Heel Pain & Injury

Heel Pain & Injury

Article by John Miller

What Causes Heel Pain?

Heel pain is a prevalent foot complaint and may involve bone, fat pad, ligaments, tendons or muscles.

Common Causes of Heel Pain

Plantar Fasciitis

The most common cause of heel pain is plantar fasciitis, a condition where your main arch ligament (fascia) becomes inflamed and causes pain.

More info: Plantar Fasciitis

Heel Spur

Plantar fasciitis can develop into a heel spur (calcaneal spur) when delayed fascia healing and bone is laid down due to excessive load through the injured soft tissue. Heel spurs are often related to flat feet or pes planus.

More info:

Achilles Heel

The attachment of your Achilles tendon can cause Achilles heel issues onto your heel, and this can be due to tendonitis or a related Achilles tendinopathy. While not necessarily painful, a ruptured Achilles tendon causes functional limitations such as an inability to rise on your toes, walk or run.

More info:

Other Tendinopathies

Peroneal tendonitis is a common lateral heel condition due to altered foot biomechanics or hind-foot control issues. Medially (inside your heel), another tendinopathy known as tibialis posterior tendinopathy can cause heel pain.

More info:

Retrocalcaneal Bursitis

Bursitis is another source of heel pain, and it can cause pain between your Achilles tendon and heel.

More info: Retrocalcaneal bursitis

Posterior Impingement Syndrome

Heel pain can also be associated with posterior impingement syndrome conditions, common in dancers or athletes who need to plant their foot, e.g. cricket fast bowlers. It can also occur in any athlete with a relatively unstable ankle, e.g. poorly rehabilitated sprained ankle.

More info: Posterior Impingement Syndrome

Heel Arthritis

Your heel pain can arise from osteoarthritis affecting the subtalar joint or talocrural (ankle) joint.

More info: Heel Arthritis

Stress Fracture

Bone injuries such as fractures can occur from a trauma such as a fall from a height onto your heel. Athletes, especially runners and landing sports, can also suffer overload fractures known as calcaneal stress fractures.

More info: Stress Fracture

Children’s Heel Pain

Sever’s Disease

Sever’s disease is a ubiquitous source of children’s heel pain. Sever’s is related to overactivity and overloading of the calcaneal growth plate.

More info: Sever’s disease.

Referred Sources

You must be thoroughly assessed to ensure an accurate diagnosis and subsequent treatment. Heel pain can also be referred to from a pinched nerve in your lower back, e.g. sciatica. Neural-origin pain such as sciatica and sural nerve pathologies can be tricky to diagnose and requires the professional opinion of an experienced spinal health care practitioner such as your physiotherapist.

Who Suffers Heel Pain?

Anyone can suffer from heel pain, but certain groups seem to be at increased risk, including:

  • Middle-aged men and women
  • Active people, e.g. running sports
  • People who are very overweight
  • Children aged between 8 and 13 years
  • Pregnant women
  • People who stand for long periods.

Common Sources of Heel Pain

Some of the many causes of heel pain can include:

  • Abnormal walking style (such as rolling the feet inwards)
  • Obesity
  • Ill-fitting shoes, e.g. narrow toe, worn-out shoes
  • Standing, running or jumping on hard surfaces
  • Recent changes in an exercise programme
  • Heel trauma, e.g. stress fractures
  • Bursitis (inflammation of a bursa)
  • Health disorders, including diabetes and arthritis.

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Article by Scott Schulte

How Do You Treat Achilles Tendinopathy?

The Achilles tendon is one of the biggest and strongest tendons in the human body. It is a continuation of the calf muscles and inserts at the bottom of the calcaneus (heel bone). “Achilles tendinopathy” refers to a combination of changes affecting the Achilles tendon, usually due to overuse or chronic excessive stress on the tendon. It can occur in athletes and non-athletes.

Treatment Options:

The specific approach used to treat Achilles tendinopathy can differ slightly depending on the location and stage of your tendinopathy. However, there are common strategies that research has shown to be effective.

