Heel Pain While Walking

Why Do Heels Hurt?

Painful heels are a life-disrupting condition, particularly in older age, causing significant discomfort and making normal movement difficult. In both younger and older individuals, heel pain is often more intense in those who are physically active. Heel pain while walking can stem from various conditions, such as plantar fasciitis, Haglund's deformity, tarsal tunnel syndrome, or Baxter’s neuropathy. In each case, proper diagnosis is crucial for effective treatment. To avoid degenerative changes, significant intensification of pain symptoms, and potential nerve damage, consulting an orthopedist for diagnosis and initiating appropriate treatment is essential.

What Is a Heel Spur?

Many patients visit an orthopedist with complaints of severe heel pain, asking whether it might be caused by a so-called heel spur. This common term refers to plantar fasciitis, a condition frequently encountered in clinical practice. Patients report sudden and severe pain at the back of the heel, in the plantar region. The issue involves the soft tissue (the fascia) extending from the calcaneal tuberosity to the toes. The term "heel spur" comes from radiographic imaging, where a bony growth—an outgrowth of the calcaneus—is visible. This spur forms due to inflammation at the junction where the heel bone connects with the plantar fascia.

What Are the Symptoms of Plantar Fasciitis?

Heel spur issues affect both women and men and are more common in older individuals, especially those who work or spend long hours standing, due to degenerative and overload-related changes. Heel pain is particularly prevalent among overweight individuals or those with limited ankle joint mobility. In overweight individuals, the longitudinal arch of the foot flattens, causing the plantar fascia to stretch further. This condition often affects athletes, especially runners whose training is overly intense. It can also result from years of wearing high-heeled shoes.

The primary symptom is piercing pain under the heel, felt in the morning during the first few steps after getting out of bed. Sometimes, heel pain after a night of rest subsides during the day but returns in the evening, spreading across the entire heel. Pain on the medial side of the heel is often accompanied by tension in the plantar fascia, along with difficulty dorsiflexing the foot.

Diagnosis and Treatment of Plantar Fasciitis

Palpation is key in diagnosing heel pain, as the tenderness in the heel spur area is significant. An X-ray is necessary to confirm the presence of a sharp bony outgrowth on the heel as the source of the pain. Additionally, the doctor may recommend an MRI to detect abnormalities in the plantar fascia. MRI can also reveal hidden stress fractures causing sharp heel pain in the plantar region.

In mild cases of plantar fasciitis, proper footwear selection, the use of shock-absorbing heel inserts, and stretching exercises are often sufficient. It’s important to note that pain relief will not occur immediately. Conservative treatment aimed at addressing the underlying pathology tends to be prolonged. In more advanced cases, pharmacological treatment with non-steroidal anti-inflammatory drugs or corticosteroid injections may be beneficial. However, caution is advised, as injecting the plantar fascia carries the risk of rupture, which could significantly complicate further treatment. Physiotherapy is a cornerstone of treatment, as the condition often accompanies calf muscle contractures or foot structure abnormalities, requiring a comprehensive therapeutic approach.

When Is Surgery for a Heel Spur Necessary?

Surgical intervention is considered when non-surgical treatments fail to alleviate heel pain after a standard period of up to 12 months. Plantar fascia surgery typically involves partially cutting the fascia. Historically, various techniques were used to adequately expose the affected area. Nowadays, endoscopic procedures are most common, involving two small skin incisions to introduce instruments and a camera. The surgical intervention in the foot structure is minimal, with a low risk of complications. However, the surgeon must exercise caution, as the procedure occurs near Baxter’s nerve.

Post-surgery recovery is rapid. No cast immobilization is required. Exercises to restore foot function are recommended the day after surgery. Crutches are used for about two weeks to prevent pain during walking. Prognosis after plantar fascia surgery is excellent. Heel pain should no longer be an issue, and athletes who recover can return to their previous training regimens.

What is Haglund’s Disease?

Haglund's disease was first described in 1927 by Patrick Haglund. This condition was initially classified as idiopathic, meaning it has no clear cause, although medical professionals have linked it to several factors. Haglund’s deformity, or "Haglund’s heel," is a condition where an extra bony growth forms on the calcaneus (heel bone), causing irritation and inflammation. This is well illustrated by the X-ray image of a patient’s heel before surgery. Just as people have different nose shapes and sizes, variations in the size and shape of these bones also occur. The protruding bony growth can rub against the Achilles tendon above it, leading to tendon pain. In this case, heel pain at the back is not the result of a single injury but is often related to physical activity and strenuous training (especially running or sports like soccer). However, this is not always the rule, as heel pain can also affect individuals with no connection to sports.

