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Posterior & Plantar Heel Pain Causes and Treatments

By Dr. Steven Gershman, DPM

In my podiatry practice of over 31 years, heel pain is one of the leading complaints presenting and one of the most challenging to treat. It can negatively affect everyday life, especially at work and for just plain ambulation.

Heel pain is divided into bottom heel pain or plantar heel pain which is the most common, and back of heel pain or posterior heel pain which is the more difficult to treat. Both can make walking miserable.

Plantar Heel Pain

Plantar heel pain can be a component of plantar fasciitis which I have written about in previous blogs. Usually the patient complains of pain when first getting up, then an improvement after that for a short time followed by increased pain as the day goes on with time on the feet. It can be felt as a sharp pain in the heel or calcaneus (heel bone) or a dull chronic ache like a toothache.

Causes of Plantar Heel Pain

  1. Plantar fasciitis induced heel pain is often due to the abnormal pull of the plantar fascia on the connection point to the heel bone. This can result in a heel spur on x-ray. The spur is not the cause of the pain but more of a barometer or measure of chronic pull on the heel bone. Without getting too technical, this abnormal pull of the fascia is caused by a combination of over pronation which drops the arch and lengthens the foot and dysfunction of the big toe joint from the over pronation and arch drop. The plantar fascia is a piece of connective tissue that spans the bottom of the foot from the heel to the base of the toes. When the foot pronates and lengthens, the fascia is stretched and pulls on the heel bone abnormally causing damage to the fascia including micro tears and irritating the heel itself causing heel pain. Over pronation can also cause dysfunction of the big toe joint which again leads to increased fascia pull on the heel resulting in sharp pain in the heel.
  2. Another cause of plantar heel pain is simply direct micro trauma to the bone caused by standing on hard surfaces for many hours daily. Over the years I have seen many patients who work standing on metal or cement or other very hard surfaces and develop "sore heels". The bone has a covering over it called periosteum which has many pain nerve fibers making it very sensitive. Constant pressure on the heel while standing on hard surfaces irritates the periosteum causing sore heels and in some cases sharp pain in the heel. In addition, as we age the normal fat pad under the heel that is protective thins out. This allows more pressure on the bottom of the heel bone causing pain. Also, weight gain over the years adds to the problem.

Posterior Heel Pain

Pain in the back of the heel or posterior heel pain is a totally different and more challenging issue. Most commonly patients present with soft tissue swelling and bony enlargements on the back of the heel.  The achilles tendon inserts at the back or posterior of the heel bone (calcaneus) and there is a bursa sac there also. The achilles tendon connects two calf muscles, the gastrocnemius and soleus to the heel. In addition to moving the foot/ankle up down, these muscles are potent anti-pronating muscles. So, when the foot pronates, the muscles work to limit the pronation. This is important as when a patient over pronates, these muscles over work which causes an increased pull on the achilles tendon and the heel insertion. This can cause inflammation and pain directly at the heel insertion and an inflamed bursa or heel bursitis.

Many patients present with bony enlargements on the back of the heel. On x-ray there are usually spurs at the achilles tendon insertion. Unlike plantar heel spurs which are usually not an issue, these spurs are quite painful. Any ankle motion irritates the spurs as does the heel counter on the back of the shoes which can directly rub on the spurs causing pain. Furthermore, over pronation which can cause the spurs to form, also causes a direct traction on the spurs inducing more pain. This pain can be a sharp pain in the back of the heel.

Other causes of posterior heel pain are:

  1. An abnormality in the heel bone shape called Haglund deformity which is an enlargement of the back of the heel bone that protrudes back causing a visible bump on the back of the heel. This is not a spur but an actual bony abnormality which is often congenital. I have this issue and have since I was a child. It can be irritating as it rubs in the back of the shoe.
  2. Arthritis can cause spurs on the back of the heel.
  3. Sever’s disease which is pain at the posterior heel growth plate of a child around the ages of 9 to 13.
  4. Abnormally tight achilles tendon or calf muscles. This pulls on the heel insertion causing direct pain and an increase in pronation which can cause spurs and pain.

Treatment of Plantar Heel Pain

Treatment for plantar heel pain is based on cause. I ALWAYS start with looking at shoes. Soft and poorly supportive shoes especially OLD shoes can be one direct cause. To best treat heel pain, the shoes MUST be stable and fairly stiff on the bottom without a big heel build up. Orthofeet has a full line of this type of shoe. In fact, I wear them myself and they are the most comfortable shoes I have ever worn. Orthofeet heel pain shoes are designed with many advanced features to help provide comfort and protection. They feature premium orthotic insoles with anatomical arch support that prevent excessive pronation and help keep the foot in “neutral position”. They improve the alignment of the body and provide exceptional support with unsurpassed cushioning. The ergonomic sole design facilitates foot motion and alleviates stress on the joints. They feature soft supportive cushioning designed with air and foam to absorb shock forces and soften every step you take. It is also very important the shoes fit well since shoes that are too short or too narrow can affect the big toe joint or the gait cycle which can lead to multiple foot issues and continued heel pain.

If over pronation is the cause of heel pain, I recommend a non-custom orthotic along with the proper shoes first. I usually use the Orthofeet Biosole Gel Sport Orthotic as my first line treatment for plantar heel pain. I have dispensed thousands of this orthotic for heel pain throughout my professional career in my practice. I have many patients who repeatedly replace them over the years as they find them comfortable and relieve their pain. When necessary, I can back this treatment up with a "cortisone" injection and/or oral steroids like prednisone. If this fails to alleviate the pain, I often take it to the next level and prescribe a true custom orthotic with rigid control and soft cover cushioning. In severe cases or recalcitrant cases, I immobilize the foot in an air cast walker with the Orthofeet Biosole Gel Orthotic inside it for a few weeks.

If the issue is more lack of fat padding or standing on hard surfaces, I also start with well-made shoes like Orthofeet shoes, and then a more cushioned insert like the Orthofeet Thermofit Orthotic. It has a nice arch and superb cushioning. Orthofeet Thermofit Orthotics are Medicare approved and are only dispensed through medical providers. To locate a provider that carries Thermofit insoles click here. Orthofeet also has other options for this type of problem including the Biosole Gel Soft Orthotic or the Biofit Orthotic. If the issue is more complicated and more support and specific needs are necessary, I turn to a custom orthotic.

Treatment of Posterior Heel Pain

Posterior heel pain is much more difficult to treat. However, I have had excellent success with rigid custom orthotics and proper shoes that are well made offering stability and extra depth, like the Orthofeet shoes. I have had patients with large painful posterior spurs, that were told to have surgery by other practitioners, heal without the surgery just with proper shoes and orthotics. Surgery is not pleasant and can fail so I work hard to treat non-surgically. The key is to control the pronation with the orthotic as it is usually the main underlying cause of the posterior heel pain. If the calf muscles are tight, stretching is often helpful in younger patients especially. Injections are not administered in the back of the heel due to the risk of achilles tendon damage. However, sometimes oral steroids or NSAIDS like Ibuprofen are useful for short durations.

Even Haglund deformity and arthritis induced posterior heel pain often improve with proper shoes and custom orthotics.

Bottom line, sore heels are a big issue in our society and can affect so much of life and work. The good news is most all heel pain is treatable without surgery. Starting with well-made shoes like the Orthofeet shoes, is a good start and even if you need medical intervention, the shoes are the foundation in treatment.