Heel pain

What is it?

Heel pain is a common symptom that has many possible causes. Although heel pain sometimes is caused by a systemic (body-wide) illness, such as rheumatoid arthritis or gout, it usually is a local condition that affects only the foot. The most common local causes of heel pain include:

• Plantar fasciitis — Plantar fasciitis is a painful inflammation of the plantar fascia, a fibrous band of tissue on the sole of the foot that helps to support the arch. Plantar fasciitis occurs when the plantar fascia is overloaded or overstretched. This causes small tears in the fibers of the fascia, especially where the fascia meets the heel bone. Plantar fasciitis may develop in just about anyone but it is particularly common in the following groups of people: people with diabetes, obese people, pregnant women, runners, volleyball players, tennis players and people who participate in step aerobics or exercise running up and down stairs. You also can trigger plantar fasciitis by pushing a large appliance or piece of furniture or by wearing worn out or poorly constructed shoes. In athletes, plantar fasciitis may follow a period of intense training, especially in runners who push themselves to run longer distances. People with flat feet have a higher risk of developing plantar fasciitis.
• Heel spur — A heel spur is an abnormal growth of bone at the area where the plantar fascia attaches to the heel bone. It is caused by long-term strain on the plantar fascia and muscles of the foot, especially in obese people, runners or joggers. As in plantar fasciitis, shoes that are worn out, poorly fitting or poorly constructed can aggravate the problem. Heel spurs may not be the cause of heel pain even when seen on an X-ray. In fact, they may develop as a reaction to plantar fasciitis and they can also be found in people without pain or problems in the heel.
• Calcaneal apophysitis — In this condition, the center of the heel bone becomes irritated as a result of a new shoe or increased athletic activity. This pain occurs in the back of the heel, not the bottom. Calcaneal apophysitis is a fairly common cause of heel pain in active, growing children between the ages of 8 and 14. Although almost any boy or girl can be affected, children who participate in sports that require a lot of jumping have the highest risk of developing this condition.
• Bursitis — Bursitis means inflammation of a bursa, a sac that lines many joints and allows tendons and muscles to move easily when the joint is moving. In the heel, bursitis may cause pain at the underside or back of the heel. In some cases, heel bursitis is related to structural problems of the foot that cause an abnormal gait (way of walking). In other cases, wearing shoes with poorly cushioned heels can trigger bursitis.
• Pump bump — This condition, medically known as posterior calcaneal exostosis, is an abnormal bony growth at the back of the heel. It is especially common in young women, in whom it is often related to long-term bursitis caused by pressure from pump shoes.
• Local bruises — Like other parts of the foot, the heel can be bumped and bruised accidentally. Typically, this happens as a "stone bruise," an impact injury caused by stepping on a hard object while walking barefoot.
• Achilles tendonitis — In most cases, Achilles tendonitis (inflammation of the Achilles tendon) is triggered by overuse, especially by excessive jumping during sports. However, it also can be related to poorly fitting shoes if the upper back portion of a shoe digs into the Achilles tendon at the back of the heel. Less often, it is caused by an inflammatory illness, such as ankylosing spondylitis (also called axial spondyloarthritis), reactive arthritis, gout or rheumatoid arthritis.
• Trapped nerve — Compression of a small nerve (a branch of the lateral plantar nerve) can cause pain, numbness or tingling in the heel area. In many cases, this nerve compression is related to a sprain, fracture or varicose (swollen) vein near the heel.

Symptoms

The heel can be painful in many different ways, depending on the cause:

• Plantar fasciitis — Plantar fasciitis commonly causes intense heel pain along the bottom of the foot during the first few steps after getting out of bed in the morning. This heel pain often improves or goes away once you start to walk around, but it may return in the late afternoon or evening.
• Heel spur — Although X-ray evidence suggests that about 10% of the general population has heels spurs, many of these people do not have any symptoms. In others, heel spurs appear to cause pain and tenderness on the undersurface of the heel that worsen over several months.
• Calcaneal apophysitis — In a child, this condition causes pain and tenderness at the lower back portion of the heel. The affected heel is often sore to the touch but not obviously swollen.
• Bursitis — Bursitis involving the heel causes pain in the middle of the undersurface of the heel that worsens with prolonged standing and pain at the back of the heel that worsens if you bend your foot up or down.
• Pump bump — This condition causes a painful enlargement at the back of the heel, especially when wearing shoes that press against the back of the heel.
• Local bruises — Heel bruises, like bruises elsewhere in the body, may cause pain, mild swelling, soreness and a black-and-blue discoloration of the skin.
• Achilles tendonitis — This condition causes pain at the back of the heel where the Achilles tendon attaches to the heel. The pain typically becomes worse if you exercise or play sports, and it often is followed by soreness, stiffness and mild swelling.
• Trapped nerve — A trapped nerve can cause pain, numbness or tingling almost anywhere at the back, inside or undersurface of the heel. In addition, there are often other symptoms — such as swelling or discoloration — if the trapped nerve was caused by a sprain, fracture or other injury.