The soft tissue on the heel bone, near the Achilles tendon attachment, becomes irritated when the bone rubs against shoes during walking. This often leads to painful inflammation of the Achilles tendon bursa. The heel bone slightly protrudes outward, increasing the likelihood of rubbing against the back of the shoe, which exacerbates heel pain. Contrary to popular belief, the pain is not caused by overly tight shoes but by poorly designed or overly stiff heel counters, often found in women’s pumps, men’s winter boots, rubber boots, hockey skates, or rollerblades. Some studies suggest that heredity (such as the shape of the calcaneus and foot arch) and being overweight also play significant roles in developing Haglund’s deformity.

What Are the Symptoms of Haglund’s Deformity?

The first symptom is pain at the back of the heel, over the bony prominence, without significant swelling. Early symptoms are mild, leading only to discomfort while walking. Patients report pressure in the rear part of the heel, especially when putting on shoes. Initially, the symptoms are not severe or bothersome enough to prompt a visit to the doctor. This allows the deformity of the heel bone to progress over time. Gradually, these symptoms worsen, leading to noticeable limping while walking. Heel pain most often occurs after physical activity or in the morning but rarely at night. Over time, the heel develops a visible deformity accompanied by painful swelling, as shown in the images. In such an advanced stage of the condition, the calcaneus becomes very painful, especially during dorsiflexion of the foot. A further stage may involve inflammation at the Achilles tendon attachment to the calcaneus.

Main Symptoms of Haglund’s Disease:

• A visible lump on the upper rear part of the heel.
• Heel pain at the back, near the Achilles tendon attachment to the calcaneus.
• Heel pain after a night's rest.
• Redness in the inflamed tissue area.
• Swelling at the back of the heel.
• The condition may affect one or both feet.

Diagnosis and Treatment of Haglund’s Disease

Haglund’s deformity can often be diagnosed through a physical examination, but X-rays are necessary to confirm the diagnosis and rule out other causes of heel pain, such as assessing the structure of the calcaneus. With an early diagnosis and the initiation of conservative treatment, Haglund’s deformity offers good prognoses for patients. Non-surgical treatment focuses on reducing inflammation of the bursa and begins with rest and significantly reducing physical activity. To decrease swelling, ice packs should be applied to the inflamed area (cooling the heel for 20 minutes, followed by at least a 40-minute break before repeating). Doctors may prescribe oral non-steroidal anti-inflammatory drugs (e.g., ibuprofen) to alleviate pain and inflammation.

In some cases, the doctor may recommend corticosteroid injections into the bursa under ultrasound guidance. However, direct steroid injections into the Achilles tendon are not recommended, as they may weaken the tendon and increase the risk of rupture. Stretching exercises for the lower limbs are also essential to relieve tension in the Achilles tendon. Another important element is modifying footwear to reduce irritation to the affected bursa. Patients may consider using orthopedic insoles (either full-length or heel lifts) to offload the longitudinal arch of the foot or wear special shoes with soft heel counters or open-back designs. While conservative treatment can reduce heel pain and minimize inflammation, it cannot reverse the bony deformity of the calcaneus.

When Is Surgery for Haglund’s Heel Necessary?

If conservative treatment fails to deliver results and the deformity of the heel bone progresses, the orthopedic surgeon may decide to proceed with surgery. Surgical treatment involves removing the protruding bony growth, the deep Achilles tendon bursa (the main source of pain), and cleaning the front part of the Achilles tendon at its attachment to the calcaneus. The procedure can be performed using traditional open surgery (leaving a 4-5 cm scar) or minimally invasive endoscopic techniques, which require only two small incisions. Endoscopic techniques result in fewer complications during wound healing, allow for faster weight-bearing on the affected foot, and may enable a shorter rehabilitation period, quicker return to wearing shoes, recovery, physical activity, and sports. During the operation, the surgeon may also inject platelet-rich plasma into the Achilles tendon to promote healing.

