Heel Pain a Runners’ Perspective Management and Treatment

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Heal pain is common in people that do sports that involves a lot of running. It is something that could happen over a period of time, or could be instant depending on several factors. It is also not only limited to runners but could be experienced by anyone that does sports that involve running or jumping, although it may be more prevalent in runner for reasons such as the stress of over using the heal while running which could be caused by a sudden increase in miles run along with the increased level of impact on the heal bone (calcaneous) and ankle joint, or the over use of shoes that do not have the proper support and cushioning which can in fact cause tiny tears in the tendon fibres.

In this article, we will be looking at heal pain in general and other medical conditions that are the common causes of heal pain along with Bruised heels and Severs disease.   So, let’s start with…

What is Heel Pain?

Heal pain is probably the most common foot complaint of people who go to the doctors for foot and ankle pain. It is generally localized to the heal itself and is generally noticed either under the heel which affects the plantar fascia and is called plantar fasciitis or just behind the heal affecting the Achilles’ tendon and is called Achilles tendinitis. It is not usually caused by one single incident like a twist or a fall but rather is a result of repetitive pounding and stress of the heal such as by the motion of running. It may also be caused by recent damage or injury or an accumulation of smaller injuries over the years.

Although heal pain can be extremely painful and even possibly disabling for a period of time it is rarely a health issue and is something that can resolve itself in most instances by resting but occasionally could become something that you may have to deal with long term.  Out of the 26 bones in your foot the heal bone called the calcaneous, is the largest and it is shaped as it is to support the weight of our body, so when we are either walking or running it absorbs the impact when your foot strikes the ground.

Your foot strikes the ground at 1.25 times your body weight when you are walking and 2.75 times when running, this is stated by experts. It is this impact that makes the heal vulnerable to damage which in turn results in pain. Heal pain is not necessarily something that causes severe pain or will disable you but it is something that will cause you to limit movements such as walking running or even standing if there are times where you have to stand for long periods of time. There are treatments for alleviating heal pain however some of them could possibly take up a lot of time and effort.  Some causes include:

Plantar Fasciitis can be very painful, it is inflammation of the plantar fascia ligament that runs from the heal of the foot to the toes (mainly the big toe). If Plantar fasciitis is left untreated for a while it can become difficult to treat, however it is easier to treat and heal if it is caught early. It can be caused by several things such as obesity, running, inadequate shoe support and also if the way the foot and ankle movement supports our body weight is unnatural it can affect the way the ligament works and therefore could cause it to thicken.

Causes

There are a number of contributing factors to planter fasciitis, some of which are age, being overweight, new forms of exercise or a sudden increase in exercise intensity, standing for a number of hours daily, medical conditions such as rheumatoid arthritis or lupus, switching to flat shoes suddenly after wearing heals for a long period of time, ill-fitting shoes or shoes with no support, having flat feet (no arches) or unusually high arches, also if your legs are of differing lengths or if you have an abnormal walk or foot position or finally if you have a tight Achilles tendon.

Symptoms
With Plantar fasciitis, the pain primarily occurs under the heal especially the front and centre, and sometimes will also go along the foot into the arch of the foot. At the heal the pain is more likely to be sharp and then as it goes further along the foot towards the arch it may feel more like soreness or an ache in that general area. You may find that the pain is worse in the mornings after you have been sleeping for many hours and this is due to the plantar fascia tightening up overnight, it may also occur when you have been seated for extended periods of time or if you have increased activity especially if you are doing any activity in unsupportive shoes. The pain should subside after a while once you start walking as walking will help to warm up the ligament. If the pain is occurring after a period of inactivity doing some stretches will help to warm up the ligament alongside walking and therefore it will become looser and more pliable. Look at what you are or are not doing when the pain increases with relation to the plantar fasciitis and do the opposite to help to reduce the pain.
If the pain does not respond to treatment within a period of 4 – 6 weeks or if there is redness or bruising in the heal area then seek medical assistance.

Treatment 
There are some therapies that can be done at home for mild cases of plantar fasciitis and these therapies are what the doctor would most probably advise you to try first. You may need to use one or a combination of methods as the aim is to begin reducing the inflammation and stress while improving the flexibility of the ligament. The goal is to help the fascia heal through these methods, however for more severe or long term cases it is probably best to see a doctor, sports or physical therapist who will then be able to have a look at the affected area and come up with a treatment plan.

