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Heel Pain & Midfoot Pain Causes

Updated: Aug 15, 2023



Plantar Fasciopathy

Plantar fasciopathy refers to a process of inflammation and/or degeneration that occurs in the plantar fascia. It is also sometimes called plantar fasciitis or plantar fasciosis. The plantar fascia is a long fibrous tissue that extends from the heel bone all the way to the toes. The plantar fascia has poor blood flow, and because of this, it may sometimes take a long time to heal. Characteristic pains that are experienced with plantar fasciopathy include sharp pains first thing in the morning, dull aching pains throughout weight-bearing hours and aching pains shortly after getting off your feet for the day. Risk factors for developing plantar fasciopathy include flat feet, high-arched feet, arthritis, obesity/overweight, poor footwear and excessive weight bearing. Treatment options include footwear advice, stretching and strengthening exercises, foot orthoses, weight loss, load management, corticosteroid injections and surgical release.


Heel spurs

Heel spurs are growths of bone that occur at the origin of the plantar fascia. They grow due to excessive tension travelling through the plantar fascia. This is because bone adapts to the stresses that act on them - meaning that bone will grow towards the forces that are pulling on them. This is called Wolff's Law. Most of the time heel spurs do not cause pain, and in some instances, they may cause irritation to local soft tissues. There is usually another problem present, such as plantar fasciopathy, that causes heel pain.


Plantar fat pad atrophy

We are all born with the ultimate cushioning for our heels, and that cushioning is known as our plantar fat pad. The plantar fat pad can however degenerate and break down over time, causing larger impacts on the underlying bone and subsequent pain. Pain from plantar fat pad atrophy is usually right in the centre of the bottom aspect of the heel and is mostly experienced whilst barefoot on hard surfaces or in unsupportive footwear. Our plantar fat pads decrease in thickness naturally as we age, so you should not be surprised if this occurs in people aged 70+, however, there can be other causes that are responsible for damage to the plantar fat pad. Repeated corticosteroid injections and trauma can be responsible for damaging the plantar fat pad. Being overweight can also lead to the displacement of portions of the plantar fat pad too. Treatment for plantar fat pad atrophy includes footwear advice, padded/cushioned foot orthoses and silicone inserts.


Calcaneal fracture

A calcaneal fracture refers to a fracture of the heel bone. The heel bone is a part of a group of bones called the 'tarsals'.

Of all the tarsal bones, the heel is the most fractured, making up 60% of tarsal fractures. Heel fractures are usually caused by a large traumatic force, commonly associated with car accidents, and jumping from heights. In the instance of a traumatic event followed by severe heel bone, a CT scan is the gold standard imaging to ascertain the extent of the injury. If diagnosed with a fracture, depending on the extent of the injury, most of the time it can be managed by rest, anti-inflammatories/pain medication and an offloading boot for up to 8 weeks. In more serious cases surgery may be required. Our heel bone can also be fractured in other ways besides trauma. A stress fracture is a tiny fracture that occurs when the bone is stressed beyond its capability to regenerate and usually results in weight-bearing aching and throbbing of an evening. Stress fractures can be caused by excessive weight-bearing activities, as well as more pathological reasons, such as osteoporosis, where the bone becomes weak and brittle. Therefore, we can usually expect heel stress fractures in two groups of people - athletes who train hard, such as sprinters and elderly people susceptible to osteoporosis. Stress fractures are usually managed with the use of an offloading boot for up to 8 weeks, exercise modifications, footwear advice and strength programs (to help with bone mineral density).


Calcaneal periostitis

Calcaneal periostitis is often referred to as a heel bone bruise, however, there is not any bruising, and this is just an analogy to make it easier to understand. All the bones in our body are covered by a special type of connective tissue that acts as 'bone skin'. This bone skin is called the periosteum, and periostitis refers to inflammation of that tissue. Calcaneal periostitis usually follows a traumatic event, is painful during weight-bearing, and feels better when offloaded. Treatment of calcaneal periostitis includes protective weight bearing until the condition subsides. Protective weight bearing often includes activity modification, padded/cushioned insoles, and footwear advice.