The entire procedure takes about 40 minutes. After surgery, a splint is applied to minimize heel pain, which the patient wears for a week. After this period, rehabilitation begins, although patients may need to use a Walker boot (orthopedic shoe) for another two weeks. It is crucial to follow the instructions of the orthopedic surgeon and physiotherapist after the surgery. Patients usually return to sports and running about 12 weeks post-operation, depending on their rehabilitation progress. To prevent the recurrence of Haglund’s deformity and avoid further heel pain, it is recommended to:

Wear properly fitted shoes, avoiding stiff heel counters.
Perform regular stretching exercises.
Avoid running on hard surfaces and uphill during training.

Causes of Tibial Nerve Neuropathy

Foot pain localized in the heel area may also result from tibial nerve neuropathy. This condition is often referred to as tarsal tunnel syndrome (characterized by a mysterious burning sensation in the foot or heel pain). Although tibial nerve neuropathy is a common cause of foot discomfort, it is rarely correctly diagnosed and, consequently, improperly treated. The tibial nerve, along with blood vessels (posterior tibial artery and vein) and tendons of muscles (flexor digitorum, flexor hallucis longus, and tibialis posterior), passes through the narrow tarsal tunnel below the medial malleolus, where compression frequently occurs. Oxygen deprivation of the nerve, caused by venous stasis, leads to fibrotic changes in nerve fibers. Common causes of tibial nerve neuralgia include inflammation of the tendon sheaths within the tarsal tunnel and chronic irritation of the tibial nerve by bony elements due to improper foot placement during walking and running. Direct causes may also include various injuries to the heel and ankle, such as fractures, sprains, as well as scarring and adhesions.

What Are the Symptoms of Tarsal Tunnel Syndrome?

Tibial nerve neuropathy manifests as a burning pain on the plantar surface of the foot. Heel pain at the back may radiate to the medial calf. Venous stasis (and sometimes varicose veins), mentioned earlier, exacerbates the pain at night. Heel pain after a night of rest often subsides on its own once walking begins. Occasionally, swelling or thickening around the ankle and heel may occur. Predisposing factors include ankle injuries, swelling, rheumatic diseases, and obesity. Among athletes, particularly runners, causes of compression may include overuse in pronation, overly tight shoelaces, or anatomical abnormalities following a heel bone fracture. Before the typical symptoms of tarsal tunnel syndrome appear, athletes often subject their feet to prolonged strain, such as during running (increased training volume – more kilometers run) or weightlifting (lifting heavier weights). Symptoms tend to worsen with physical activity, especially running. It’s important to highlight the role of biomechanics, as improper foot placement affects its performance with every running stride.

Characteristic Symptoms:

• Numbness and tingling on the plantar surface of the midfoot,
• Pain under the heel,
• Weakness in the flexor muscles of the toes,
• Possible cramping of the toes,
• Worsening symptoms at night,
• Increased pain during walking,
• Reduced pain when the affected limb is elevated.

Diagnosis of Tibial Nerve Neuropathy

Accurate diagnosis is essential in treating tibial nerve neuropathy. While obvious injuries make diagnosis straightforward, persistent heel pain from chronic overuse injuries can be challenging to identify. During a clinical examination, a positive Tinel’s sign (a neurological test performed by tapping on the course of the affected peripheral nerve) is observed along the tibial nerve within the tarsal tunnel. A positive result is indicated by a sensation of pain or tingling in the foot. Valuable diagnostic insights can also be gained from imaging studies, including:

X-rays: Taken under weight-bearing conditions to rule out fractures, osteolytic lesions, and joint conflicts,
Ultrasound (USG): Identifies issues such as synovial membrane inflammation,
Magnetic Resonance Imaging (MRI): Reveals pathological changes within the tarsal tunnel or unnecessary tissue masses.

Additionally, EMG (nerve conduction studies) can confirm dysfunction at the nerve level. However, it is worth noting that nerve conduction studies often yield negative results, which does not rule out the diagnosis. This discrepancy arises because EMG tests are conducted on immobilized feet, while symptoms primarily occur under load.

How to Treat Tarsal Tunnel Syndrome?

