Heel Pain (Talalgias)
Talalgias refer to conditions affecting the hindfoot and heel. These pains can be highly disabling and significantly impact a patient’s ability to walk and perform daily activities.
Inferior Calcaneal Enthesopathy
Inferior calcaneal enthesopathy results from excessive traction of the plantar fascia and shares the same mechanism as plantar fasciitis. It is often associated with plantar fasciitis.
Pain is typically located under the heel, slightly anteromedially, in an area where micro-tears occur due to repeated tension. This condition is also known as a “heel spur,” visible on X-rays as a bony calcification at the site of stress. However, the spur is a consequence of the condition and not the primary cause of pain, and it may not always be present.
Treatment with custom orthoses is similar to that for plantar fasciitis, aiming to reduce tension in the SACP system. A heel lift with a relief cut-out over the painful area can also be used to decrease local pressure.
Athlete’s Heel Pain (Heel Cushion Syndrome)
Athlete’s heel pain refers to irritation of the soft tissues surrounding the calcaneus. It typically presents as a ring-like pain around the heel and is often caused by repetitive impact sports involving frequent jumping, such as volleyball or basketball. It may also be associated with inflammation of the subcalcaneal bursa (Lenoir’s bursa).
Treatment involves using custom foot orthoses with shock-absorbing heel pads, which help reduce impact forces and relieve pain.
Tarsal Tunnel Syndrome
The tarsal tunnel is an osteofibrous canal located beneath the medial malleolus. It contains several tendons, blood vessels, and the tibial nerve.
Tarsal tunnel syndrome occurs when a valgus deformity of the midfoot or hindfoot leads to compression of the canal, particularly affecting the tibial nerve. Symptoms include pain on percussion of the tarsal tunnel, tingling sensations in the toes, and weakness of intrinsic foot muscles, such as difficulty flexing the big toe during functional tests.
Treatment involves custom orthoses designed to correct hindfoot valgus, thereby reducing pressure within the tarsal tunnel and relieving nerve compression.
Achilles Tendinopathy
Achilles tendinopathy is one of the most common tendon disorders, especially in athletes such as sprinters and jumpers. Biomechanically, the Achilles tendon is an integral part of the Suro-Achilles-Calcaneo-Plantar (SACP) system. It connects the calf muscles (triceps surae) and plays a key role in controlling forward leg movement and providing push-off during walking by lifting the heel.
Pain develops when there is reduced flexibility of the calf muscles or excessive tension within the SACP system. Two main types exist: mid-portion tendinopathy, sometimes with nodular changes, and insertional tendinopathy at the lower attachment of the tendon on the calcaneus (heel bone).
This condition should not be ignored, as it may progress to an Achilles tendon rupture if left untreated. Management includes reducing calf load with a heel lift and decreasing strain on the SACP system using custom orthoses, along with rest, stretching, and ice during painful phases.
In some cases, a pre-Achilles bursitis (inflammation of the bursa behind the tendon) may also be present.
Calcaneal Stress Fracture
A calcaneal stress fracture can occur after repeated mechanical stress or trauma to the heel bone (calcaneus). Pain appears immediately on weight-bearing and quickly becomes severe, significantly limiting walking distance.
Optimal healing usually requires around 6–7 weeks of offloading with crutches, although this is often difficult in daily life. After an initial period of approximately 3 weeks of crutch use, custom orthoses with shock-absorbing materials may be introduced to reduce mechanical stress and support bone healing.
More severe fractures, such as those caused by a fall onto the heels, are treated with immobilization in a cast boot, followed by rehabilitation and later use of orthoses.