Posterior Heel Pain – pain at the back of the heel

Do you have pain at the back of the heel?

This is called Posterior Heel Pain and there are actually lots of different causes for pain in this area. There are some common signs and symptoms for each of them. Here we will go through each of them, from most common to least common, so you can work out which problem you might have!

 

Achilles Insertional Tendinopathy

An achilles insertional tendinopathy is the most common cause of pain at the back of the heel. This is an irritation of where the achilles tendon attaches onto the back of your heel (calcaneous). It is quite different to your usual achilles tendon pain which is typically felt higher up on the tendon, about 2-3cm above the calcaneous. Because the bone AND the tendon are involved, they can be tricky to treat and often take longer.

The symptoms will typically involve pain on initial weight-bearing in the morning, that warms up within 30mins. It may also warm up when beginning running/sport then come on again after a period of activity. They can often ache afterwards.

Unlike a traditional achilles problem, they won’t respond to eccentric calf raises off the edge of a step. You generally have to start with higher range work right up on your toes before slowly dropping down lower as the pain improves. In serious cases, a heel raise worn for a short period can also help settle it down before starting some strength work.

 

Posterior Ankle impingement

In athletes such as ballet dancers where activity requires frequent rising up onto the tip toes they could experience a syndrome called posterior ankle impingement. This is where both hard and soft tissue can get stuck or “pinched” at the back of the ankle.

Posterior ankle impingement occurs when excessive plantaflexion (pointing the foot) pinches the soft tissue or compresses the back of the joint resulting in a sharp pinching pain.

Os Trigonum: A common cause of pain at the back of the ankle

Os Trigonum at the back of the talus bone.

There are 2 anatomical variations that cause posterior ankle impingement.

  1. Prominent Posterior Talus. The talus is the main weight-bearing bone in your ankle. The back of this bone can grow in response to abnormal loading. If it grows too much it can start to irritate structures at the back of the ankle.
  2. Os Trigonum. If the prominent part of the talus grows enough and then breaks off, it becomes labeled as on Os Trigonum. About 20-30% of the population have an os trigonum, with obviously not everyone having symptoms. If however, it does start to cause symptoms, then surgery to remove the loose bone can be highly effective.

 

Both of these anatomical variations can be diagnosed with a plain x-ray.

Treatment will likely include strengthening of the deep muscles in the lower leg such as tibilalis posterior, flexor digitorium longus, flexor hallicus longus and the peroneals.

 

Severs disease

Sounds “severe” but it’s not! Severs disease an “apophysitis”, or an inflammation/irritation of where the achilles tendon attaches to the back of the heel. When we’re younger, our bones are a bit softer, so repetitive pulling of the achilles tendon on the bone can cause some pain.

Severs disease is more common in boys than girls, aged 8-14 yrs. The typical presentation is pain caused by running, jumping and the pain gets worse with more activity then settles with rest. It often coincides with a growth spurt. As the bones grow, our muscles and tendons can sometimes struggle to keep up, so they get tighter and start to pull on the attachment.

Treatment of Severs disease involves rest from running and jumping until the pain settles, then addressing any tightness and/or weakness of the calf muscles. Sometimes a gel heel cup in the shoe will help offload the attachment. In serious cases, a boot may be required to be worn for 2-4 weeks.

 

Sural nerve compression

Sural Nerve Impingement - Ankle, Foot and Orthotic Centre

There is a little nerve that runs in behind the heel and tracks towards the outside of the ankle called the Sural nerve. It can be irritated by inflammation from surrounding tissues and normally exists with one of the other pathologies mentioned above or can occur after an ankle sprain (click here for ankle sprain management tips)

The sural nerve will obviously give you nerve pain, which feels very different. Common symptoms of nerve pain are “burning”, “tingling” and “numbness”. We can test the nerve with a nerve tension test and this will reproduce the same pain you are having.

Treatment will normally involve addressing the other problems in the area as well as nerve glides which can help restore mobility to the nerve.

Haglunds Deformity

Haglunds Deformity is a growth at the back of the calcaneuous that causes pain and swelling in the bursa (retrocalcaneal bursitis) and the achilles tendon.

