Introduction to Plantar Heel Pain
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Top Contributors - Merinda Rodseth, Kim Jackson, Jess Bell, Ewa Jaraczewska and Tarina van der Stockt
Terminology[edit | edit source]
Many terms have been used to describe pain under the plantar aspect of the heel, including:(Riel 2017, Sullivan 2020, Rios-Leon 2019)
- Gonorrhoeal heel
- Policeman’s heel
- Heel spur syndrome
- Calcaneal spur
- Fat pad syndrome
- Subcalcaneal pain
- Jogger’s heel
- Plantar fasciitis
- Plantar fasciopathy
- Plantar fasciosis
- Plantar heel pain
Many of the terms used to describe pain under the heel are related to specific pathologies, even when the actual underlying pathology of pain under the heel remains largely unknown (Riel 2017, Cotchett 2020 ). Many clinicians have focused on the plantar fascia when presented with complaints of pain under the heel, but sufficient evidence now exists to indicate that the plantar fascia is not the only culprit (Riel 2017). Therefore, in order to facilitate effective communication between clinicians, improve patient’s understanding of their condition, encourage shared decision making and enhance treatment outcomes, consistent and unambiguous terminology is needed (Riel 2017). The term “plantar heel pain” was hence proposed to describe the condition of pain under the heel where no differential diagnosis exists (Riel 2017, Rios-Leon 2019).
Anatomy and Function of the Heel[edit | edit source]
The calcaneal bone is the largest bone in the foot and specifically adapted to sustain high tensile, bending and compressive forces, especially during weight-bearing (Cichowitz 2009, Palastanga 2012). Weightbearing is not equally distributed over the foot during stance but concentrated on the heel area. The inferior part of the calcaneus is roughened and covered by strong fibrous tissue, the fat of the heel pad and thick skin (Palastanga 2012). The lowest part of the posterior calcaneus transfers body weight from the heel to the ground during the heel-strike phase of walking (Palastanga 2012). The heel is very active in the gait cycle and takes weight for about 40% of the gait cycle - from heel strike to heel off (Levangie & Norkin 2011). The anteromedial aspect of the calcaneus also provides attachment to the plantar fascia, an important structure in the maintenance of the longitudinal arches of the foot (Palastanga 2012).
Prevalence of Plantar Heel Pain[edit | edit source]
Plantar heel pain (PHP) is one of the most common musculoskeletal conditions affecting the lower limb (Thomas 2019), with an estimated prevalence of 3.6-9.6% (Thomas 2019, Cotchett 2020) and accounting for 11-15% of all foot complaints in adults seeking professional care (Rasenberg 2019). It affects highly active people with high training volumes, such as runners, as well as middle-aged to older sedentary individuals (40-60 years) with high body mass indexes (Riel 2017, Rasenberg 2019). PHP can be long-standing and negatively impacts the quality of life. It is also associated with significant disability due to the pain complicating every day and sports activities (Rasenberg 2019, Cotchett 2020).
Despite the significant personal disability as well as the societal burden, the aetiology of PHP remains unclear (Sullivan 2020, Thomas 2019). PHP is associated with a range of foot-level factors such as
- pronated foot type
- limited ankle joint dorsiflexion
- first metatarsophalangeal joint dorsiflexion
- reduced muscle strength in the foot and the ankle
as well as personal-level factors such as
- high body mass index
- depression
- anxiety
- stress
- occupations requiring prolonged periods of standing (Thomas 2019, Sullivan 2020).
These factors may not infer causation, but they support the view that PHP is a complex and multifactorial problem (Thomas 2019, Sullivan 2020). The complexity of PHP combined with the limited understanding of its aetiology leads to uncertainty regarding the most effective intervention strategies (Sullivan 2020).
Location of the Pain[edit | edit source]
Clinically, pain is the most common complaint in PHP, resulting in difficulty with weight-bearing activities such as walking and standing and negatively impacting occupational and recreational activities (Saban 2016). Pain under the heel is typically located on the anteromedial aspect of the plantar heel (Riel 2017). Clinicians commonly use thumb pressure when manually palpating the heel, in order to locate the exact site of pain and formulate a diagnosis (Saban 2016). Foot pressure has long been considered significant in the aetiology of PHP (Sullivan 2020). Saban & Masharawi (2016) proposed the use of pressure pain thresholds (PPT) as a semi-objective method for quantifying the magnitude of mechanical pressure required to elicit pain. PPT is defined as “the minimal amount of pressure with which a sensation of pressure first changes to pain” (Rios-Leon 2019) and easily tested with pressure algometry (Saban 2016). PPTs are generally higher in the normal weight-bearing parts of the foot, expressing a lower mechanical sensitivity. Thereby the heel has the highest PPT level of the plantar aspect of the foot, which is consistent with the loading pattern of the heel during gait (Saban 2016, Rios Leon 2019). To measure the PPT, Saban & Masharawi (2016) had the patient lay supine with the feet over the edge of the bed and no pressure on the heel. The heel area was divided into 5 regions and PPT measurements were recorded at each of the sites using a hand-held computerised mechanical pressure algometer. In their study, Saban & Masharawi (2016) found the anterior medial aspect of the heel to be the most sensitive area of the heel, consistent with the area commonly cited by patients, but it did not differentiate between individuals with PHP and controls. Ríos-León et al (2019) reported lower PPTs (higher pressure pain sensitivity) in the general plantar region of both feet in individuals with PHP. This pressure pain sensitivity was also associated with higher pain intensity at first step in the morning as well as increased thickness of the plantar fascia at its origin but not with disability or foot posture (Rios-Leon 2019). They reported a more generalised hyperalgesia on the affected foot in patients with PHP (Rios Leon 2019).
Behaviour of the Pain[edit | edit source]
Pain under the heel typically presents as pain on the anteromedial aspect of the plantar heel during weight-bearing. It is generally exacerbated by prolonged periods of walking and standing and can be particularly sharp when first stepping on the heel after long periods of rest (for example, first stepping out of bed in the morning, or getting up after long periods of sitting down) (Riel 2017, Rios-Leon 2019, Morissey 2021). This “first step pain” is also the most commonly described symptom in PHP (Cotchett 2020).