 

The first thing to do when you notice any pain in your foot is to rest it and if this is not possible reduce whatever activity you are doing that is causing the pain. Some of the treatment that may work are icing the affected area or alternating between heat and cold which will dilate and constrict the blood vessels that run through the ligament. The heat will increase the skin and ligament temperature and will increase the circulation and relaxation of the muscles and ligaments in the area whereas the cold will numb the pain, decrease the inflammation, constrict blood vessels and block nerve impulses to the joint even if it is for a short period of time, this should be repeated a few time throughout the day.

Buying and wearing better fitting shoes that have the right support and cushioning for your foot will also help in the healing process of the plantar fascia, or orthotics can be a good alternative if you do not want to buy new shoes. Doing physical therapies such as stretching and strengthening the muscles and ligaments will also help as stretching the Achilles tendon and plantar fascia will help to increase the flexibility in them and strengthening the muscles of the foot and ankle will help to support the arch. In a small amount of instances surgery may be needed however this is very rare.
The main cause of foot problems is training in shoes that are worn out or do not fit properly. It is good practice to replace you shoes every few months or sooner if needed as wearing shoes that have worn tread, heals or padding could limit what you can do due to the heal pain or if it does get severe could even stop you from doing something that you enjoy for a few months.

You will need to exercise patience while treating plantar fasciitis and be consistent with the methods you are using as this is what will help to relieve it over time. Also ensure you start treatment straight away as the longer you leave it or ignore it the longer it will take to heal when you eventually do start treatment. Although it is a long process back to full recovery you will start to notice a difference within weeks however if after a few weeks you are not noticing any change then it would be best for you to go and see your doctor, physical or sports therapist to look at alternative treatments.

Achilles Tendonitis
Achilles tendonitis is inflammation of the largest and strongest tendon we have in our bodies, the Achilles tendon. It is an injury that is fairly common and can happen to anyone from someone who is going about their daily lives to elite athletes. It is the Achilles tendon that connects your calf muscle (gastrocnemius) to your heal bone. It is because of this tendon that we can run, walk and jump however overusing it can cause the inflammation and if it is not treated there will be a lot of scar tissue which the can affect treatment. If you push down on the tendon which is located above the back of the heal of your foot you will feel it is springy. It is this tendon that allows extension of the foot. This injury is generally due to activities in which you must either speed up or slow down quickly or pivot so doing sports such as gymnastics, football, basketball or tennis will increase your risk of Achilles tendonitis.

Cause
There are a few causes of Achilles tendonitis. Some of the ones to look out for are overdoing any activity, increasing the activity level too quickly, and for women high heels can be an issue as it can stress the tendon. This injury generally occurs at the beginning of the movement for example when a sprinter pushes off the starting blocks as the pushing motion can be too much for the tendon, or when a tennis player is having to stop quickly after hitting the ball and change direction to hit the ball again. Men over the age of 30 can also be more likely to get this injury.

Symptoms

You may notice a burning pain, stiffness, tenderness, bruising and possibly some swelling at the back of the ankle from the top of the heal especially when you attempt to do actions such as standing on your toes. If the tendonitis lasts more than 6 weeks or it is severe it could be partly torn or ruptured, the pain will be instant and severe and you may also be able to hear a popping or snapping sound should this be the case.

Treatment
As with any injury the first thing you should do is rest the affected area until the pain and swelling subsides. You can also use cold compression (ice wrapped in a towel or in a bag is always good, never put ice straight on the skin as it can burn you) to help reduce the swelling for short periods of time of a maximum of 30 minutes every 3 to 4 hours, and elevate the injured area. You can also use orthotics to lift the heal which will take the pressure of the tendon and once the pain has reduced it is a good idea to stretch out the tendon, however only go to the point of tension. If the stretch hurts then it is too deep and it is best to ease off it a little. It is also a good idea to do some strengthening exercises once the injury has healed as there could possibly be some atrophy and the strengthening of the muscle will help support the tendon. If these treatments do not work there is also the option of having surgery to repair the damage done to the tendon.

It may take a while for the injury to heal depending how serious it is and how your body heals itself but you can still do some activities. For a list of which activities you can do it would be best to see a doctor or physical or sports therapist who can access the injury before informing you which exercises would be best for you to do. Also remember to take things slowly while you are healing and wait until you can have the same level of movement and strength again in the injured leg as in the uninjured leg, and you also want to ensure you are pain free. It is not a good idea to overdo things before you have fully healed as you could damage the tendon again and then it could become a problem long term.

