Causes of Heel Pain and Treatment Options
- Updated on: 2019-09-05
- Read original article here
Heel pain is an extremely common complaint, and there are many potential causes, ranging from conditions that affect the actual heel bone, like a bruise or stress fracture, to conditions that affect structures near it, like plantar fasciitis or Achilles tendonitis. The pain can be throbbing and simply annoying, stabbing and debilitating, or something in between depending on what's behind it and the severity of your case.
Your heel bone—called the calcaneus—lies at the back of the foot beneath the ankle. Along with surrounding tissues and another small bone called the talus, your heel bone works to provide balance and side-to-side movement of the back of the foot.
But because the anatomy of your foot is rather complex, your family doctor, podiatrist, or orthopedist will consider issues related to bones, soft tissues, nerves, and skin that comprise your entire foot and ankle when working to find the reason behind your discomfort.
Causes
Considering this, it's probably no surprise that there are many potential causes of your heel pain that may be suspected. While deciding which applies to you best left to your doctor, knowing more about them can help you prepare for that conversation.
Common
The two most common causes of heel pain are plantar fasciitis and Achilles tendonitis.1
Plantar Fasciitis
Plantar fasciitis refers to irritation and inflammation of the tight tissue band that forms the arch of the foot and connects your heel bone to the base of your toes. The severe, stabbing, or throbbing pain of plantar fasciitis is felt on the bottom of the heel and occurs upon weight-bearing after rest, such as when taking your first steps in the morning or when standing up after prolonged sitting.2
If plantar fasciitis persists for a long time, a heel spur—a bony protrusion—may form where the fascia connects to your heel bone.2 Rarely, the plantar fascia may tear (rupture). The pain of plantar fascia rupture is severe, sharp, and sudden, and there may be swelling and bruising present as well.
An Overview of Plantar Fasciitis
Achilles Tendonitis
Achilles tendonitis refers to inflammation of the Achilles tendon—a large, cord-like tendon that attaches to the back of your heel bone.
The tightening or burning pain of Achilles tendonitis is located at the part of the tendon that is slightly above the heel bone. Mild swelling around the tendon and morning stiffness in the heel and calf are also often experienced.
Achilles tendonitis most commonly develops from overuse (e.g., running too much and/or not warming up your calf muscles).3 Bone spurs from wearing poor-fitting shoes or arthritis may also lead to Achilles tendonitis.
Rarely, the Achilles tendon ruptures; this typically occurs as a result of engaging in a vigorous type of physical activity where the foot pivots suddenly (as in basketball or tennis). Besides severe heel pain, some people report hearing a "pop" or "snap" when the tendon tears.4
An Overview of Achilles Tendonitis
Less Common
Other causes of heel pain must also be considered, even if you've experienced this discomfort and gotten one of the above diagnoses before:
Tarsal Tunnel Syndrome
Tarsal tunnel syndrome is a nerve condition in which a large nerve in the back of the foot becomes pinched.5 Tarsal tunnel pain, described as aching or burning, may be felt in the heel but is more common in the bottom of the foot and near the toes. Similar to carpal tunnel syndrome in the hand, numbness and tingling may be present, and the pain is often worse at night.
Stress Fractures
Stress fractures of the foot and heel commonly occur in athletes or long distance runners who increase their running mileage over a short period of time. Repeated stress on the heel bone eventually leads to a break.6
Other factors that increase a person's chance of developing a stress fracture include:
Low bone mass (osteopenia)
Having an eating disorder, like anorexia or bulimia
Experiencing infrequent or absent monthly periods
A stress fracture causes significant pain that intensifies with activity and improves with rest. In addition to pain, swelling may be present, along with tenderness felt in the area of the bone break.
Heel Pad Bruise
A heel pad bruise causes a sharp pain over the bottom of the heel.7 It may occur after trauma (e.g., landing from a high fall or stepping on a stone) or excessive weight-bearing exercises (e.g., running long distances in poorly cushioned shoes).
Fat Pad Atrophy
In older adults, the cushioning fat of your heel pad may atrophy or breakdown. Unlike plantar fasciitis, the pain of fat pad atrophy is absent in the morning but worsens with activity during the day.8
Heel pad syndrome is due to thinning of this fat pad that results from trauma, such as the consistent pounding of the foot in marathon runners or pressure put on the foot due to obesity. This causes a deep, aching pain felt in the middle of the heel that worsens with weight-bearing activity.
Haglund's Syndrome (With or Without Bursitis)
Haglund's syndrome, also referred to as "pump bump," occurs when a bony prominence at the back of the heel rubs against rigid shoes.9
It's unclear why some people develop this bony bump, but experts suspect it may be due to a tight Achilles tendon, high arch of the foot, wearing tight or poorly fitted shoes, and/or heredity.
