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    James Metcalfe

    Consultant Orthopaedic Surgeon

    James Metcalfe

    James Metcalfe

    Heel Pain and Plantar Fasciitis

    Why does my heel hurt

    The cause of heel pain can originate from one of several areas. The first step in the diagnosis is taking

    a history and making a clinical examination. This will lead the clinician to locating the exact area of the pain.

    Investigation for heel pain:

    Plain radiology

    A plain X-ray may be useful in assessing the cause of heel pain. This can usually be performed in the clinic and the results viewed immediately.

    Ultrasound Scan

    The cause of heel pain may arise from the soft tissue around the foot and ankle. These areas may be assessed by using an ultrasound scan. This is usually performed by a special X-ray doctor

    (radiologist) at a different appointment. The scan itself is not usually painful. If an area of inflammation

    is seen then the radiologist may be able to inject the area with local anaesthetic and steroid.

    The local anaesthetic acts to numb the affected area for a time lasting up to 24 hours. The steroid can provide some long lasting pain relief. If the pain is relieved even for a few hours then the area injected

    is the source of that pain. This is the diagnostic part of the injection.

    days, weeks, months or even longer. The length of pain relief is unpredictable.

    If the pain relief lasts for a few hours or days then returns the injection has still been useful. If the pain has not been totally relieved then the source of the pain may be somewhere else. In this situation than

    further injections may be necessary to locate the source of the pain.

    necessary to produce a more long lasting pain relief. I will assess you in this situation and be able to advise you on an individual basis.

    Magnetic Resonance Imaging (MRI) Scan

    This scan is useful for assessing soft tissue, bone and joint problems. This scan uses magnetic fields

    The steroid injection may relieve the pain for a longer period of time. The pain relief may last for a few

    If the injection has produced pain relief but the pain has returned then a further intervention may be

    to assess the tissues. The patient is placed into a tunnel for about 20 to 30 minutes. The tunnel is quite narrow.  You may not be able to have an MRI scan if you have metal or electronic implants. You

    will be asked prior to the scan if you are suitable for this scan.

    Plantar Fasciitis

    This is inflammation of the strong fibrous structure under the foot linking the front to the back of the

    foot. Where this fibrous tissue joins the heel bone there can be inflammation. This inflammation is called planar fasciitis. This typically causes pain in the sole of the foot which is worst in the morning.

    The pain is worsened with activity.

    Plantar Fasciitis Investigation and Treatment

    The diagnosis of plantar fasciitis can be made by history and examination. The vast majority of planar

    fasciitis can be treated by simple measures. In patients with plantar fasciitis there is usually an

    accompanying tightness in the calf muscles. Stretching these tight muscles is usually very helpful in the treatment as this will take the pressure off the plantar fascia. These stretches are very useful in preventing a recurrence of the plantar fasciitis.

    Cushioned shoe wear will also take the pressure off the planar fascia. Either a cushioned shoe or a special insole can be used. The insole of choice is a silicone heel cup and can be found on the

    internet. Rocker bottom shoes may be of benefit. (please see other information page)

    silicon heel cup

    A typical silicone heel cup.

    If the above measures do not help then an ultrasound guided injection may help to relieve the pain. The injection must be used in addition to the stretching exercises and insoles.

    If the pain continues then a new type of treatment with shock waves may help with the symptoms.

    Achilles Tendonopathy

    The Achilles tendon is a thick fibrous structure connecting the calf muscles to the bone of the heel. The tendon is made of special fibrous cells called collagen. These collagen cells are arranged in coils and the structure resembles rope.
    The Achilles tendon can be a source of pain in the middle of the tendon or at the area where it joins the heel bone. In the Achilles tendonopathy some of the small cells become torn. This is like the

    fraying of a section of rope. This area of damaged tendon will heal by producing excess collagen. This

    is the painful process. 

    not strong. The aim of treatment is to stimulate the tendon to heal and to reorganise the healing collagen into a tightly coiled and strong structure. This is done by an exercise programme called eccentric calf raises.

    The eccentric calf raises are best taught and monitored by a physiotherapist. These exercises are proven to work in excess of 80% of patients. The exercises must be performed until the tendon hurts. With effort and time the symptoms will improve in a 6 – 8 week period.

    If the eccentric exercises fail to relieve symptoms then further treatment may help. The use of extra

    corporeal shock wave therapy may help in reducing the pain. Surgery may be of benefit but only as a last resort

    This new collagen that is formed is not arranged in an ordered fashion and the resulting tendon area is