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Plantar Heel Pain is an umbrella term covering different diagnoses of pain experienced in the heel of the foot. These findings can be broken down into three main categories or types:

  1. Plantar fasciopathy/fasciitis.
  2. Heel fat pad syndrome.
  3. Calcaneal stress fractures, nerve irritation or heel spurs.

1. Plantar fasciitis (PF)

This is the most common cause of chronic heel pain in adults, affecting both young active patients and older more sedentary individuals. PF accounts for about 10% of runner-related injuries and 11% to 15% of all foot symptoms requiring professional medical care. It is thought to occur in about 10% of the general population as well, with 83% of these patients being active working adults between the ages of 25 and 65 years old.
PF more often affects only one foot, although approximately 30% of patients have symptoms in both feet.

What causes plantar fasciitis?

  • Overuse, as seen in runners and military personnel.
  • Excessive loading, as seen in obese (body mass index >30) people who spending most of their day sitting or lying down.
  • Standing for prolonged periods of time.
  • This condition is more frequently seen in individuals with structural foot deformities.

What is the treatment for plantar fasciitis?

  • Relative rest from offending activity as guided by the level of pain should be prescribed.
  • Ice after the activity
  • Oral or topical NSAIDs (Non-steroidal anti-inflammatory drugs)
  • Both pre-fabricated and custom-fitted orthotics have been shown to reduce pain and improve function in the short term with few risks or side effects.
  • Specific strengthening of the stabilising muscles of the foot.
  • Your physiotherapist can assist with treatment.

2. Heel fat pad syndrome (HFPS)

HFPS is a condition that occurs because of changes in the elasticity and/or the thickness of the heel fat pad. This is often caused by wear and tear over time of the fatty tissues that make up the heel pads on our feet, causing pain that could impact our daily routine and interfere with our regular activities. HFPS is the second leading cause of plantar heel pain after PF.

 

What causes heel fat pad syndrome?

  • Inflammation of the fat pad.
  • Displacement or thinning of the fat pad.
  • Force: Walking or running barefoot, particularly on hard surfaces like concrete or tiles.
  • Gait imbalance: Patients with excessive pronation or supination.
  • Overweight and obesity: Patients that are overweight or obese are at higher risk of developing heel pad pain since their excess body weight puts additional pressure on the feet.
  • Plantar fasciitis: When the PF is injured or inflamed, it has a reduced ability to distribute the forces while walking or running which leads to extra pressure on the heel fat pad, and consequently, leads to quicker wearing.
  • Medical conditions causing fat pad atrophy: Lupus, rheumatoid arthritis and Type 2 diabetes.

What is the treatment for heel fat pad syndrome?

  • Icing – to reduce pain and inflammation.
  • Activity modification – reducing load on heel fat pad.
  • Taping – to take the foot out of pronation, specialised taping for plantar fasciitis is applied.
  • Possibly orthotics and heel cups.
  • Addressing altered foot biomechanics – kinetic chain work (strengthening and core/breathing work).
  • Increase load on tissue, adding sport-specific/dynamic exercise – Prepare the foot and lower limb for more explosive movements to gradually progress back to full function.

3. Calcaneal stress fractures

A calcaneal stress fracture is one or more small fractures/cracks in your calcaneus or heel bone. These fractures often occur because of repetitive, long-term stress on the bone, such as running. Calcaneal stress fractures account for 20% of all fatigue-induced fractures.

What causes calcaneal stress fractures?

  • Repetitive high impact activities.
  • Training errors and/or a change in sport.
  • Inadequate shoes (running with a heel-strike style in minimalist shoes over-strains the heel).
  • Vitamin D and calcium deficiency.
  • Excessive tobacco and alcohol usage.
  • More common in overweight female population.
  • Osteoporosis.

What is the treatment for this condition?

  • Education on optimal loading, correcting training errors and suggesting alternative exercises that are minimal weight bearing.
  • Load reduction – stop aggravating activities; some studies suggest wearing a moonboot and using crutches for 6 weeks.
  • Icing.
  • Wearing cushioned shoes/heel cups/gel pads.
  • Hydrotherapy.
  • Kinetic chain exercises.
References
  1. Buchanan BK, Kushner D. Plantar Fasciitis. [Updated 2022 May 30]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from https://www.ncbi.nlm.nih.gov/books/NBK431073/
  2. L. Daniel Latt, David Eric Jaffe, Yunting Tang, and Mihra S. Taljanovic Foot & Ankle Orthopaedics 2020 5:1
  3. Morrissey D, Cotchett M, Said J’Bari A, et al Management of plantar heel pain: a best practice guide informed by a systematic review, expert clinical reasoning and patient values.
  4. British Journal of Sports Medicine 2021;55:1106-1118.
  5. Saad A, Kho J, Almeer G, Azzopardi C, Botchu R. Lesions of the heel fat pad. Br J Radiol. 2021 Feb 1;94(1118):20200648. doi: 10.1259/bjr.20200648. Epub 2020 Oct 15. PMID: 33002374; PMCID: PMC7934309.
  6. Chang AH, Rasmussen SZ, Jensen AE, Sørensen T, Rathleff MS. What do we actually know about a common cause of plantar heel pain? A scoping review of heel fat pad syndrome. J Foot Ankle Res. 2022 Aug 16;15(1):60. doi: 10.1186/s13047-022-00568-x. PMID: 35974398; PMCID: PMC9380282.