Heel pain is a common complaint seen by our expert musculoskeletal physiotherapists and orthotists. The exact rehabilitation program followed is carefully planned by our clinicians according to the diagnosis and possible causes. Causes of heel pain are often related to the insertion of the achilles tendon (insertional achilles tendinopathy) or the insertion of the plantar fascia when the pain is located under the heel.
In cases of insertional tendon and soft tissue related heel pain evidence dictates that there is often a multifactorial cause. Causes may include a sudden increase in load on these structures such as sports related training errors, biomechanical problems as well as reduced strength of the soft tissue structures themselves.
Rehabilitation in these cases, aims to address all relevant causes. Depending on existing strength and levels of pain a modified strengthening or loading program will often be introduced early in the rehabilitation phase.
Insertional achilles tendon loading programs may involve a graduated program of heel lift exercises. These may be progressed from being performed with both legs simultaneously to single leg and then involving increasing the load with weights. These exercises are modified by performing them from the floor rather than off the edge of a step as is often the practice with non insertional achilles tendinopathy. This modification ensures that the problematic insertion point of the achilles tendon is not excessively tractioned from the heel bone, thereby, aggravating symptoms.
Loading the plantar fascia and it’s insertion point to the calcaneum is more troublesome. However, as the toes extend during a heel raise exercise from the floor this will tension the plantar fascia. As a result many therapists offer a similar heel raise loading program to treat insertional plantar fasciitis. In some circumstances physiotherapists may place a wedge under the big toe which may accentuate the tension through the plantar fascia and ensure some of the smaller muscles supporting the arch of the foot are activated
In other cases heel pain may be related to inflammation of fluid filled sacs terms bursae or atrophy of the protective fat pad under the heel. The primary treatment for these cases will be aimed at offloading these structures by way of a footwear insert (orthotic) or with cushioning and support around the inflamed structure. If a more comprehensive or long term solution is needed this will be constructed by our expert orthotist.
With all causes of heel pain our expert physiotherapists and orthotists will work to establish underlying biomechanical causes of the trouble which may inform additional exercise based rehabilitation strategies. Some common examples of biomechanical problems causing heel pain may include:
- Tight calf muscles (increased tension through the calf muscle complex and plantar fascia)
- Tight hamstring muscles (increased tension through the calf muscle complex and plantar fascia)
- Flatfoot/ hypermobile foot posture (reduced stability and increased time loading the rearfoot)
- High arched foot posture (poor shock absorption)
- Poorly fitted/ unsuitable footwear (poor shock absorption)
Our clinical team will base their analysis of relevant risk factors for each individual based on a clinical examination and possibly an expert review of footwear and a gait analysis using force plate measurements and subsequent software analysis. If a flexibility program for the calf or hamstring muscles needs to be considered our physiotherapists will take you through the relevant exercises. If there is an inherent foot posture which may be contributing to the problem then our expert orthotist will provide customised insoles.
Due to the multi factorial causes of heel pain, these cases may take several months to resolve and in some cases may require ongoing management of symptoms. The soft tissue and tendon insertion points (termed entheses) around the heel bone have a very poor blood supply which is one cause for the prolonged timeframe for recovery. The other cause for the prolonged timeframe is that with the multi factorial causes it may take some time to establish a primary treatment strategy.
Circle Health offer consultant and physiotherapy led shock wave therapy (SWT) which may be used to treat certain types of heel pain when physiotherapy and orthotic management have not led to a full resolution. SWT is a relatively new, innovative treatment which delivers significant blasts of energy (shock waves) to tendons and soft tissue by way of a probe. It is thought that the energy produces some inflammatory effect in the tendon, thereby, resetting the healing process.
For more in depth information on shock wave therapy please visit our Shock wave therapy treatment page