of the plantar fasciitis. In fact, in this day and age, seeing a heel spur on x-ray, does not change my treatment plan for any given patient.
Below is a picture of a true heel spur; a calcification of the plantar fascial ligament.
Additionally, when the pain in the heel seems to worsen the more you ambulate other problems may be present. In addition to the plantar fasciitis you may also be suffering from:
A heel neuroma, which is simply a pinched nerve that gets entrapped in the area of inflammation.
Tarsal tunnel syndrome
Lack of fat in the heel. The fat is supposed to act as a cushion, but some people either do not have enough fat, or as we age we lose some of the fat, and now the heel bone becomes bruised because there is not enough fat to protect it.
Plantar fascial tear- instead of being inflamed, the ligament may actually be torn.
heel fracture- a fracture of the calcaneus bone will cause heel pain that will worsen the more you ambulate.
It is essential that a well-trained foot specialist be consulted to rule out the cause of the heel pain. (These are the most common but not an all inclusive list of causes of heel pain).
Making the right diagnosis and eliminating the factors aggravating the heel pain are essential in alleviating the problem. If my patient happens to be very much overweight or wears very flimsy shoes, the chances of success in alleviating the problem are greatly diminished unless those issues are addressed.
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