Heel Pain in Sport
Although most cases of heel pain are not associated with sport, still a large number experience heel pain during sport every year. This can include football, rugby, cricket, hockey, and most commonly, running. The most common type of heel pain associated with sport is Sever’s, which affects children usually from 9 to 13 years of age. Sever’s is rare in children who don’t play a lot of sport and probably, as a consequence of higher activity levels is more common in boys than girls.
There are three common types of heel pain associated with adults playing sport. These are plantar fasciitis, Achilles tendinopathies, and Haglund’s or pump bumps. All are most common in runners, but turn up in football, cricket, rugby and hockey, as well as among other sports.
Sever’s in Sport
Sever’s is described as a traction apophysitis. In childhood our bones are made of a cartilage mould of the bone, which over time as we grow slowly turns into a full bone. The reason for this is that it is easier to grow cartilage to the length required, and then back fill with bone later than it is to actually grow new bone. Most bones have a least two growth of bone centres, one by the joint and one making the main body of the bone. In the growing heel bone (calcaneus) the posterior part has a separate growth area where the Achilles tendon attaches.
When playing lots of sport, especially football, rugby and hockey, the two areas of bone can be pulled apart, producing pain. Recent evidence has also suggested that the appearance of this condition on MRI (magnetic resonance imaging), appears to indicate that Sever’s is a type of stress fracture. Whether that fatigue stress is from compression or tension remains in debate, and is probably a combination of both.
Plantar Fasciitis in Sport
Although it can occur in any sport from soccer, cricket, and rugby to hockey, it is far more common in runners than anyone else. Again injury to the plantarfascia and its support structures can occur at any age, but is more common in the veteran runner over 35 years of age. I’m afraid as we age our soft tissues become a little less elastic, and consequentially easier to strain.
Usually the onset is insidious with the pain starting as a little awareness that builds up on each run. Pain is often noticeable after you rise from sitting or after getting out of the car after driving home from a run. Soon it will start hurting first thing in the morning as well, worse after a run. However, many sports people feel the pain suddenly and sharply, often during sport, such as reaching for a tackle, slightly miss-stepping when running, or pushing hard off a foot. Sometimes the pain is on a single step, but just after sport rather than during. Although how the onset occurred is slightly academic for the sufferer, it can help reveal the type of damage that has occurred, and that can help with treatment.
Achilles (tendinitis) Tendinopathy in Sport
By far the most common heel pain for runners is Achilles tendonitis, which is better called an Achilles tendinopathy, as it is a mixture of degenerative and inflammatory changes in the tendon. Achilles tendinopathy is extremely common among athletes with prevalence around 11%. It can be a very stubborn condition to help, as the pathology has biochemical and vascular aspects to the disease process. Also when running the Achilles is subject to strain very close to its ultimate tensile stress. Using a tendon like humans use their Achilles is rare in biology, and leaves us very susceptible to injury.
Pain is felt at the posterior aspect of the heel, which can radiate for a few cm up towards the calf. Gentle squeezing of the Achilles, or pressure on the posterior part of the heel bone, helps locate the pain to the Achilles and its structures.
Although all types of sporting foot shapes can develop Achilles problems, those runners who strike the ground on their forefoot, especially if they are new to running, or if they have recently increased their pace and distance.
Typically Achilles tendinopathy is divided into two. These are insertional and non-insertional.
Insertional occurs where the Achilles tendon attaches to the heel bone (calcareous), but a complex blending of tendon to fibro-cartilage, then fibro-cartilage to bone. It is generally more common in cavoid (high arch) feet, where it can be harder to lift the heel off the ground, which causes increased strain in the attachment and increased compression on the Achilles where it lays over the bone. Tendons do not like being compressed!
This is the most common type of Achilles injury. The tendon itself, or the sleeve that covers it (the paratenon) can be injured. Sometimes the inside of the tendon is more painful, sometimes the outside. Where the injury lies gives a clue as to where the mechanical strain is running into the tendon. Sometimes the shoe counter is cutting into the back of the tendon. If you have recently got new shoes and then shortly after developed Achilles pain, especially if it is right on the posterior edge of the tendon matching the edge of the heel counter, then check out your shoes.
Haglund’s in Sport
Haglund’s deformity, also know as a “pump bump”, consists of enlargement of the posterior part of the heel bone (calcareous) and soreness of the skin over the boney lump. Often there is a painful blister. The boney bump usually grows during our teenage years, when the growing heel bone can be rubbed by footwear, usually sports shoes, causing increased blood flow to the bone. This stimulates excessive bone growth. Haglund’s can be quite painful, particular for those who wear tight football boots. The heel counter of the boot continually irritates the heel. Sometimes softening the back of the heel counter of the boot or trainer with a hammer can solve the problem. However, large Haglund’s may require surgical excision.