Heel pain is usually caused by plantar fasciitis that is sometimes called heel spur syndrome since a bony is usually present coming off the calcaneus. However, pain in the heel has a differential diagnosis of many potential causes. The foot and ankle surgeon will properly diagnose the cause of heel pain ruling out stress fracture, Achilles insertional tendinitis, bony growth to the posterior calcaneus, nerve irritation, arthritis, bony cyst, or infection. In children still undergoing growth, heel pain may be due to irritation and inflammation of the growth plate within the calcaneus called apophysitis.
Plantar fasciitis is irritation and inflammation of the plantar fascia. The plantar fascia extends from the toes to the heel. It is a fibrous band of connective tissue that serves to support the plantar arch of the foot. Heel pain due to plantar fasciitis presents with sharp and achy pain to the plantar medial heel where the plantar fascia inserts onto the calcaneus. Plantar fasciitis pain may or may not present with having a heel spur. This depends on how long the condition has been going on. Heel spur formation is a sign of enthesopathy that results when the plantar fascia pulls against the calcaneus under tension over time resulting in formation of bony growth along the course of the tension. Patients with plantar fasciitis usually states a consistent history of having heel pain that is worse after taking the first step after getting up from rest. Patients with high-arched foot or flatfoot are more prone to developing plantar fasciitis.
The foot and ankle surgeon will obtain an accurate medical history and obtain imaging studies to determine if the heel pain is due to plantar fasciitis or of another differential diagnosis. Having a plantar heel spur seen on x-rays only confirms diagnosis as plantar fasciitis and provides information on the chronicity of the condition, but it is important to note that the spur itself is not the cause of the pain. In fact, the heel spur is not even present in many cases of plantar fasciitis having been diagnosed through clinical history.
Initial treatments of plantar fasciitis include stretching exercises, icing area of the heel, topical and oral anti-inflammatories, avoid going barefoot, and wearing more supportive shoes. Biomechanical treatments such as strapping of the foot or wearing orthotics support the medial arch and decrease the traction tension and attenuation of the plantar fascia against the calcaneus. Cortisone injections may be necessary to provide immediate relief of more intense pain. Additional treatments involve physical and massage therapy of the plantar fascia. Most patients do not need surgery to relieve plantar fasciitis pain; however, a small percentage of patients will require surgery after conservative treatments have all failed to relieve pain. Surgery involves releasing the plantar fascia at its insertion site to the plantar calcaneus.