The bone grows due to repetitive stress over the years and can be aggravated by resting the heel on a table or from wearing shoes with a firm heel support.Haglund's Deformity – Pump Bump on Heel | Foot Health Facts - Foot Health Facts

Treatment involves anti-inflammatories, choosing footwear that doesn’t compress the back of the heel, calf and foot strengthening

and a heel raise to offload the tendon and bursa. In serious cases that fail to improve, surgery may be required to remove the bony enlargement.

 

Calcaneal bone stress/fracture

A bone stress injury or fracture of the heel is rare and makes it almost impossible to weight-bear.

Pain with weight-bearing, likely with a history of increased load or overload. This one is needed to be confirmed by MRI and you will likely end up with a very fashionable moon boot for 6-8 weeks.

 

If any of these sound like your pain, then please don’t hesitate to get it seen to quickly.

Get strong arches!

Build strong feet with these 2 exercises.

  1. Sitting or standing, push toes down into the floor so your arch raises slightly. Keep you heel on the ground. Hold for 10 seconds and repeat x 5 each foot.
  2. Calf raises with band around ankles. Raise up onto your toes whilst pulling outwards into band. Do 3 sets of 20. To progress, try doing it on one leg at a time and/or make the band tighter.

 

A Runners Guide to Shin Splints

Medial Tibial Stress Syndrome (MTSS) or “shin splints” is one of the most commonly reported lower limb injuries by competitive and recreational athletes. Recent research has shown that shin splints affects approximately 20% of the running population, with the majority of sufferer’s partaking in long distance training/competition.

What causes the pain?

Currently, there is two widely accepted theories on the cause of shin splints:

  1. The bony bending/bowing theory
  2. The traction theory

The bony bending theory suggests that during running, the Tibia (shin bone) bends due to the stress placed upon it. This bending causes small amounts of strain in the bone that enables it to adapt and get stronger (a good thing!!). When this strain exceeds the adaption process the shin bone becomes overloaded (a bad thing!), subsequently leading to injury and pain.

The traction theory states that shins splints is caused by the continual contraction of the muscles (Soleus, Flexor Digitorum Longus & Tibialis Posterior) that attach to the inner border of the shin. As these muscles contract during running, they place a traction stress on the shin bone, which results in inflammation at their attachment onto the bone, causing pain.

Am I at risk?

Current research has identified several risk factors leading to an increased likelihood of developing shin splints. These include:

  • A previous history of shin splints

  • Prior orthotic use
  • High Body Mass Index (BMI)

  • Female gender

  • Decreased running experience

  • Decreased running cadence (step rate)

  • Excessive pronation

  • Over striding
  • Crossover running style

  • Increased vertical oscillation (ground clearance)

  • Forefoot running

How do I know if I have shin splints?

To diagnose shin splints accurately, two symptoms must be present:

  1. Exercise induced pain along the distal 2/3 of the medial Tibial border
  2. Recognisable pain produced by pressing the medial Tibial border, which spans a distance of 5cm or more.

If you are experiencing symptoms not typical of shin splints such as cramping, pain spanning less than 5cm, burning pain, numbness or pins and needles, you should seek a thorough assessment by a physiotherapist to properly diagnose and treat your condition.

Treatment – Technique Technique Technique!!!

Arguably one of the biggest contributors to the development of shin splints in a runner is their running technique, particularly their lower limb mechanics. One of the quickest ways to reduce shin splints related pain is to address the technical aspects of running that can contribute to increased stress across the Tibia and associated musculature. What you should focus on is:

  • Cadence – Normal cadence should be between 165-185steps/min. Decreased Cadence causes increased ground contact time resulting in prolonged pronation and excessive tibial torsion stress.
  • Over striding – Excessive stride length results in poor tibia positioning upon heel strike, increasing Soleal traction and reducing force absorption ability.
  • Cross Over Gait Landing across the midline of the body causes excessive tibial torsion and pronation, reducing proper force attenuation.
  • Vertical Oscillation Increased vertical oscillation during running increases Tibial impact forces and often results in a loud foot strike.

How do I improve my technique?

Increase your cadence!! – This is by far the biggest bang for your buck. Increasing your cadence by approximately 10%:

  • Reduces lower limb impact forces by 20%

  • Reduces vertical oscillation
  • Reduces ground contact time

  • Reduces stride length

The best way to achieve an increase in your cadence is by using GPS watches, phone applications or by simply running on a treadmill.

Eliminate a crossover running style – On a track, run straddling a line across 2 lanes or alternatively, try and maintain a space between your knees with every stride.