  • Activity modifications include a temporary reduction in the activities that cause more than mild discomfort.
  • Heel lifts, supportive shoes and offload taping can effectively allow acute symptoms to settle.
  • Manual therapy, including massage or dry needling to improve mobility and ease muscle spasms around the lower leg and ankle.
  • Appropriate tendon loading exercises to restore flexibility and strength in the Achilles tendon and surrounding muscles.
  • Anti-inflammatory medications may be considered in particularly stubborn cases to assist in settling acute symptoms.
  • Management of other contributing factors such as obesity, diabetes and lifestyle habits is also beneficial.

Your physiotherapists at PhysioWorks will diagnose your Achilles tendinopathy and identify any contributing factors. They use various strategies and manual therapy techniques to settle your pain and guide you through a specific tendon loading program to restore tendon strength and allow you to return to usual activities and sports.

For more advice regarding Achilles Tendinopathy, please contact your nearest PhysioWorkc clinic.

More Info: Achilles Tendinopathy

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Article by John Miller

When Should You Worry About Foot Or Ankle Pain?

Some cases of foot and ankle pain require urgent attention.

Sudden Onset Foot Or Ankle Pain

Traumatic injuries that occur at speed or involve a multi-direction component such as twisting may result in foot or ankle fractures or significant soft tissue injuries, e.g. syndesmosis or high ankle sprains.

The Ottawa Ankle Rules determine the need for X-rays in acute ankle or foot injuries.

Ankle X-ray is only required if:

  • There is any pain in the malleolar zone; and,
  • Any one of the following:
    • Bone tenderness along the distal 6 cm of the posterior edge of the tibia or tip of the medial malleolus, or
    • Bone tenderness along the distal 6 cm of the posterior border of the fibula or end of the lateral malleolus, or
    • An inability to bear weight immediately and in the emergency department for four steps.

Foot X-ray is indicated if:

  • There is any pain in the midfoot zone; and,
  • Any one of the following:
    • Bone tenderness at the base of the fifth metatarsal (for foot injuries), or
    • Bone tenderness at the navicular bone (for foot injuries), or
    • An inability to bear weight immediately and in the emergency department for four steps.

Chronic Ligament Instability

Chronic ligament instability in your foot and ankle can cause premature osteoarthritis and joint deformity. Some conditions can be safely rehabilitated without surgery, whereas other conditions, such as a Lisfacnc injury, may require surgical repair.

Please consult your doctor or physiotherapist for specific foot or ankle injury advice.

Gradual Onset Pain That Fails To Improve

Stress Fractures

Stress fractures can be serious. While you may not have had a sudden traumatic injury, the ankle and foot are highly susceptible to stress fractures. Several bones in your foot can have their blood supply compromised by a stress fracture, leading to bone necrosis (death). These potentially life-changing conditions should seek an early assessment from your doctor or physiotherapist.

The good news is that most ankle and foot pain is not sinister and improves with physiotherapy and other non-surgical options.

Please ask your physiotherapist or doctor for advice.

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Article by Matthew Batch

What Triggers Plantar Fasciitis?

The plantar fascia supports the foot's arch by adding tension to it during weight-bearing activities. Plantar fasciitis may develop if the demands placed on the plantar fascia exceed what it can tolerate. This is usually a gradual process. Rarely is a single clear event that a person can refer to and say, “this was the moment it started”. However, a recent increase in weight-bearing tasks is often reported. Several risk factors can make it more likely for a person to develop plantar fasciitis. These include reduced ankle range of motion, increased body mass, a history of running, and work-related weight-bearing activities - specifically, people who spend a lot of time standing on hard surfaces or getting into and out of vehicles.

More info: Plantar Fasciitis

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Article by Alex Clarke

How Can You Tell The Difference Between Heel Spurs And Plantar Fasciitis?

Well, unless you have X-ray vision, you can’t! First, let’s look at what heel spurs and plantar fasciitis are.

