Overuse by serious runners can result in various forms of heel pain, including plantar fasciitis, calcaneal apophysitis and Achilles tendonitis. This author discusses the classification and diagnosis of heel pain due to overuse injuries, and offers a comprehensive treatment plan.
Heel pain in runners is one of the most common injuries you will encounter in a sports medicine practice. There are many causes of heel pain but the main focus of this article will be on overuse injuries. Some initial considerations are biomechanical factors, the level of running, training factors, running shoes, frequency and mileage, terrain and conditioning of the runner. Many of the athletes we see in our practices are participating in different sports and may be running as part of their conditioning or offseason program. Accordingly, they may not be accustomed to the demands of running as well as the proper footwear.
In ascertaining the history of heel pain, important factors in your workup of pain include onset (sudden or gradual), whether the pain is localized or diffuse, pain intensity, duration, relief, prior history and treatment, changes in training, footwear, and medical history. It is also very important to localize the heel pain to plantar or posterior to help guide your assessment, diagnosis, and treatment plan.
Evaluate for functional causes such as inadequate shoe support, playing surfaces (which may cause stress on different muscle groups), kinetic chain dysfunction (muscle weakness, alignment, excessive pronation), and compulsion for running and training.
The physical exam includes a review of systems: vascular, neurological, dermatological, musculoskeletal, biomechanical and gait.
The differential for heel pain should include: plantar fasciitis, calcaneal apophysitis, Achilles tendonitis, stress fracture, retrocalcaneal exostosis, posterior tendonitis, bone cysts/tumors, bursitis. Rule out systemic causes such as rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, Reiter syndrome, inflammatory bowel disease, sarcoidosis, Paget disease, infectious causes, metastatic disease, hyperthyroidism, gout and sickle cell anemia.
How To Classify Overuse Injuries
It is helpful to classify overuse injuries according to the timing of pain to the onset of activity. Here is the system I have developed:
Type 1: pain after activity
Type 2: pain during activity, not restricting activity
Type 3: pain during activity, restricting activity and performance
Type 4: chronic, unremitting pain
What You Should Know About Treatment Approaches
There is a two-pronged approach to treating heel pain. One can treat the symptoms of pain and inflammation with non-steroidal anti-inflammatory drugs (NSAIDs), cortisone injections, ice/contrast soaks, physical therapy modalities, modified activity/cross-training. Clinicians can also treat the cause of pain (overuse versus biomechanical) with taping, shoe recommendation/modifications, addressing possible training and conditioning issues, stretching and strengthening, and possible custom functional orthotics.
Surgical treatment options are often a last resort after conservative and biomechanical measures are not satisfactory to the runner.
In my experience, if you do not address the symptoms and the cause, your treatment plan will not be as effective or successful, especially in the subacute to chronic cases. I typically will not jump to orthotics for heel pain unless the pain is chronic, appears to be biomechanical in nature and the runner has responded to low Dye strapping and using the proper type of shoe (stability, motion control or cushion).
Cross-training is extremely useful for modifying the activity but also allows runners to keep up their cardiovascular fitness, muscle strength and flexibility. Incorporating upper body circuit training, pool work, cycling and elliptical workouts can be very helpful in the return to activity plan.
The initial treatment of heel pain consists of the following:
Rest. Restricting running and modifying activity with cross-training is actually a better plan.
Stretching. Patients should not actively and aggressively stretch if they have an acute injury as it can actually aggravate the injury and hamper recovery. Stretching is helpful in the recovery phase after healing begins taking place. A gradual stretching program is helpful with the patient taking care to prevent pain while stretching. Stretching often happens too soon and too aggressively following an acute injury, which can lead to further injury to the muscle fibers.
Pads and orthotics. Options include prefabricated or custom orthoses.
Night splints. Consider night splints, especially in recalcitrant cases.
Steroid therapy. Steroids can be useful when pain is at higher levels. Repeat injections two or three times, depending on the response to the initial injection.
Keys To The Four Phases Of Treating Running Injuries
Treatment phase 1: Acute phase. The focus in the first phase is to decrease acute pain and inflammation, and decrease activity to avoid rebound pain. Patients should have cryotherapy two or three times daily for 20 minutes, and NSAIDs with meals.
Treatment phase 2: Rehabilitation phase. In this phase, we are seeking to further decrease pain and inflammation. This often involves the use of physical therapy modalities, maintaining/increasing flexibility of injured tissue and stretching posterior muscle groups.
Treatment phase 3: Functional phase. The emphasis of the functional phase is to strengthen the intrinsic muscles of the foot and protect the injured area during functional activity with taping, stability shoes and orthotics. This phase also prepares athletes for return to activity.
Treatment phase 4: Return to activity. This phase is the most important and challenging of the four phases for your serious athletes and runners. Usually, there is a gradual systematic return “to tolerance.” The runner will start back with walking, transition to a combination of walking and jogging, move to jogging, and proceed to running and interval training with the transitions and timing based on minimal to no pain or discomfort. During this phase, cross training can continue as supplemental or off-day training. You may want to initiate preventative strategies as well as orthotics and appropriate running and/or trail shoes. One can prescribe functional exercises for weak muscle groups. It is best to give the runner an individual training program with attainable goals based on response to your treatment and recovery plan.