How to beat shin splints using strength

Strength exercises for shin splints should aim to improve the localised muscular capacity of the calf complex as well as the bone load capacity of the Tibia. This is best addressed with weight bearing functional exercises that mimic running postures.

One of the most important and often forgotten muscles of the calf complex is the Soleus. The soleus muscle is vital for absorbing excessive loads placed on the Tibia during running by minimising excessive pronation as well as resisting the bending forces experienced by the Tibia due to ground impact.

The best Soleus exercise that runners can do is the Bent Knee calf raise (pictured above). To perform the exercise correctly:

  • Bend your knee as far forward as possible, keeping your foot flat on the floor

  • Keeping your knee bent, raise yourself up onto your toes
  • Lower your heel back to the ground

Perform 3 sets of 15 repetitions in a slow and controlled manner.

As always, if you are having problems, please do not hesitate to contact one of our experienced physiotherapists.

 

Plantar Fasciitis, Heel Spurs and Cortisone Injections

What could be causing my sore heel?

Plantar fascia is a thick fibrous band of connective tissue originating on the bottom surface of the heel bone and extending along the sole of the foot towards the toes. It acts as a passive limitation to the over-flattening of your arch.

Plantar heel pain accounts for approximately 11-15% of all foot symptoms requiring medical attention in adults and for 8-10% of all running-related injuries. (Rasenberg et al, 2018)

What is it?

Plantar fasciopathy (previously known as ‘Plantar Fasciitis’) is an overuse condition at the point where the band of fascia attaches to the calcaneus (heel bone). People typically first notice pain under their heel or in their foot arch in the morning or after resting.

Why is it called fasciopathy now instead of plantar fasciitis?

The term “itis” means inflammation. On ultrasounds and MRI, thickening and degenerative tissue findings of the fascia are more commonly seen than inflammatory changes. “opathy” Simply means pathology (or problem) of the tendon so “fasciopathy” has become the more correct term.

Who is affected?

Heel pain commonly affects very physically active people (e.g. runners) or people with high amounts of standing occupational work (who may also have a high BMI). 1 in 10 people will suffer from plantar fasciopathy in their lifetime.

Are Heel Spur’s causing my pain?

A heel spur is a calcium deposit causing a bony protrusion on the underside of the heel bone. They are very common in people WITHOUT heel pain and there is a very poor correlation between spurs and pain. If you have been diagnosed with a heel spur it is unlikely to be causing your pain. It is very likely to be plantar fasciopathy due to its location (attaching under the heel).

How do we diagnose it?

The most important part of the diagnosis is the history. Patient’s will report a gradual onset of heel pain that it worse in the mornings when getting out of bed (“first-step pain”) and then warms up with activity. It may then return as an ache post-activity of after sitting long periods.

There is pain or tenderness along the medial/dorsal aspect (inside/underneath) of the heel bone, which may extend along the medial and central components of the plantar fascia. Stretching the plantar fascia via lifting the big toe up (during the windlass test) may reproduce pain and may assist with palpation of the plantar fascia.

Do I need to get a scan?

X-rays and MRI’s are not indicated if there is a classic history and examination findings.

What are some other possible causes of heel pain?

Bruised heel (Fat pad contusion):

A bruised heel is an injury to the fat pad that protects the heel bone. It can occur acutely and chronically due to poor heel cushioning or repetitive stops, starts and changes in direction. Pain is felt laterally in the heel during weight-bearing activities due to the pattern of heel strike. Tenderness is felt in the posterolateral heel region. This activity helps with differentiating fat pad contusion with plantar fasciopathy.

Calcaneal stress fracture:

Occurs in runners, ballet dancers and jumping athletes. History of insidious onset of heel pain that is aggravated by weight-bearing activities, especially running. Presenting with localised tenderness over the medial or lateral aspects of the heel bone. Pain is reproduced by squeezing the posterior aspect of the calcaneus (heel bone) from both sides simultaneously.

Nerve pain:

This condition presents with rear foot pain caused by entrapment of the first branch of the lateral plantar nerve. Pain radiates to the medial inferior aspect of the heel proximally into the medial ankle region. Patients do not normally complain of numbness in the heel or foot. Often confused with plantar fasciopathy, the two conditions were shown to coexist in 52% of patients with this nerve entrapment. There is maximal tenderness at the plantar medial heel just proximal to the plantar fascia.

