Achilles & Heel Pain
Heel pain generally either occurs under the heel (plantar heel) or at the back of the heel (posterior heel), in the region of the Achilles tendon and where it joins the heel bone.
The most common cause of plantar heel pain is 'plantar fasciitis'. The condition is very common but fortunately usually responds to relatively non-invasive treatment. You will find many treatments available in shops. magazines and on the internet, but the simple measures of appropriate footwear, insoles and stretches are the most effective. When the condition fails to respond to these measures, further investigation may be required. Occasionally injection, night splints or Podiatry are required. In very rare cases, surgery is necessary.
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The Achilles tendon is the strongest tendon in the human body, but can also be one of the most problematic. It is prone to degenerative and inflammatory disorders, as well as rupture. Degeneration of the Achilles tendon is known as 'tendinosis'. Patients with this condition suffer with pain on activity, such as running, sport or climbing stairs, and may be quite disabled during flare-ups. There is often a tender swelling in the tendon, above the heel-bone, which when severe, may indicate inflammation of the tendon sheath ('Peritendonitis'). These conditions are collectively known as Non-insertional tendinopathy, as distinct from Insertional tendinopathy, when the pain and swelling occur near the heelbone.
Non-insertional Achilles tendinopathy, otherwise known simply as 'Achilles tendonitis', often affects active people, particularly runners. Typical symptoms include pain in the tendon on running or walking, often associated with swelling. Patients often feel that they stiffen up at rest and during the night, and that the tendon has to “warm up”. The condition can be very difficult to treat, and often patients try many different treatments before seeking the advice of a specialist. A myriad of different treatments are available, but as with most things, it is best to stick to the tried and tested methods. Resting the tendon with heeled shoes or a heel-lift and a particular ty
pe of physiotherapy (eccentric calf strengthening) are usually all that is required. If your foot is unusually flat or high-arched, you may also require orthotics. The full course of treatment lasts 3 months, and is effective in the majority of cases, even if symptoms have been long-standing. If not, other experimental treatments are sometimes appropriate. These include laser, ultrasound, electromagnetic frequency therapy, shock wave therapy or injection (own blood or sclerosant). Rarely, surgery may be indicated.
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Insertional Achilles tendinopathy is otherwise termed 'Haglund’s deformity' or 'Pump bump'. Typically, there is a hard (bony) lump at the back of the heel, which causes discomfort with shoes. The skin over the bump becomes red and tender, and may even blister and break down. The condition is caused by a bony prominence on the heel-bone (calcaneum), and this in itself can cause further problems by 'impinging' on the Achilles tendon, leading to marked swelling ('retro-calcaneal bursitis') and degeneration of the tendon itself. Often the symptoms settle with simple measures, such as shoe modification, rest or specialised padded appliances. Sometimes a podiatrist can help with a custom-made insole, and occasionally an injection is indicated for retro-calcaneal bursitis (although not into the tendon itself). If these measures fail, surgery is required, and involves removal of the retro-calcaneal bursa and prominent bone, along with any degenerate tendon tissue. This is called a Haglund’s excision operation, and in some cases can be done endoscopically (keyhole surgery). The success rate of surgery is 85 – 90%.
These Achilles tendon problems are sometimes referred to as 'injuries', but strictly are 'overuse' or 'chronic' conditions. However, in certain circumstances, the tendon may rupture, either partially or completely. Rupture of the Achilles tendon is becoming increasingly common, and usually occurs in middle age during “explosive” sport such as squash, badminton or tennis. Typically a “pop”, “snap” or “tear” is felt behind the ankle, followed by bruising, swelling, pain and loss of function. Sometimes an Achilles rupture can be mistaken for a severe ankle sprain, because of the obvious similarities. The difference is that whereas an ankle sprain will usually heal well without any intervention, an Achilles rupture left untreated will usually result in a weak foot and a limp. It is therefore very important that you seek immediate advice from a specialist, if you suspect you have ruptured your Achilles. If seen at an early stage (within a few days), there are two options for treating a rupture – immobilisation or surgical repair. There are pros and cons of each form of treatment, and so treatment is tailored to the individual. Non-operative treatment usually involves wearing a cast or boot with close monitoring over a 10 – 12 week period, followed by physiotherapy. Repair can be performed either open or 'percutaneously' (minimally-invasive), followed by a period of immobilisation and rehabilitation. The results of early treatment are usually very good. If the rupture is discovered 3 or more weeks after the injury, a more involved procedure (a reconstruction) may be necessary, and even after surgery perfect function is rarely achieved.