You can help reduce the risk of having such an injury by limiting the amount of uphill running you do, wearing shoes that fit well and have adequate support for your feet, increase your exercise intensity gradually rather than suddenly and the moment you feel any sort of pain or tightness in the back of your lower leg just above the heel, stop exercising.

Bruised heels
Another term for a bruised heel is policeman’s heel which is a bruise to either the skin, bone or tissue under the heel causing pain. There could also be a fracture to the heel bone (calcaneus) as well. The bruising itself can cause you a lot of difficulty doing normal day to day activities let alone doing any sort of exercise, with the possibility of a fracture as well this can be an extremely painful and limiting condition.

Risk Factors

Heel bruises can be caused by a number of small events that occur over and over again or one really major, severe event. In cases that are not so severe it is more likely to be just the fat pad that is affected but the more severe cases are where there is more likely to be a bone fracture or possibly multiple fractures as well. The two main causes are repetitive motions and a sudden strong impact.

Repetitive motion is very similar to repetitive stress injury in that repetitive motions such as running or walking long distances all at one time can cause bruised heals. You will find that marathon runners will more than likely at some point have bruised heals due to the distance they run in one go.   Sudden strong impact is pretty much as the name suggests. It is a sudden impact onto a hard surface such as concrete which has no give, landing too hard on that surface feet first. This is something that athletes who do events such as pole vaulting or triple jump are at a higher risk of developing, however it is not just limited to athletes, anyone who lands heel first is at risk of developing bruised heels such as someone who decides to jump of a ladder and lands on their heels.

The higher the height you fall from, the higher the risk of injury, for example if you have difficulty landing at the end of a sky dive the impact can cause your heel bone to have multiple fractures or breaks producing instant pain and swelling which would stop you from walking instantly. This would not result in permanent bone deformation however. The reasons for the two main causes above are the same, they are as followed: footwear is a main contributor again. As mentioned earlier in the article you need to have adequate footwear for the activity you are doing. Weight can be an issue too as excess weight can increase the stress levels on weight bearing bones such as the heel bone which in turn increases the risk of injury.

Another factor we have to take into consideration is our age, as we get older our bone density decreases and can make our bones become brittle especially if we are lacking in calcium or the body does not absorb it properly as this along with collagen is what helps keep the bones strong. Going barefoot when doing anything which is going to cause impact i.e. running is also not a good idea as you do not have any cushioning or support from the impact. Getting good quality footwear helps alleviate the impact therefore reducing the stress on the joint.

If you do decide to do some bare foot running then you are likely to experience bruised heels initially. This is because when you are running your feet expect to be planting down on a firm, level surface so when you try running on uneven surfaces it can produce sudden shocks of stress. The best way to explain this is when you try running in the sand it falls way from under your feet and constantly changes when you plant and lift your foot, this should give you an indication as to how easy it could be to cause foot strain when running in these conditions.

Prevention

Stress due to sudden shock could also be a problem if training on hard surfaces however, some sports have to be played on hard surfaces such as tennis which can be played on hard courts as well as grass and clay. A sudden change of direction can have the same sort of stress on the foot pad and the muscles which may not be ready for this action, especially if you are not an elite athlete or a person who is highly tuned in to your body and how it works.

Symptoms
Some of the common symptoms of bruised heels are tenderness when pressure is applied, swelling in and around the heel area, pain when on your feet while either standing, running, walking, or jumping. If you find that you have a flattened spot on your heel it could be because the fat pad that covers the heel has moved which means the bone is more exposed, this being more serious than the previous symptoms. If you were to continue exercising whilst having these symptoms then this could lead to a further symptom of inflammation to the external surface of the bone (calcaneus), the periosteum. If this happens then the condition will become chronic and the injury is going to hinder the sports person or athlete.

Treatment

You need to rest and protect the affected area either by using padding or taping. You also need to find out what caused the injury in the first place and take preventative measures so it does not happen again. By catching the heel pain in its initial stages and resting you should be able to recover fairly quickly, however if it is ignored and there is damage to the fat pad that protects the heel bone then it could take longer and be more difficult to treat. Resting is the most important part of treating this injury as any sort of impact through walking or running will prevent the healing from taking place. If you must be on your feet for your job then ensure that you have some shock absorbing and cushioning heel pads in both your shoes rather than just one as just having a heel pad in one shoe will cause you to have different leg lengths bringing on a whole new set of problems. Also remember to replace your running shoes if they are old as ideally you should only be using them for 400 miles of running. After this they become weaker in the mid sole and therefore do not give you adequate cushioning and shock absorption while you are running.