Midfoot pain:

Acute midfoot pain results from a sprain of the mid tarsal joint or plantar fascia. Gradual pain is a sign of overuse injury such as extensor tendinopathy, tibialis posterior tendinopathy or navicular stress fracture (pain poorly localised).

Other:

Blood tests may be warranted to rule out inflammatory arthritis, which can cause symptoms in the heels (although frequently symptoms will be more widespread). Plain radiographs (lateral view) are used to investigate the presence of a ‘calcaneal spur’. MRI is useful for identifying stress fractures of the calcaneus and other soft tissue pathologies; soft tissue tumours, medial tendinopathy and plantar fat pad pathology.

How do I treat plantar fasciopathy?

Research shows the best long term relief of heel pain is strength training. (Almubarak et al., 2012)

The 2 best strength exercises:

CLICK HERE TO SEE THE VIDEO!

1. Intrinsic foot muscles:

Begin sitting with your feet flat on the ground. Raise your arch by curling the big toe towards your heel, without curling your toes or lifting your heel.

2. Calf raises:

High load strength training consisting of heel-raises with a tight band around your ankles. Progress by performing on one leg at a time or by placing a towel under the toes.

What can I do for short-term relief?

The best short term relief of heel pain includes stretching and corticosteroid injections. (Babatunde et al., 2018)

The 3 best Stretching/flexibility exercises:

1. Big toe extension with ankle dorsiflexion:

Holding the big toe into slight extension and bringing the foot back into dorsiflexion.

2. Calf stretch:

Standing with your hands leaning against a wall for support and place the affected leg behind. Keep the leg straight and slight lean forward at the ankle joint. Feeling the gentle stretch in the calf muscle.

3. Self-massage with a golf ball:

Place a golf ball under the bottom of your foot and gently roll the ball back and forth.

Do Corticosteroid injections work?

Corticosteroid injections, alone or in combination with exercise were ranked most likely to be effective for management of short-term pain and function in the ‘Comparative effectiveness of treatment options for plantar heel pain’ study. However, in the long term, only exercise was beneficial.

What doesn’t work?

  • Heat/ice pack
  • Massage
  • Orthotics
  • Interferential
  • Ultrasound
  • Acupuncture

These options provide short term pain relief of up to 2-3 hours post treatment and are not as effective as exercise therapy. Interventions such as exercise (strength and flexibility) provide excellent long term benefits and pain relief solutions for plantar fasciopathy.

Foot orthoses vs Stretching

A systematic review and meta-analysis in the ‘Efficacy of foot orthoses for the treatment of plantar heel pain,’ explores the effect of different foot orthoses versus stretching exercises (Achilles and plantar fascia). The study showed that foot orthosis interventions are not superior in improving pain, function or self-reported recovery when compared with other conservative interventions in patients with plantar heel pain.

Orthotics vs Exercise therapy

The systematic review of ‘Exercise Therapy for Plantar Heel Pain,’ discussed the effect of exercise therapy versus the combination of customised orthotic devices and exercise. The trial concluded that both exercise therapy and combination of exercise with a customised orthotic device reduced the overall foot pain when compared with baseline results. However, the exercise therapy alone group was more effective in reducing overall pain than the combination group in those who stood for 8 hours or more daily.

The findings of this review support the use of exercise therapy following acute and chronic plantar heel pain over control/sham therapy, repetitive shock wave therapy, NSAIDs and orthotic devices.

References

Almubarak, A., & Foster, N. (2012). Exercise Therapy for Plantar Heel Pain: A Systematic Review[Ebook].

Babatunde, O., Legha, A., Littlewood, C., Chesterton, L., Thomas, M., & Menz, H. et al. (2018). Comparative effectiveness of treatment options for plantar heel pain: a systematic review with network meta-analysis. British Journal Of Sports Medicine, 53(3), 182-194. doi: 10.1136/bjsports-2017-098998

Brukner, P., Clarsen, B., Cook, J., Cools, A., Crossley, K., & Hutchinson, M. et al. (2017). Clinical Sports Medicine (5th ed.).

Rasenberg, N., Riel, H., Rathleff, M., Bierma-Zeinstra, S., & van Middelkoop, M. (2018). Efficacy of foot orthoses for the treatment of plantar heel pain: a systematic review and meta-analysis. British Journal Of Sports Medicine, 52(16), 1040-1046. doi: 10.1136/bjsports-2017-097892