What is heel pain?

Heel pain is pain felt in one or both heels that may become worse at certain times of the day, or develop after exercise or strenuous activity.

The foot is made up of more than 20 bones, 30 joints and 100 tendons. Of these bones, the heel bone, or calcaneus, is the largest in the foot. The heel supports the body weight during walking, running and generally moving around. In particular, the heel acts as a cushion that protects the other structures of the foot, such as the muscles, ligaments and tendons.  

Heel pain can be localised in the underside or the back of the heel. Heel pain is a very common complaint and although many people will only experience mild and short-lived pain, for some people this pain can become debilitating.

 

Ligaments

Short, flexible fibrous tissue that connects the bones and cartilage of joints.

Tendons

Dense bands of connective tissue that attach muscles to bones.

Causes

Heel pain is commonly the result of an abnormal gait, which can lead to excessive stress on the heel bone and soft tissues attached to it. Other factors that can cause heel pain are:

Plantar fasciitis

The most common cause of heel pain is plantar fasciitis. It occurs when the connective tissue that supports the arch of the foot (plantar fascia) becomes inflamed and irritated. Plantar fasciitis is often associated with heel pain experienced first thing in the morning, or after sitting for a period of time. The pain tends to reduce after some walking, as the fascia is stretched. Plantar fasciitis can occur rapidly and cause intense pain.

Overweight or obese

Many people who experience heel pain are commonly overweight or obese. Carrying extra weight puts an incredible amount of stress on the plantar fascia and the bursa of the feet, which normally act as shock absorbers. The excessive stress on the bursa and plantar fascia over time can cause inflammation and injury, resulting in heel pain.

Diabetes

High blood glucose levels due to diabetes can cause nerve damage and poor blood circulation in your feet and legs. This can result in serious foot problems such as muscle deformities, poor healing, infections, ulcers and various pains, including heel pain.  

Neuroma

The constant stress placed on the heel during walking and exercise can cause irritation or inflammation of nerves. The chronic irritation and entrapment of nerves supplying the heels can eventually lead to a neuroma, which is a swelling of a nerve that causes burning pain, tingling and numbness.

In particular, entrapment or compression of the lateral plantar nerve in the heel can cause a neuroma, which becomes worse with daily activities such as walking. This compression may be caused by an injury to the ankle, or a swollen vein near the heel.

Stress fractures

A stress fracture of the big heel bone, the calcaneus, is associated with a sudden increase in activity level, or change to a harder walking surface. This kind of fracture is common in people who walk or run long distances. The heel pain progressively worsens with weight-bearing activity.

Achilles tendonitis

The Achilles tendon is the largest tendon in the body and attaches the calf muscle to the heel bone. The tendon enables the lifting of the foot during walking, running or lifting onto the balls of the feet. Inflammation of this tendon - known as Achilles tendonitis - as a result of overuse or strenuous activity can result in pain in the back of the heel.

Rheumatoid or psoriatic arthritis

People with an inflammatory form of arthritis, such as rheumatoid or psoriatic arthritis, as well as reactive arthritis, are more likely to develop heel pain. The pain is caused by plantar fasciitis.

Gout

Gout is the excessive build-up of uric acid crystals in joints and around the heel. This causes inflammation and leads to development of pain in the affected area, such as the heel.

Bursitis

Bursitis is an inflammation of the bursa, which are fluid sacs that reduce friction between bones, muscles and ligaments. When excessive friction, or an abnormally prominent heel bone, causes irritation to the bursa that protects the tendons of the heel, the resulting inflammation can cause heel pain.

Haglund's syndrome

Haglund's syndrome is the result of excessive pressure of the back of the heels, often caused by wearing shoes that are overly tight and stiff. Haglund's syndrome is associated with a noticeable bump on the back of the heel, swelling in the back of the heel and severe pain where the Achilles tendon attaches to the bone.

Sciatica

Sciatica can result from the compression of the sciatic nerve, which supplies sensation to the heel. It can lead to development of 'referred pain' to other areas in the body including the heels, legs and buttocks.

Heel spurs

Excessive stress to the plantar fascia over time can cause chronic inflammation and the development of a bony growth at the heel, called a heel spur. Although heel spurs themselves are painless, they can cause pain in the heel as they rub against the heel bone.

Tarsal tunnel syndrome

Tarsal tunnel syndrome is a result of compression of the posterior tibial nerve on the inside of the ankle. This can lead to inflammation of the nerve, which causes pain and tingling underneath and inside the heel.