If you can it might be a good idea to go to a sports injury specialist who will be able to diagnose the injury, find out what could have caused it through analysing your gait and then advise you on how best to protect the heel while it is healing and if needed correct any biomechanical problems of the foot. They may also use tape to give the heel some added support and protection while it is healing as well.

Symptoms
The symptoms of bruised heels are usually a gradual onset of pain; however, it can also be instant if you jump from a height and land on your heels. You will notice pain or discomfort while walking and athletes may continue to train until such time that it becomes worse and prevents them from training. Symptoms for bruised heels can be like plantar fasciitis however bruised heels are not generally worse in the morning and do not radiate towards to foot arch as plantar fasciitis would. Bruised heels generally improve with rest as long as it is not ignored and allowed to become worse due to continuing training.

Severs disease
Severs disease is also known as calcaneal apophysitis. This is a condition where the growth plates in the back of the heel become irritated which can be due to an increase in running. This pain is located at the back of the heel rather than under the heal as in bruised heels, plantar fasciitis or Achilles Tendonitis. This is common cause of heel pain in children between the ages of 9 and 12 and even though it can affect any child in that age range children that are active and do sports that involve a lot of jumping have an increased risk of developing this condition.

Cause
The cause of severs disease is the overuse and stress placed on the heel bone due to taking part in sports such as running, football or basketball. This is due to the growth plate of the heel being sensitive to running and pounding on hard surfaces repeatedly, although there are other causes such as obesity, tightness in the Achilles tendon and problems such as flat foot or a high arch which is biomechanical.

Symptoms
Pain in the back or bottom of the heel, limping, walking on the toes, difficulties in taking part in sports that involve running or jumping and when the sides of the heels are squeezed there is pain.

Treatment
The most common treatments for severs disease are heal lifts which can help to support the heel, stretching the calf muscles and ice. It would also be advisable for your child to stop doing the activity that is causing the pain. Physical therapies can help with the healing process as well as stretching and in some cases which are more severe a cast may be used to immobilise the ankle helping the healing process.
There are times when the heel pain will come back in children due to the heel bone still growing, however as much as the pain could be due to severs disease it could also be a sign that there is a different problem which needs to be addressed. If this pain is reoccurring then make sure to have it checked by a professional.

Wrapping It Up

You can reduce the chances of developing heel pain by avoiding obesity, wearing shoes that are supportive for the activity that is being undertaken and not pushing past your abilities too far.   To finish off remember you only have one set of feet. Do as much as you possibly can to protect them such as wearing the right foot wear and minimise the impact as much as is possible. When you notice any issues with your feet if you are doing any exercise, stop, take steps to alleviate the pain and if needed get them looked at by a professional as soon as you possibly can, so that you can start the necessary treatment straight away, allowing the healing process to take place, hopefully reducing the time it will take to fully recover back to full health and so the injury does not become chronic.

Please be aware that this article is for information purposes only.  If there is anything you are concerned about it is advisable to go and see a medical professional, physical therapist or sports therapist.

 

Sources

  1. Christian Nordqvist, Heel Pain: Treatments and Prevention, Medical News Today, Dec 11, 2018
  2. Staff Writer, Bruised Heel, Sports Injury Clinic, May 30, 2017
  3. Staff Writer, Bruised Heel, Web MD, May 30, 2017
  4. Staff Writer, Plantar Fasciitis, Runner's World, May 29, 2017
  5. Staff Writer, Plantar Fasciitis Home Treatment, Web MD, May 29, 2017
  6. Staff Writer, Bruised Heel Fat Pad Contusion, Beat Plantar Faciitis, May 29, 2017
  7. Staff Writer, Calcaneal Apophysitis (Sever's Disease), Foot Facts, May 29, 2017
  8. Staff Writer, What Is Sever’s Disease?, WebMD, May 29, 2017
  9. Staff Writer, Sever's Disease, Boston Children's Hospital, May 29, 2017
  10. Staff Writer, Sever's Disease, Sports Injury Clinic, May 29, 2017