Heel Spurs

Heel spurs are bony growths that extend from the heel bone called the calcaneum. They occur in response to an overload of tissue. The plantar fasciitis, the connective tissue that runs through the foot's arch, pulls at its attachment point at the heel. Excessive pulling may overload this attachment point. The body’s response to this excessive loading is to lay down more bony tissue to strengthen the area. The problem may be that this harder bony structure can further irritate the softer tissue around it.

It is not uncommon to have heel spurs without any pain. However, a heel spur's presence makes plantar fasciitis more likely.

More info: Heel Spurs.

Plantar Fasciitis

To describe this condition briefly, the connective tissue helping to provide stability to the foot's arch (plantar fascia) can become irritated (inflamed) and /or change the fascia fibre shape. Your plantar fascia is a thick fibrous band of connective tissue originating on the heel's bottom surface and extending along the sole towards the toes. Your plantar fascia passively limits the over-flattening of your arch. It is known as plantar fasciitis when your plantar fascia develops micro tears or becomes inflamed.

More info: Plantar Fasciitis

How Do We Tell The Difference?

We use imaging such as X-ray, ultrasound, or MRI to determine the presence of a heel spur. We can also use ultrasound or MRI to diagnose plantar fasciitis. We can also use some clinical tests and look for key symptoms such as first-step pain to diagnose plantar fasciitis without needing expensive imaging.

Remember that the two can occur together, or you can have a heel spur without plantar fasciitis or plantar fasciitis without a heel spur!

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Article by Matthew Hewitt

What is the Cause of Sever's Disease?

Sever's are caused by repetitive loading stress to the heel bone growth plate in growing adolescents. Microtrauma is caused by repetitive loading from running and jumping activities, which stresses the developing bone via the Achilles tendon.

Risk factors for Severs disease include high activity levels, running on hard surfaces, rapid growth, inadequate or worn-out footwear, weakness in the lower leg muscles, obesity and poor biomechanics.

How Long Does Sever's Syndrome Last?

Sever's syndrome typically lasts anywhere from 2 weeks to a few months, depending upon various factors, including activity levels, interventions required and growth rates.

Can You Play Sports With Sever's Disease?

Sever's is a self-limiting condition, so the individual's activity is limited by pain. However, as the condition is caused by loading of the calcaneus through the Achilles, it may be recommended that running is temporarily suspended or that modifications such as reduced training and/or game time are considered during the condition to reduce the duration and intensity of symptoms, and encourage a faster return to pain-free participation.

Can Sever's Be Permanent?

Sever's is a condition that only affects the growing skeleton and only occurs in growing children. Severs never occur after puberty as the calcaneal growth plates have finished ossification, usually between the ages of 15-17.

How Do You Treat Sever's At Home?

Management of Sever's symptoms can be aided by using ice and non-steroidal anti-inflammatories such as ibuprofen, increasing recovery and rest times, or reducing the loading frequency, duration and/or intensity. Improving the biomechanics of the foot through specific foot stretches and soft tissue release techniques may also be appropriate. Your podiatrist or physiotherapist can guide you towards these management strategies if appropriate.

More info: Sever's Disease

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Article by John Miller

What is a Tendinopathy?

Tendinopathy (tendon injuries) can develop in any tendon of the body. You may have heard of tendinopathies referred to as its aliases: tendonitis, tendinitis, tenosynovitis and tendinosis. In simple terms, they are all tendon injury pathologies, so the medical community now refers to them as tendinopathies.

Typically, tendon injuries occur in three areas:

  • tendon insertion (where the tendon attaches to the bone)
  • mid-tendon (non-insertional tendinopathy)
  • musculotendinous junction (where the tendon attaches to the muscle)

What is a Tendon Injury?

Tendons are the tough fibres that connect muscle to bone. Most tendon injuries occur near joints, such as the shoulder, elbow, knee, and ankle. A tendon injury may seem to occur suddenly, but usually, it is the result of repetitive tendon overloading. As mentioned earlier, health care professionals may use different terms to describe a tendon injury. You may hear:

Tendinitis (or Tendonitis): This means "inflammation of the tendon".