Nerve entrapments

Another cause of heel pain that is often mistaken for plantar fasciopathy/plantar fasciitis is a nerve entrapment known as Baxter's Neuritis. Baxter's Neuritis is an impingement of a nerve in the foot that is called the lateral plantar nerve. It is often mistaken for plantar fasciitis because the symptoms are remarkably similar, however, there are a couple of distinct differences; there are often no morning/first-step pains and there is often what we refer to as neurological symptoms, which include burning, tingling, pins & needles, and numbness. Causes of Baxter's Neuritis include poor footwear, overused foot muscles and other conditions that affect nerve health such as diabetes, vitamin B12 deficiency or undergoing chemotherapy. Treatment of Baxter's Neuritis includes footwear advice, activity modification, management of underlying conditions and foot orthoses.


Tarsal coalition

A tarsal coalition refers to two bones in the foot that have fused together. When a tarsal coalition causes heel pain it is usually because the heel bone has fused with one of its neighboring bones. Tarsal coalitions can be categorized into three types: Fibrous, cartilaginous, and osseous. This means that the fusion of the bones occurs through diverse types of tissues. Tarsal coalitions often result in a flat foot that is very rigid and does not move much, which is often the cause of the pain, as the foot was intended to be mobile to adapt to the different forces of motion. Tarsal coalitions are often diagnosed by a physical examination as well as X-ray, CT, or MRI scans. Treatment of tarsal coalitions includes activity modifications, footwear advice, foot orthoses, corticosteroid injections and sometimes surgery.


Midfoot Pain Causes


Arthritis

Osteoarthritis is the most common cause of arthritis that affects the midfoot. Other less common types include rheumatoid arthritis, psoriatic arthritis, reactive arthritis, and ankylosing spondylitis. Pain from osteoarthritis is usually caused by cartilage damage and bone rubbing on bone, therefore, appropriate treatment includes aiming to splint the foot with specialized footwear and sometimes foot orthoses. The less common types of arthritis that can cause midfoot pain often do so by inflammation of tendons that cross or insert into the midfoot area. Management of this includes medical management by a rheumatologist, and if you are being managed by particular drugs and you are still symptomatic, then implementation of foot orthoses and footwear as well as corticosteroid injections are essential treatment modalities to be considered.


Nerve entrapment

There is a nerve that runs over the top of our foot known as the superficial peroneal nerve and sometimes this nerve can get trapped by bony enlargement caused by midfoot osteoarthritis. This entrapment can go on to cause what we call neurological symptoms such as burning, numbness, pins & needles and tingling over the top side of the foot. It is especially important that this condition is diagnosed and treated for correctly. Treatment usually only consists of surgical removal of the bony enlargements caused by osteoarthritis.


Ligament injury

There are many ligaments that hold together the bones of the midfoot, and all these ligaments can be subjected to injury. Sometimes damage to these ligaments is referred to as a Lisfranc injury and is usually caused by a high-impact traumatic event, such as a motor vehicle crash or kicking a rigid and fixed object. Lisfranc injuries are often very painful on weight bearing and usually do not get better if left untreated. Treatment includes non-weight bearing in a cast for a period of up to 8 weeks followed by a rehabilitation program that may involve footwear changes.


Fractures

A stress fracture is a tiny fracture that occurs when the bone is stressed beyond its capability to regenerate and usually results in weight-bearing aching and throbbing of an evening. Stress fractures can be caused by excessive weight-bearing activities, as well as more pathological reasons, such as osteoporosis, where the bone becomes weak and brittle. Therefore, we can usually expect midfoot stress fractures in two groups of people - athletes who train hard, such as sprinters, and elderly people susceptible to osteoporosis. The most common site of midfoot stress fractures is the navicular bone, which sits on the inside aspect of the midfoot. Stress fractures are usually managed with the use of an offloading boot for up to 8 weeks, exercise modifications, footwear advice and strength programs (to help with bone mineral density). Other fractures that can cause midfoot pain often affect the outside part of the foot due to a broken fifth metatarsal bone. This can be either a complete avulsion - where part of the bone is torn off, or another type of fracture lower down the shaft of the bone, known as a Jones fracture. These fractures are usually managed conservatively using offloading boots and activity modification, however, sometimes Jones fractures require surgical intervention because of poor blood flow impairing healing.




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