The cornerstone of treatment is conservative therapy. This involves primarily limiting physical activity (to avoid further nerve irritation), using anti-inflammatory and pain-relieving medications, and employing special shoe inserts or completely changing footwear. If conservative treatment proves ineffective and heel pain persists, surgical intervention is considered. The procedure involves decompressing the tarsal tunnel (lasting up to 45 minutes). Unfortunately, surgery does not always yield complete relief. In some cases, irreversible changes to the tibial nerve may cause symptoms to recur after an initial period of relief.

Tarsal tunnel syndrome is an irritating overuse injury with initial symptoms that may be ignored and later misdiagnosed. This can result in permanent damage to the tibial nerve. Treating this condition becomes significantly more challenging, or even impossible, if therapy begins more than three months after the onset of symptoms. Therefore, any discomfort around the medial malleolus or burning sensations near the heel should prompt consultation with an orthopedic specialist.

What is Baxter’s Nerve Neuropathy?

Another condition related to heel pain, also involving a nerve (previously the tibial nerve), is Baxter’s nerve neuropathy. Anatomically, Baxter’s nerve is the first branch of the tibial nerve, which runs medially along the calcaneus (heel bone) toward the plantar side of the foot. The nature of this condition is very similar to tibial nerve neuropathy. Statistically, Baxter’s neuropathy is reported as a rare cause of heel pain. However, this may result from difficulties in proper diagnosis, leading to the condition being overlooked. Symptoms such as heel pain are often similar to those of plantar fasciitis, and both conditions can coexist. An experienced orthopedic specialist can distinguish between these two conditions based on their characteristic features.

In Baxter’s neuropathy, there is a burning pain on the medial side of the calcaneus, radiating toward the heel bone and often accompanied by a tingling sensation. The pain frequently worsens during physical activity.

Causes of Baxter’s Neuropathy:

• Plantar fasciitis
• High-arched foot (increased tension on the plantar fascia)
• Varus foot deformity (nerve compression along its path)
• Flat foot (posterior tibialis muscle insufficiency)
• Valgus or flat-valgus foot deformity
• Achilles tendon inflammation

How to Diagnose Baxter’s Nerve Neuropathy?

Accurate diagnosis is crucial for effective treatment, and as previously mentioned, diagnosing Baxter’s neuropathy can be challenging. Diagnosis primarily relies on a clinical examination, during which the orthopedist conducts a medical interview and palpation tests. Diagnostic imaging may assist in confirming the condition, including:

Magnetic Resonance Imaging (MRI): Reveals atrophy of the abductor digiti minimi muscle.
Ultrasound (USG): Provides detailed visualization of soft tissue structures.
To confirm the diagnosis, an orthopedist may administer a steroid injection around the lateral plantar nerve or the tibial nerve trunk near the flexor retinaculum. If the heel pain subsides following the injection, this confirms the diagnosis of Baxter’s neuropathy.

Treatment of Baxter’s Neuropathy

Treatment begins with physiotherapy, focusing on relaxing the tissue directly surrounding the nerve (the plantar fascia and muscles, such as the abductor hallucis and quadratus plantae). The gastrocnemius muscle and the hamstring group are also targeted, as their increased tension impacts the plantar fascia and contributes to nerve compression. Additionally, patients are advised to perform stretching exercises and use foam rollers to relax the posterior myofascial chain, reducing tension.

While physiotherapy and exercises can be effective, they may not always suffice, particularly in chronic cases where the patient seeks medical attention too late or the therapy is incorrectly administered (e.g., physiotherapy may exacerbate symptoms). For severe pain, an orthopedist may prescribe pain relief medications. If manual therapy fails to bring significant improvement and heel pain persists, surgical intervention is recommended.

The surgical procedure, performed by an orthopedic specialist, involves decompressing the lateral plantar nerve. Although technically challenging, it yields excellent results when performed correctly.

Conclusion

Heel pain can stem from a wide variety of causes. Many issues originate in early life, making heel pain frequently associated with wearing poorly fitted footwear or inappropriate insoles. Consider custom orthopedic insoles recommended by Rehasport Clinic to address such issues.

Related Articles:
Learn about other potential injuries to the foot and ankle joint.

References:

• Ortho Virginia – Minimally Invasive Achilles: Haglund’s Syndrome and Endoscopic Calcaneoplasty, Paul J. Switaj.
• Medical News Today – How do you treat Haglund’s deformity, Jennifer Berry, William Morrison.
• Health direct - Heel Pain