Pertinent Principles In Diagnosing And Addressing Common Causes Of Heel Pain In Runners
The most common causes of heel pain in runners that I see are plantar fasciitis, Achilles tendonitis, calcaneal apophysitis (young runners), bursitis, stress fractures and posterior tibial insertional tendonitis. The history and physical exam will guide your diagnosis and treatment plan. However, there is much overlap in treating heel pain for the common causes, namely reducing pain and inflammation, addressing biomechanics and shoes, working with the athlete to reduce training errors, and modifying activity. The return to activity guidelines will depend on the response to your treatment, adherence with your treatment and conditioning plan, as well as age, weight and motivation to name a few factors.
Plantar fasciitis is very common, presenting classically with the post-static dyskinesia cycle and tenderness on palpation of the medial tubercule of the calcaneus near the origin at the medial tubercle of the calcaneus. Hallux dorsiflexion can increase pain (windlass effect). Often, there is a muscle tightness of calf and/or fascia. Ankle joint equinus, which produces hypermobility and increased pull on the fascia, is also common. Any motion that puts fascia in excessive stretch (planus/pronated foot position) or a contracture (cavus/supinated foot position) can cause plantar fasciitis. If pain is more diffuse, sometimes the posterior tibial tendonitis is also involved but the treatment is similar as you want to decrease the pronatory forces.
Calcaneal apophysitis commonly occurs in boys of 10 to 12 years of age and girls of 8 to 10 years of age, frequently occurring before or during a growth spurt and beginning a new sport. The youngster will complain of pain with running and jumping activity. Factors that contribute to this condition include tightness of the Achilles or plantar fascia, overuse, high-impact sports, improper footwear and training surface. The “squeeze test,” which involves squeezing the heel with medial and lateral compression over the apophysis, will cause pain. The plan is to restrict running and guide the young athlete to cross-training activity until pain subsides. Then the athlete can begin a gradual stretching program.
Achilles tendonits is most common in runners at the insertion of the Achilles tendon or within 2 to 6 cm of the insertion. The heel counter of the running shoe can also irritate and aggravate the bursa as well as the tendon sheath. Often, the runner will have a muscle imbalance/tightness or a recent change in activity, training or running shoe model. The treatment plan is to add heel lifts, correct training errors, have the athlete begin a gradual stretching program (eccentric and concentric stretching), provide shoe recommendations and consider possible functional orthotics for biomechanical causes.
Calcaneal stress fractures can be due to fatigue or insufficiency fractures. Most of the type we see in runners is due to fatigue. Bilateral incidence is not uncommon. The heel pain can be diffuse with weightbearing and rest relieves the pain. Pain increases with prolonged activity. A positive squeeze test and pain on the plantar heel on exam are common. Usually, there is a history of starting a running program recently.
Imaging is important to assess for a stress fracture as it is usually not visible on X-rays until two or three weeks after the onset of symptoms. A bone scan or magnetic resonance imaging (MRI) will confirm a stress fracture. Usually, if one suspects a stress fracture or stress reaction, put the runner in a walking boot and prescribe a cross-training regimen with a gradual increase in activity. Address biomechanical factors before the patient returns to a running program.
Finding Success With Conservative Treatments
Running and trail shoes. It is very important for the sports podiatrist who treats runners to be familiar with the various classes of running shoes: stability, motion control and neutral as well as more recent categories like minimalist and maximalist shoes. Preference and comfort are the guiding reasons runners choose their make and model of shoe so the podiatrist often needs to work within that framework when prescribing custom orthotics and running shoes. There needs to be a balance between controlling biomechanical function as well as providing adequate comfort and cushioning for the runner.
It is best to have a running shoe list in your practice that covers brands and models in simple categories, and covers shoes that tend to be orthotic friendly. Proper shoe fit, socks, orthotics and terrain are all import factors. Most of the runners with heel pain should be wearing their running shoes with most weightbearing activity until they are healed.
Orthotics. We very commonly prescribe orthotics for heel pain treatment in runners with a biomechanical cause of the chronic heel pain. It is important to remember that most runners will want a softer, more flexible device. While this device will not give them as much biomechanical control as they would want, combining the device with the shoe should provide the optimum amount of control, comfort and support for running. If the runner has responded well to low-Dye strapping, it will maximize the success of the orthotic.
One should consider the following for increasing control and decreasing pronatory forces: deep heel cup, medial heel skive, wider plate, thicker plate, cobra pad and medial flange. I think the main concern with orthotics and running shoes is to make sure you are not over controlling the runner with a rigid device in a stability running shoe.
Stretching. Stretching is another common prescription for heel pain. Here are just a few useful guidelines when it comes to stretching for your patients. Do not have them stretch an injured tendon. Stretching should begin once heel pain subsides and during the rehabilitation phase. It should start gradually with a focus on both the plantar fascia and the Achilles tendon groups. Evidence-based medicine shows about a 50-50 split on the benefits of stretching in general.1 However, when it comes to heel pain, stretching is believed to be helpful, especially when one combines it with a warm-up and cool down period.
Dr. Dutra is a Fellow and Past President of the American Academy of Podiatric Sports Medicine. He is an Assistant Professor in the Department of Applied Biomechanics at the California School of Podiatric Medicine at Samuel Merritt University. He is affiliated with Kaiser Permanente in Oakland, Calif., and is a podiatric consultant for intercollegiate athletics at the University of California at Berkeley.
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