Diagnosis

After you have described your foot symptoms, your doctor will want to know more details about your pain, your medical history and lifestyle, including:

• whether your pain is worse at specific times of the day or after specific activities
• any recent injury to the area
• your medical and orthopedic history, especially any history of diabetes, arthritis or injury to your foot or leg
• your age and occupation
• your recreational activities, including sports and exercise programs
• the type of shoes you usually wear, how well they fit, and how frequently you buy a new pair.

Your doctor will examine you, including:

• An evaluation of your gait — While you are barefoot, your doctor will ask you to stand still and to walk in order to evaluate how your foot moves as you walk.
• An examination of your feet — Your doctor may compare your feet for any differences between them. Then your doctor may examine your painful foot for signs of tenderness, swelling, discoloration, muscle weakness and decreased range of motion.
• A neurological examination — The nerves and muscles may be evaluated by checking strength, sensation and reflexes.

In addition to examining you, your health care professional may want to examine your shoes. Signs of excessive wear in certain parts of a shoe can provide valuable clues to problems in the way you walk and poor bone alignment. Depending on the results of your physical examination, you may need foot X-rays or other diagnostic tests.

Expected duration

How long heel pain lasts depends on the cause. For example, heel pain that is related to obesity should improve gradually as you lose weight.

If your heel pain is related to a specific sport or exercise regimen, a period of rest may bring relief. Once your heel is pain-free, you may need to modify your training program to prevent your pain from returning. Most heel pain goes away in a short period of time, either on its own or after treatment.

Prevention

You can help to prevent heel pain by maintaining a healthy weight, by warming up before participating in sports and by wearing shoes that support the arch of the foot and cushion the heel. If you are prone to plantar fasciitis, exercises that stretch the Achilles tendon (heel cord) and plantar fascia may help to prevent the area from being injured again. You also can massage the soles of your feet with ice after stressful athletic activities. Sometimes, the only interventions needed are a brief period of rest and new walking or running shoes.

Treatment

Treatment of heel pain depends on its cause:

• Plantar fasciitis — Most doctors recommend a six- to eight-week program of conservative treatment, including temporary rest from sports that trigger the foot problem, stretching exercises, ice massage to the sole of the foot, footwear modifications, taping of the sole of the injured foot, and acetaminophen (Tylenol) or nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin or ibuprofen (Advil, Motrin and others) for pain. If this conservative treatment doesn't help, your doctor may recommend that you wear a night splint or a short leg cast, or he or she may inject corticosteroid medication into the painful area. Surgery is rarely necessary and is not always successful.
• Heel spur — Conservative treatment includes the use of shoe supports (either a heel raise or a donut-shaped heel cushion) and a limited number of local corticosteroid injections (usually up to three per year). As in plantar fasciitis, surgery is a last resort.
• Calcaneal apophysitis — This condition usually goes away on its own. In the meantime, conservative treatment includes rest and the use of heel pads and heel cushions.
• Bursitis — Treatment is similar to the treatment of heel spurs. Changing the type of footwear may be essential.
• Pump bump — Treatment is similar to the treatment of bursitis and heel spurs. In rare cases, the bony growth at the heel may need to be removed surgically.
• Local bruises — Heel bruises can be treated by applying an ice pack for the first few minutes after injury.
• Achilles tendonitis — This condition is treated conservatively with rest, NSAIDs and physical therapy.
• Trapped nerve — If a sprain, fracture or other injury has caused the trapped nerve, this underlying problem must be treated first. In rare cases, surgery may be done to release the trapped nerve.

Heel pain due to a systemic condition, such as gout or reactive arthritis, will usually improve with treatment of the underlying disease.

When to call a professional

Make an appointment to see a health care professional if you have significant heel pain that does not improve within a few days.

Prognosis

Although the outlook depends on the specific cause of the heel pain, most people respond to conservative, nonsurgical therapy. For example, at least 90% of people with plantar fasciitis heal within 6 to 8 weeks of conservative therapy, or conservative therapy followed by 6 to 8 weeks of night splints. Less than 5% of people with plantar fasciitis require surgery.

Heel pain may return if you return too soon to your previous level of exercise or sports participation.

Additional info

National Institute of Arthritis and Musculoskeletal and Skin Diseases
https://www.niams.nih.gov/

American Orthopaedic Foot and Ankle Society
https://www.aofas.org/

American Podiatric Medical Association (APMA)
https://www.apma.org/

American College of Foot and Ankle Surgeons
https://www.acfas.org/