Mild inflammation is actually a normal tendon healing response to exercise or activity loading, but it can become excessive, where the rate of injury exceeds your healing capacity.

Tendinopathy Phases

The inability of your tendon to adapt to the load quickly enough causes the tendon to progress through four phases of tendon injury. While it is healthy for normal tissue adaptation during phase one, further progression can lead to tendon cell death and subsequent tendon rupture.

1. Reactive Tendinopathy

  • Normal tissue adaptation phase
  • Prognosis: Excellent.
  • Normal Recovery!

2. Tendon Dysrepair

  • Injury rate > Repair rate
  • Prognosis: Good.
  • The tendon tissue is attempting to heal.
  • You must prevent deterioration and progression to permanent cell death (phase 3).

3. Degenerative Tendinopathy

  • Cell death occurs
  • Prognosis: Poor!
  • Tendon cells are dying!

4. Tendon Tear or Rupture

  • Catastrophic tissue breakdown
  • Loss of function.
  • Prognosis: very poor.
  • Surgery is often the only option.

What is Your Tendinopathy Phase?

It is crucial to have your tendinopathy professionally assessed to identify its current injury phase. Identifying your tendinopathy phase is vital to direct your most effective treatment since certain treatment modalities or exercises should only be applied or undertaken in specific tendon healing phases.

Systemic Risk Factors

The evidence is growing that it is more than just the tendon and overload that causes tendinopathy. People with diabetes, post-menopausal women and men with high central adiposity (body fat) seem to be predisposed to tendinopathies and will need to observe their training loads.

What are the Symptoms of Tendinopathy?

Tendinopathy usually causes pain, stiffness, and loss of strength in the affected area.

  • The pain may get worse when you use the tendon.
  • You may have more pain and stiffness during the night or when you get up in the morning.
  • The area may be tender, red, warm, or swollen if there is inflammation.
  • You may notice a crunchy sound or feeling when you use the tendon.

The symptoms of a tendon injury can be similar or combined with bursitis.

How is a Tendon Injury Diagnosed?

To diagnose a tendon injury, your physiotherapist or doctor will ask questions about your past health, symptoms, and recent exercise regime. They'll undertake a thorough physical examination to confirm the diagnosis. They will then discuss your condition and devise an individualised treatment plan.

They may refer you for specific diagnostic tests, such as an ultrasound scan or MRI.

Tendinopathy Treatment

Tendinopathies can normally be quickly and effectively rehabilitated. However, there is a percentage of tendinopathies that can take months to treat effectively.

As mentioned earlier in this article, it is important to know what phase your tendinopathy currently is. Your physiotherapist can assist not only in your diagnosis but also guide your treatment to fast-track your recovery.

Before you seek the advice of your physiotherapist or doctor, you can start treating an acute tendon injury at home. To achieve the best results, start these steps right away:

  • Rest the painful area, and avoid any activity that makes the pain worse.
  • Apply ice or cold packs for 20 minutes at a time, as often as 2 times an hour, for the first 72 hours. Keep using ice as long as it helps.
  • Do gentle range-of-motion exercises and stretching to prevent stiffness.

When to Return to Sport

Every tendinopathy is different, so please be guided by your physiotherapist assessment. Be patient, and stick with the treatment exercises and load doses prescribed by your physiotherapist. If you start using the injured tendon too soon, it can lead to more damage and set you back weeks! It may take weeks or months for some tendon injury to heal and safely cope with a return to sporting loads.

Tendinopathy Prevention

To minimise reinjuring your tendon, you may require some long-term changes to your exercise activities. These should be discussed with your physiotherapist. Some factors that could influence your tendinopathy risk include:

  • Altering your sport/activities or your technique
  • Regular prevention exercises.
  • Closely monitoring and record your exercise loads. Discuss your loading with your physiotherapist and coach. They will have some excellent tips.
  • Always take time to warm up before and cool down / stretch after you exercise.

