Plantar fasciitis and heel pad syndrome are two common causes of foot and heel pain. Both can be caused by sudden increases in walking or running. The two conditions require completely different treatment approaches. But before treatment can begin, the cause of the heel pain needs to be identified.
There is a simple Physical test that can be performed by your Physiotherapist that’ll help differentiate between the two conditions and allow them to modify your treatment plan appropriately.
plantar fascia:
The plantar fascia is a thick connective tissue that runs from your heel (calcaneus) to the bones in your midfoot called your metatarsals. It’s made up of strong collagen fibres that support and maintain the arch of the foot during the gait cycle.
The plantar fascia is extremely important for walking and running. Studies have found that the plantar fascia rapidly elongates while your foot is in contact with the ground and recoils like a spring during toe-off. When the big toe is dorsiflexed (pulled upwards) it tensions the plantar fascia, this is known as the “windlass mechanism” and is vital for proper walking or running mechanics.
Plantar fasciitis, fasciosis or fasciopathy:
Plantar fasciitis results in pain in your heel or foot due to degenerative changes of the collagen fibres that form the plantar fascia. We use the term fasciitis, “-itis” which would imply that this is an inflammatory condition. However, this is incorrect as there are no inflammatory cells present in the tissue. The correct term that should be used is plantar “fasciopathy” or “fasciosis”. To prevent confusion, I’ll refer to it as plantar fasciitis in this article as this is
The term fasciosis “-osis” means destruction or degeneration. Fasciopathy “-opathy” has become the go-to term because it means that there is a “disease or disorder” of the tissue that could include both inflammatory and/or degenerative changes, which we know is the case in this condition.
heel pad:
The heel fat pad is a collection of adipose (fat) tissue that surrounds your calcaneus (heel bone). Its function is to absorb the impact between your heel and the ground during walking, running and jumping.
The impact between your heel and the ground is highest during the foot-strike phase of the gait cycle. The heel needs to be able to absorb 110% of the body’s weight during walking and up to 200% during running.
The fat pad is the tissue structure underneath your heel.
Heel pad syndrome:
Heel pad syndrome causes pain in your heel due to inflammation and/or destruction of the fatty tissue that surrounds your calcaneus (heel bone). It is the second most common cause of foot pain after plantar fasciitis.
The fat pad can become inflamed due to participation in sports that require a lot of jumping such as volleyball, gymnastics or athletics. An excessive increase in your running distance each week can also increase your risk of heel pad syndrome.
Plantar fasciitis VS heel pad syndrome:
Both plantar fasciitis and heel pad syndrome can cause heel pain. A quick test that can be done to differentiate between the two is simply walking on your toes.
When walking on your toes, if your heel pain increases then that would suggest that your plantar fascia is the source of pain. That is because walking on your toes causes your big toe to dorsiflex (bend upwards) which increases the tension in the plantar fascia. If there is degeneration of the collagen fibres of the plantar fascia, it’s going to be painful when that tissue is loaded.
But if you were to walk on your toes and notice a reduction in heel pain, that would indicate that your heel pad is the source of the pain. The reason is simple, by walking on your toes you’ve taken all the pressure off your inflamed heel fat pad.
An increase in heel pain in this position would suggest that plantar fasciitis is the diagnosis.
Plantar fasciitis treatment:
To treat plantar fasciitis we need to create an environment in the foot that promotes the synthesis and repair of the damaged collagen fibres. Remember, we know that it’s not a true inflammatory condition but rather a degenerative condition. To help increase the rate of collagen repair in the plantar fascia we need to create micro-trauma and restart the body’s repair process. My go-to method for treating this is by using a combination of extracorporeal shockwave therapy and manual therapy of the hip, foot and ankle. Rehabilitation exercises that gradually increase the load in the plantar fascia are also prescribed as exercise has been shown to stimulate collagen synthesis.
Taping the arch of the foot with dynamic tape or rigid athletic tape can be used to support the arch of your foot and offload the painful plantar fascia.
Heel pad syndrome treatment:
When treating heel pad syndrome we do the opposite of what we do for plantar fasciitis. Heel pad syndrome is most often a true inflammatory condition. Treatment needs to decrease inflammation of the fat pad. A treatment method like shockwave therapy would make your heel pain worse as it promotes an inflammatory response in tissues.
A taping technique can be applied to essentially compress the fat pad of the heel. This can reduce a persons heel pain and make normal walking more bearable. You can help speed up your recovery time by wearing shoes with proper cushioning and limiting the amount of time you walk barefoot.
