Heelonitis, which is medically referred to as enthesopathy or plantar fasciitis, is a prevalent type of inflammation localized on the lower portion of the calcaneus, to the onset of which factors of different orders and degrees may contribute, including certain habits, sports activities, or even the use of improper footwear.

We asked an orthopedic specialist to tell us about the leading causes of heelonitis and what the most effective therapies are today to treat this condition successfully.

The causes of heelonitis

Plantar fasciitis is manifested by a punctual type of pain, particularly intense in the morning as soon as you rest your foot to get out of bed, at the point where the plantar fascia inserts on the bone, on the side of the bearing surface.

Several factors can contribute to the onset of heelonitis, including some individual predispositions related to foot conformation, such as “flat foot” (i.e., pronated) and hollow foot (characterized by the accentuation of the plantar arch). It is more frequent in middle-aged individuals, in those suffering from obesity or other endocrine-metabolic disorders, in pregnant women, as well as in patients with hyperuricemia or immuno-rheumatologic disorders. In particular, excess body weight can play a decisive role in the onset of symptomatology, especially if the increase is sudden. Some habits can increase the likelihood of developing heelonitis, and it is essential to investigate the patient’s medical history for a correct diagnostic-therapeutic approach. Any therapy, if we fail to eliminate or at least mitigate the risk factors and trigger(s), will be less effective.

A fundamental fact to be considered in the first instance is the type of footwear used by the patient: often, people wear inadequate shoes, either because they have practically no heel (such as some types of “ballet flats”) or because they have an inadequate sole (such as “flip-flops” or other flip-flops); in some cases, the inadequacy of the footwear is related to too prolonged use of it over time.

In addition, as a result of the use of unsuitable sports footwear, or due to an incorrect athletic gesture or even functional overload, certain types of sports activities (running, soccer, tennis, basketball, fencing, dance, beach volleyball, etc.), which cause abnormal traction at the level of the plantar fascia or even continuous microtraumatism (for example, in jumping and related “landing”), can frequently be responsible for the onset of plantar fasciitis.

Interestingly, heelonitis often manifests itself with a typical “seasonal” pattern, with a peak incidence in the summer months, the season when footwear with less reinforced soles is more frequently used. In addition, especially if risk factors pre-exist, walking for a long time in dry sand, in which the foot literally “sinks,” can be a trigger for latent plantar fasciitis. Walking on the shoreline, which subjects the foot to less biomechanical effort, would be preferable. Similar considerations should be emphasized for “beach volleyball, especially in individuals not trained in this type of activity.

What to do in case of heelonitis?

In case of heelonitis, the following therapies can be recommended:

  • The therapeutic approach is, in the first instance, conservative, reserving surgery only for cases in which the patient has not responded in any way to all other therapies.
  • Silicone heel pads with a central unloading part are a “first aid” to be put in place while waiting to consult the physician.
  • The elective treatment for this type of inflammation is shock wave therapy, which is safe, non-invasive, outpatient, repeatable, and has almost no side effects. Shock wave therapy consists of micro-mechanical stimulations that stimulate cells to produce growth factors and other biochemical mediators that counteract inflammation and promote tissue healing. Shock waves do not cause tissue injury or crush calcifications and bone spurs but instead have real modulating action on inflammation. The goal of shock wave therapy is to resolve inflammation at the site, not to break or eliminate bone spurs. The treatment cycle consists of 3 therapy sessions on average weekly, and the effectiveness of shock waves is generally short-term.
  • In some cases, local infiltrative therapy with autologous growth factors, such as the platelet concentrate known as PRP, may be considered if shock waves are not enough.

The success of therapy, even in pathologies often trivialized as plantar fasciitis, depends on the correct diagnostic framing.

In any case, it is necessary to formulate a correct diagnosis, which, after the clinical examination, involves the standard radiographic examination, to which in-depth study with ultrasound or even MRI examination may be associated if there is a specific diagnostic suspicion.