What hurts?
Some possible conditions • Heel Pain – Bottom of Heel
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Baxter’s Nerve Entrapment -
Heel Spur -
Plantar Fasciitis
Some possible conditions • Heel Pain – Bottom of Heel
Baxter’s nerve entrapment is a cause of heel pain whereby entrapment of a nerve, commonly known as “Baxter’s nerve,” occurs. This nerve runs from the inside of the heel, under the arch of the foot to the outer heel. Baxter’s nerve entrapment is hard for medical professionals who do not specialize in the foot to diagnose. It causes symptoms similar to plantar fasciitis and usually also co-exists with it. It is an often overlooked cause of heel pain and literature estimates it to be the cause of 1 in 5 cases of medial heel pain.
The following signs or symptoms may be indicative of a Baxter’s nerve entrapment: • Chronic pain on the inside (medial aspect) of the heel. • A radiating or burning pain under the heel. • Where pain has persisted for some time, there can be numbness/pain in the outside (lateral) part of the heel or foot. • Symptoms are usually worse following activity.
This condition is caused by either compression or entrapment of Baxter’s nerve. Common causes of Baxter’s nerve entrapment include: • Poor foot mechanics or excess foot pronation (rolling inwards of the foot) • Flat feet • Compression from poor footwear • Fat pad atrophy (heel) • An injury to the foot that results in swelling around the inside or underneath the heel • Repetitive overuse or trauma to the nerve during certain activities e.g. running.
RICE (rest, ice, compression, elevation) and anti-inflammatory medications can help reduce the inflammation present, which in turn, will reduce pain. However, best treatment practices include assessing for biomechanical concerns and considering orthotics or footwear to best address the entrapment and open up the narrow space. Although surgery is an option, it should be considered a last resort as conservative therapies are generally successful.
A heel spur is a bony protrusion on the underside of the heel bone. It can been seen on an x-ray but might be suspected even before an x-ray is ordered. They are found in a vast majority of people and most times are incidental findings as they do not cause pain, but in some cases they can be painful.
Where pain is present, it is felt on the underside of the adult heel bone, also known as the calcaneus. It can feel sharp and is mostly bothersome when standing, walking, running or jumping. It does not radiate and is very localized to the bottom of the heel, where the plantar facia ligament attaches to the heel bone.
Heel spurs occur when calcium deposit (bone) builds up on the underside of the heel bone, a process that usually occurs over a period of many months or years. Heel spurs are often caused by strains on foot muscles and ligaments, such as stretching of the plantar fascia ligament, and repeated tearing of the membrane that covers the heel bone. Heel spurs are especially common amongst athletes whose activities include large amounts of running and jumping. Other risk factors include obesity and walking or gait abnormalities.
Conservative treatment is the first line therapy approach, which consists of off loading the heel spur. Taking the load off can be accomplished with orthotics that are modified with a “cut out” for the heel spur. Gel heel pads in shoes can offer temporary relief, but are a bandaid solution. Having a pair of orthotics made custom to your walking/gait abnormalities, addresses the causation in addition to relieving pressure and discomfort at the bottom of the heel. Conducting stretches of the calf muscle and plantar fascia are beneficial also. Proper footwear, fit by a Canadian Certified Pedorthist, and avoiding barefoot walking/running are important first steps to healing. Icing the heel after activity can help reduce the acute inflammation. Heel pain is not normal and requires a visit to a Foot care Clinician.
The most common cause of heel pain is plantar fasciitis. Plantar fasciitis is grossly defined as a thickening of the ligament (the plantar fascia) that connects the heel bone to the toes. The plantar fascia aids in holding up the arch and with shock absorption for standing and walking. It is also part of a pulley system to aid in toe push off when walking and running. The ligament can have tiny tears from overuse, which causes heel pain with first steps in the morning or after a period of rest. Pain can dissipate after walking, however pain tends to return with prolonged standing and walking. Plantar fasciitis is often associated with a heel spur on the bottom of the heel bone, but a spur does not have to be present to be symptomatic.
Plantar fasciitis presents with symptoms of stabbing/sharp pain in the bottom of the foot at the heel. Mild swelling can be felt in the arch of the foot if persistent ligament thickening is present. Pain is often temporarily relieved with icing the area. Barefoot walking tends to exacerbate the pain, especially on hard surfaces, such as concrete, wood floors or on tile. Pain can radiate to the toes or towards the calf along the back of the heel in more complicated cases but this is very rare. Radiating pain should be investigated for a condition involving the nerves. People often describe the pain as a “stone bruise” feeling to the sole of the heel bone. Limited dorsiflexion or “upward motion” at the ankle is often present in people with plantar fasciitis.
Tension and stress on the fascia can cause small tearing and inflammation leading to pain and swelling in the heel and fascia. Factors that increase the risk of developing plantar fasciitis include age (between 40 and 60 years old); activities, such as long-distance running, ballet dancing, and aerobics; flat feet; atypical gait cycle; obesity; new or inappropriate shoes and finally occupations which require long hours of walking or standing on hard surfaces. A tight gastroc complex (calf muscle) can lead to an overpull of the plantar fascia and lead to pain and inflammation.
Most patients recover with conservative treatment such as arch supports (orthotics), rest, icing, stretching and modifying activities. Supporting the plantar fascia (arch) is one of the most important things you can do to reduce additional ligament tearing and allow for healing. Other valuable treatment options include physical therapy or splinting, such as a night splint to stretch the calf muscle and help reduce overpronation. A localized cortisone injection from a Chiropodist can be immediately effective to reduce pain and swelling. Non-steroidal anti-inflammatory medications, such as ibuprofen may be necessary as well. Ultrasound therapy and Extracorporeal Shock Wave treatments have also been utilized with excellent success, prior to considering surgical options. Severe pain or delayed treatment may require a period of non-weight bearing in a boot to decrease the inflammation present.
