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Leaflet: Heel Pain - A Guide for Patients and GPs

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Last updated: April 2020
Next review: April 2022
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What is Plantar Heel Pain?

Pain in the heel can be caused by many things such as a lack of cushioning at the heel, achilles pain, pump bump rubbing and nerve like symptoms. The most common causes of plantar heel pain are are related to the plantar fascia (plantar fasciitis/plantar fasciopathy) that reaches from the heel to the toes.

Its stretches with every footstep to support the arch. Over stretching the arch due to  tight calf muscles, foot shape, unsuppportive footwear or increased activity, strains the fascia, causing it to swell and then shorten at rest.

On standing after rest, the contracted fascia pulls at the heel bone where it attaches. This causes sharp, burning pain on the inside of the heel especially getting out of bed in the morning or after walking long distances.

However this does not mean that you will not get better, most cases of plantar fasciopathy get better by themselves . This can take several months.

1. Contributing factors

  • Being overweight
  • Wearing unsupportive shoes
  • Loss of the arch in your foot
  • Changes to activity levels or types of activity
  • Jobs which involve standing for long periods of time, or people who do lots of walking/hard floors/less protective footwear

2. How common is Plantar Fasciopathy?

Plantar fasciopathy is very common. Around 1 in 10 people will get plantar fasciopathy at some time in their life.

3. How is Plantar Fasciopathy diagnosed?

A podiatrist/ physiotherapist/ doctor can usually diagnose this by examining your foot and listening to your  symptoms. Your history can allow self diagnosis. If your plantar fasciopathy doesn’t settle after several months of appropriate self management then you can see further advice from your GP.

4. What are the symptoms?

Heel pain is the primary symptom of plantar fasciopathy. This pain can be anywhere on the underside of the heel. Commonly one spot is found as the main source of pain. This is often slightly forward from the heel and may be tender to touch.

People often report their symptoms as most intense during their first steps after getting out of bed or, after prolonged periods of sitting.

Gentle exercise may ease things a little. Long walks/ being on your feet for a long time and thin soled unsupportive footwear often makes the pain worse.

Usually the pain will ease in time and in general it is a self-limiting condition-meaning it should settle itself with time.  It can take up to 18 months for plantar fasciopathy to resolve.

5. What can I do?

  • Relative rest from any aggravating activities is important. You may have to modify you activities.
  • A short course of pain relief tablets or anti-inflammatories may help. Please dicuss this with a pharmacist or GP as this may reduce symptoms.
  • Ice/frozen peas wrapped in a tea towel applied for ten minutes, two or three times a day can also relieve symptoms.
  • Cushioned structured footwear and ‘pacing’ activites can help. A gel heel cup can cushion the heel. Orthotics can also be used to support the arch of the foot.
  • Calf stretching and strengthening exercises can help ( please see advice below).
  • If you are overweight then weight loss will help reduce the load the feet are under which may improve symptoms. https://www.nhs.uk/live-well/healthy-weight/start-the-nhs-weight-loss-plan/
  • Taping can help – using a non stretch tape to offload the plantar fascia can be helpful. Information on taping can be found on the heel fix website. heelfixkit.com
  • Night splints can be used. They can be purchased from a variety of suppliers. They do take time to get used to and they do not help everyone.

6. Are there exercises I can do?

Massage

  • Seated rolls the foot on a golf/tennis ball with toes elevated towards the sky and support your thigh with your hands. This allows deep tissue massage into the plantar fascia/ arch area.
  • For 2 minutes, 3-5 times a day.

Foot Strengthening

  • Seated place foot on a towel and scrunch the toes together-raise the arch of the feet at the same time.
  • Repeat 20 times x2 daily

Plantar Fascia Stretch

  • Sit with one foot resting on the opposite knee.
  • Using your hand pull all toes upwards while holding your heel stable, until you feel a stretch in the arch. Pull your foot toward your shin. You may feel a stretch in the back of the ankle.
  • Press your thumb into the heel and arch
  • Hold for 10 seconds 10 repetitions

Straight Leg Calf Stretching

  • Standing face the wall leaning against it with two hands
  • Front leg bent, back leg straight
  • Push the back heel into the ground
  • Hold for 20 seconds

How many? Start small build up slowly. Start with 5 repetitions, 3 times a daily

If comfortable, move up to 15 repetitions, 3 times daily.

Bent Leg Calf Stretching

  • Standing face the wall leaning against it with two hands
  • Front leg bent, back leg bent
  • Push the back heel into the ground
  • Hold for 20 seconds

How many? Start small build up slowly. Start with 5 Repetitions, 3 times a day.

If comfortable, move up to 15 repetitions, 3 times daily.

Plantar Fascia Loading Exercises

This strengthening exercise aims to create more resilience in the foot and ankle muscles when the plantar fascia is tightened. This is done by doing calf raises with a rolled up towel under the toes.

Roll a towel or thick piece of fabric under the toes. Stand on the edge of a step

The aim is to lift the toes in the air whilst performing a calf raise. (A calf raise is performed going onto your tip toes lifting your heel off the ground).

Slow controlled tempo of 3 seconds up, 2 second hold, 3 seconds down.

Key message: strengthening needs to be done slowly and controlled before you progress onto a new phase.

It may take you longer to progress to the next stage over the next 12 weeks.

Phase 1

  • Week 1-2, flat surface heel raise 12 repetitions 3 times every other day.

Phase 2

  • Move to a step and perform the heel raise on a step dropping the heel below the step
  • Week 3-4, build up slowly with 12 repetitions 3 times every other day.

Phase 3

  • Week 5-6, Add a backpack and one large textbook to add weight
  • This can be progressed up to 10 repetitions 4 times, every other day week

Phase 4

  • Week 6 onwards, Add another textbook to the backpack to add more weight
  • This can be progressed up to 8 repetitions 5 times, every other day week

Warning

Never do any activity that hurts your feet. It is normal to feel some discomfort, but do not push yourself to the point where you’re in pain. Be very careful with any activity you do. Pain is the warning sign; don’t ignore it. If you have any concerns contact your health professional that issued this leaflet

You should:

  • Expect mild – moderate pain that stops with rest. Do not continue if pain persists all day.
  • Add weight in a rucksack and increase resistance as tolerable (use pain as your guide).

7. What other treatments are there?

Shockwave Therapy
Extracorporeal Radial Shockwave Therapy (ESWT) is a non-invasive treatment in which a device is used to pass acoustic shockwaves through the skin to the affected area. The body responds to shockwave by increasing the blood circulation and metabolism in the affected area which accelerates the body’s own healing processes.

Research suggests there may be a small risk of tendon rupture following this procedure. NICE Guidance reports no major safety concerns with the use of this ESWT.

Steroid Injection
Steroid is an anti-inflammatory which can help with pain relief but only a small percentage will resolve completely from an injection. One of the main risks associated with a steroid injection to this area is causing a tear or partial rupture of the plantar fascia.

Research has shown “low quality evidence that corticosteroid injection is more effective than physical therapy”. Reference: https://bmcmusculoskeletdisord.biomedcentral.com/articles/10.1186/s12891-019-2749-z