What is it?
Plantar heel pain is one of the most common foot and ankle presentations. Heel pad syndrome is the second most common cause of plantar heel pain, about 15% of all heel presentations. Up to one in ten people will suffer from heel pad syndrome at some point in their lifetime.
The gait cycle’s first point of contact, the heel, is the primary absorber of the ground reaction force. During normal walking and running, pressures in the heel can reach more than 1-3 times body weight.
Time, stress, and various other factors can trigger a cycle of degeneration, dysfunction, and pain. This leads to decreased elasticity and shock absorption, resulting in increased calcaneal stress. Atrophic and degeneration seem to be the most likely cause of trouble causing heel pad pain.
Many genetic, medical, and lifestyle factors can contribute to the development of heel pad syndrome. Age seems to be a big issue due to degenerative atrophy occurring more commonly over time. Additionally, acute inflammatory presentations are common in young athletes.
Various diseases can increase the likelihood of developing heel pad syndrome, including diabetes, rheumatoid arthritis, psoriatic arthritis, peripheral vascular disease, and collagen disorders. Co-existing plantar fasciitis can cause a limited ability to dissipate force with increased stress on the heel pad.
Biomechanical stressors, including gait imbalances and obesity, are known contributors. Heel pad stress can increase when walking on hard surfaces and when walking or running barefoot.
Clinical Presentation
Heel pad syndrome complaints are typically described as a deep, diffuse, nonspecific bruise-like pain localized at the center of the heel. Patients may complain of tenderness when the heel is touched. Symptoms are typically worsened when walking on hard surfaces or barefoot, particularly for long periods of time.
The best clinical finding to diagnose heel pad syndrome is tenderness upon palpation at the center of the heel. In cases of substantial atrophy, palpation may reveal decreased heel pad thickness.
Limited dorsiflexion, limited first metatarsal phalangeal joint (big toe) extension, and toe flexor weakness are known contributors to plantar heel pain.
Clinicians should assess for gastroc and soleus muscle flexibility as well as foot and ankle strength and joint mobility. Assessment of the biomechanical chain should screen for any related functional deficits, including foot hyperpronation and hip abductor weakness, both of which can impact foot mechanics.
Gait evaluation can identify deficits and compensations. Patients with heel pain syndrome tend to transition weight away from their heels.
Diagnosis
The diagnosis of the heel pad syndrome is primarily based upon clinical findings. Imaging may be needed in the presence of trauma, red flags, lingering symptoms, or suspicion of alternate pathology. Radiographs may be needed to exclude stress fractures or other bony abnormalities.
Management
A majority of patients with painful heel syndrome respond favorably to conservative care within three months. Without care painful heels then become chronic, which causes pain and limited function to linger for years after diagnosis.
Conservative management consists of overloading with relative rest and cushioning with padding or shoe modification. Heel cups may be helpful to diminish pressure through weight redistribution. Providers will stress the importance of wearing supportive and densely cushioned athletic footwear. Patients should avoid wearing high heels or walking barefoot.
Patients may need to resist the intensity and duration of weight bearing activities. Some athletes may need to discontinue high-impact, symptom- provoking activities, especially long distance running. Patients should minimize carrying heavy loads.
Research shows that myofascial release techniques applied to the calf muscles and plantar fascia may reduce pain and improve function in plantar heel pain patients. Foot and ankle joint restriction routinely contribute to heel pain. Manipulation and mobilization of the foot and ankle joints may improve outcomes.
Stretching exercises should focus on restoring flexibility to the gastroc, soleus, and plantar fascia. Strengthening exercises should promote foot and ankle stability. Strengthening the toe flexors is an essential component of heel pain management. Rehabilitation should emphasize correcting any associated biomechanical deficits which could include foot hyperpronation and hip abductor weakness.
Various taping techniques seek to dissipate force at the heel and limit foot hyperpronation. Anti-fatigue matting may be helpful for patients who stand for prolonged periods of time.
The value of steroid injections is questionable for plantar heel pain. Repeated steroid injections can promote fat pad atrophy, therefore making it contraindicated.