Sever's disease

Sever's disease is a common cause of heel pain in children aged 8-16 years. It is caused by an injury to the growth plate of the heel bone, which may be a result of excessive physical activity.  

Bone lesions

Although rare, bone lesions or tumours may develop in the bone of the heels, which can cause heel pain.

Bursa

A fluid-filled sac that reduces friction between tissues that slide over each other.

Infections

Entry into the body of microorganisms that can reproduce and cause disease.

Inflammation

A body’s protective immune response to injury or infection. The accumulation of fluid, cells and proteins at the site of an infection or physical injury, resulting in swelling, heat, redness, pain and loss of function.

Lateral plantar nerve

A branch of the sciatic nerve that supplies the skin of the fifth toe and the outermost half of the fourth toe, and most of the deep muscles in the outermost side of the foot.

Lesions

Damage to bodily tissue.

Ligaments

Short, flexible fibrous tissue that connects the bones and cartilage of joints.

Nerves

One or more fibres that transmit signals of sensation and motion between the brain or spinal cord and other parts of the body.

Plantar fascia

The thick band of tissue that connects the heel bone to the toes, surrounding the muscles in the sole of the foot and supporting the arch on the bottom of the foot.

A branch of the sciatic nerve that runs along the back of the leg to supply sensory innervation to the calf muscles, then further divides to supply sensation to the sole of the foot.

Tendons

Dense bands of connective tissue that attach muscles to bones.

Vein

A blood vessel carrying blood (usually non-oxygenated) from the body's tissues to the heart.

Reactive arthritis

An inflammatory type of arthritis that develops following a bacterial infection.

Risk factors

Heel pain can develop suddenly or gradually and can potentially affect anybody. It is more common in people who:

  • Are over 40 years of age;
  • Have occupations that require a lot of standing;
  • Are overweight or obese;
  • Regularly partake in strenuous exercise, and;
  • Are aged between 8-13 years, especially boys.

Signs and symptoms

Some of the more typical symptoms associated with heel pain may include:

  • Pain with the first few steps in the morning;
  • Pain that increases with standing and after exercising;
  • Sharp stabbing pain in the bottom or side of the heel;
  • Sensation of burning, numbness or heat in the heel;
  • Pain that may last for weeks to months, and;
  • Pain that throbs or radiates into the arch of the foot, or up the back of the leg.

Methods for diagnosis

Heel pain can be diagnosed by your doctor after taking a detailed medical history and performing a thorough physical examination of the foot and leg. Imaging scans, such as X-rays, ultrasound and magnetic resonance imaging (MRI), may be used to identify causes of heel pain, such as heel spurs or stress fractures.

Fractures

A complete or incomplete break in a bone.

Magnetic resonance imaging

A type of imaging that uses a magnetic field and low-energy radio waves, instead of X-rays, to obtain images of organs.

Ultrasound

A scan that uses high-frequency soundwaves to produce images of the body’s internal structures.

X-rays

A scan that uses ionising radiation beams to create an image of the body’s internal structures.

Types of treatment

The type of treatment used for heel pain depends on the cause and severity of the symptoms. Some of the potential treatment options include:

  • Compression and strapping;
  • Icepacks;
  • Changing the type and intensity of physical activities;
  • Regularly stretching calf muscles and the Achilles tendon;
  • Heel cushions to provide further shock absorption;
  • Physical therapy;
  • Massage;
  • Ultrasound therapy, for plantar fasciitis;
  • Acupuncture;
  • Regular rest from daily physical activities and exercise;
  • Wearing a leg splint at night;
  • Anti-inflammatory, pain-relief or steroid medications;
  • Shoe inserts to help correct gait abnormalities, and;
  • Surgery for cases that fail to respond to other treatments.

Acupuncture

A form of complementary therapy that involves fine sterilised needles being inserted into the skin at specific points to treat medical conditions.

Anti-inflammatory

A substance used to reduce inflammation.

Ultrasound

A scan that uses high-frequency soundwaves to produce images of the body’s internal structures.

Potential complications

Walking on sore feet can cause some people to develop an abnormal gait. This can cause development of other muscular problems that can affect the proper functioning of the feet, knees, hip or back.

Prognosis

Heel pain is rarely a symptom of a serious condition. Although heel pain may interfere with physical activities, by using appropriate treatments, its severity can be reduced or its cause completely treated.   

Prevention

Heel pain may be prevented by:

  • Wearing properly-fitting shoes;
  • Choosing shoes with good sole cushioning;
  • Using shoe inserts to correct an arch abnormality, and;
  • Stretching before and after physical activity.