Tendinopathy Prognosis

While most acute tendinopathies can resolve quickly, persisting tendon injuries may take many months to resolve. Long-term or repeat tendinopathies usually have multifactorial causes that will require a thorough assessment and individualised rehabilitation plan.  Researchers have found that tendon injuries respond differently to muscle injuries and can take months to solve or potentially render you vulnerable to tendon ruptures, which can require surgery.

For specific advice regarding your tendinopathy, please seek the advice of your trusted healthcare professional with a special interest in tendinopathies.

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Article by Matthew Batch

How Can I Get Rid Of Plantar Fasciitis?

The management of plantar fasciitis requires treatment of what contributed to its development in the first place. Reducing these may be necessary if there was a recent increase in physical activity or standing time. From an exercise perspective, this may mean less time spent doing weight-bearing tasks, and if it is work-related, then breaking up periods of standing with intermittent sitting can be worthwhile. If limited ankle movement contributes to your symptoms, stretches can be effective, particularly for the calf and foot muscles. Beyond these strategies, there is good evidence for hands-on, soft tissue treatment of the plantar fascia and surrounding structures, taping the foot, and prescribing orthoses. Strength and movement training exercises can also be effective.

Physiotherapies are skilled in assessing and managing foot conditions, so call or book an appointment online today!

More info: Plantar Fasciitis

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Article by John Miller

What is Barefoot Running?

Barefoot running is a term that means either running either without shoes or with minimalist shoes. Barefoot running has gained popularity over the last few years to return to pure running and proclaims to help reduce the rate of running injuries. But is this accurate?

To gain a more scientific basis on whether barefoot running is advantageous or not for you, let’s look at what researchers have discovered.

Who is Suited to Barefoot Running?

When you run without shoes, you tend to land on the front part of your foot. This impact is called a forefoot strike. Landing through the centre of your foot is called a midfoot strike.

If you were to land barefoot on your heel, it's called a rearfoot strike, the ground shock would be excessive, and you would develop heel pain or injury, plus some other injuries further up your leg. That's why most barefoot runners tend to have a forefoot or midfoot strike. When you put on a traditional jogger with rearfoot cushioning, this cushioning allows you to land on your heel without damage. This heel is why a lot of shoe runners become rearfoot strikers.

Ground Reaction Forces

Generally, the higher the force, the greater the risk of injury. Research tells us that ground reaction forces are higher in the forefoot strike. Surely this would mean that you would get more injuries running with a forefoot strike technique. Not exactly. As well as considering the ground reaction force, it would help if you also looked at the vertical loading rate.

Vertical Loading Rate

The vertical loading rate is a measure of how quickly the ground reaction forces increase.

The steeper the curve, the greater the risk of injury. Running with a rearfoot strike produces a steeper force curve and makes some leg injuries more likely, but not all.

Running Shoes vs Barefoot Running

Does this mean you should toss away all of your running shoes? Maybe hold on to them just a little longer. The evidence is not clear yet about whether a forefoot/midfoot strike reduces your injury rate. What appears to occur is the barefoot running reduces loads in one area only to increase loads in another. And, since you are probably running on firm or rough surfaces such as footpaths, roads or gravel, you'll need some form of cushioning and protection for your feet. Don't you hate landing on those little stones!

What Should You Do?

If you are running without injuries at present, you would probably be silly to change. Changing footwear and technique may add another increase in loading and create new injuries elsewhere. Indeed, at PhysioWorks, we see more forefoot injuries in barefoot runners, which makes sense given the load charts. Plus, most of these injuries occur within a few weeks of changing your running style.

However, if you have been suffering injuries from running, barefoot may be a consideration for you. Changes to your running technique, such as reducing your stride length or your shoe style, could help you. You may also have some muscle control issues in another part of your body that could be altering the way you adapt your running style. So, before you toss your running shoes, it may be in your interest to consult with a running physiotherapist, a sports podiatrist or a running coach. They can analyse your running style, assess your body for weakness or tightness, check your leg and foot biomechanics or help you to retrain your running technique or some slightly weak muscles.

Most problems that cause running injuries are simpler to fix than you may think.

More info: Running Injuries

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