Seasonal Insertional Heel Pain – a matter of overuse

by Andrew Coutts. BSc Hons, MSc, FCPodS, Specialist Registrar in Podiatric Surgery, Derbyshire Community Health Service NHS Foundation Trust

One of the most common questions I get asked by patients, colleagues and friends is – ‘how do I get rid of my heel pain?’ I see many patients with plantar fasciitis symptoms, insertional Achilles tendonosis and other causes of heel pain, such as retrocalcaneal bursitis, tarsal tunnel syndrome, fat pad atrophy and Sever’s Disease, however every year I see an increase in referrals specifically around February, March and April time [1]. It does make me ponder on why there is an increased tendency of seasonal referrals of insertional heel pain at this time of year and my conclusion is always overuse!

For many of us, New Year is a time when we often reflect, create plans to make changes to our lives, work and home. It’s seen as the busiest time of year for people to make alterations, more people join weight loss classes and it is well known to be the time where more gym memberships are taken out. January and February are the busiest times in gyms where queuing for a machine is not unusual, whereas the Sunday prior to Christmas has been shown to be the quietest day when only the hardcore gym goer can be seen [2]. So in many cases, people will join the gym to lose weight, however seeing and hearing someone who is significantly overweight pound on the treadmill for 20 minutes with a pair of 5 year old trainers on just makes my joints ache, never mind theirs. Many think it’s only doing me some good if it’s hurting, which as we know isn’t the case. During running we can generate and have to support three times or more of our body weight through our joints, the Achilles tendon and plantarfascia and hence in a case of a 14 stone lady with a BMI of 30+, they’d be generating over 40 stones through these structures and hence this can seriously increase the risk of injury.

Common aetiological factors of plantarfasciitis and insertional Achilles tendonosis are: [3]

  • Overweight and/or obese;
  • Poor footwear;
  • Occupation;
  • Running;
  • Age;
  • Structural abnormalities – genu valgum, cavoid foot (high-arched foot).

Activities such as cycling and elliptical trainers are much better as they’re gentler on the lower limb structures. So, yes more people join the gym at the beginning of the year, so it’s easy to see why more people develop insertional heel pain of different descriptions in February, March and April time. However, as I pointed out earlier, ultimately this is a set of overuse injuries from structures that are not strong enough to take the load being asked of them and so onto another great pastime of the nation, running. Around April in the Midlands, North of England and London there are key marathon events which also accounts for increase in referrals into our clinics. More recently due to the current COVID pandemic insertional heel pathologies have increased out of “season”, mainly due to a, people having more time if furloughed, so running more frequently and b, gyms being closed so having to look for another activity to keep them fit.

With heel pain being one of the main reasons for chronic pain in the foot, which is known to have a longer lasting impact on patient’s wellbeing [4], management of these overuse conditions is critical. Initially: rest, ice and weight loss, if applicable [5], are the main pieces of advice given. Then introducing a gentle calf stretch that will stretch the Achilles tendon and the fascia, as it is a similar structure. Secondly, I advise them on avoiding walking barefoot or with a flat shoe such as a ballet pump, slipper, etc. Then finally look at improving the strength in the foot and ankle to prepare the structures for future episodes of load. Other treatments such as custom made orthotics, night splints, ultrasound guided steroid injections, NSAID’s, ultrasound guided high volume injections, shock wave therapy are also things that I may discuss with a patient to manage pain levels.

If the simple options don’t work, then referral to a HCPC registered podiatrist may be of help to patients seeking further advice and treatment.