The pain of Haglund's syndrome is felt at the back of the heel and may be associated with limping and signs of inflammation like swelling, warmth, and redness.10 As the soft tissue surrounding the bony bump at the back of the heel gets irritated, bursitis may develop.
There are two types of heel bursitis:
Retrocalcaneal bursitis: Inflammation of the bursa (a fluid-filled sac) that lies beneath the Achilles tendon where it attaches to the back of the heel bone11
Calcaneal bursitis: Inflammation of the bursa that lies between your Achilles tendon and your skin
Retrocalcaneal bursitis causes pain deep in the back of the heel, while calcaneal bursitis pain is felt on top of to the side of your Achilles tendon.
Sinus Tarsi Syndrome
The sinus tarsi, referred to as "the eye of the foot," refers to the space on the outside of the foot between the ankle and heel bone. This space, while small, contains several ligaments, as well as fatty tissue, tendons, nerves, and blood vessels.
Rolling out your ankle often triggers this syndrome, which may lead to pain with weight-bearing activities, a sensation of ankle looseness, and difficulty walking on uneven surfaces, like grass or gravel.12
Rare
These heel diagnoses are rare, but worth keeping in the back of your mind:
Piezogenic Papules
Piezogenic papules are painful, yellow or flesh-colored heel bumps that represent fat from deep within the skin pushing through the heel capsule (called fat herniation). The papules are benign and only cause pain in less than 10 percent of cases.13
The cause is unknown, although experts suspect the papules may result from a hard heel strike during walking. Interestingly, they are a characteristic skin finding in people with the connective tissue disease Ehlers-Danlos syndrome.13
Heel Bone Infection
Rarely, an infection of the heel bone (called osteomyelitis) may cause pain—although, unlike most other sources of heel pain, the pain from an infection of the heel bone is usually constant. A fever may also be present.14
Heel Bone Tumor
A tumor in the heel bone may cause pain, usually reported as deep, boring, and worse at night.15
When to Call the Doctor
If you are unsure of the cause of your symptoms, or if you do not know the specific treatment recommendations for your condition, seek medical attention.
Here are some definite signs that you should be evaluated by a doctor:
Inability to walk comfortably on the affected side
Heel pain that occurs at night or while resting
Heel pain that persists beyond a few days
Swelling or discoloration of the back of the foot
Signs of an infection, including fever, redness, warmth
Any other unusual symptoms
Diagnosis
Most heel conditions can be diagnosed with a medical history and physical examination alone. In certain cases, though, additional tests like imaging studies and/or blood tests are warranted.
Medical History
A detailed medical history is often the crux for diagnosing heel pain. With that, it's sensible to come prepared to your doctor's appointment with answers to these basic questions:
Where is your pain located? (e.g., directly over the heel or above the heel)
What does your pain feel like? (e.g. tingling or burning pain suggests a nerve problem, whereas sharp or aching pain suggests a soft tissue or tendon problem)
Does your pain occur with weight-bearing activities or while at rest?
If your pain occurs with weight-bearing activities, do you notice it first thing in the morning after rest (as in plantar fasciitis) or later in the day after activity (as in heel pad syndrome)?
Is your heel pain worse at night? (Nighttime pain is more common with nerve-related sources of pain, as well as with tumors.)
Are you experiencing other symptoms besides heel pain, such as fever, numbness, or swelling?
Do you recall changes to your regular activity and/or any trauma or injury that precipitated the heel pain?
Physical Examination
During your physical exam, your doctor will inspect and press on ("palpate") various areas of your foot, including your heel, as well as your ankle, calf, and lower leg. By doing this, she can check for areas of focal tenderness, swelling, bruising, rash, or deformity. She will also likely evaluate your gait, as well as move your foot and ankle around to see if that elicits pain.
Blood Work
While blood tests are not commonly ordered for the diagnosis of heel pain, your doctor may order one or more laboratory studies if she suspects or wants to rule out a particular condition. For example, a white blood cell count or erythrocyte sedimentation rate may be ordered if a bone infection is being considered.16
Imaging
An X-ray of the heel may be ordered to diagnose certain conditions like a stress fracture of the heel, Haglund's syndrome, heel spur, or bone tumor. Less commonly, other imaging tests are used. For instance, magnetic resonance imaging (MRI) may be used to diagnose a soft-tissue injury or an infection.17
Differential Diagnoses
While it is reasonable to think that heel pain must stem from your heel, this is not always the case. Sometimes pain is referred to the heel, as in certain neurological conditions.
Nerve Pain
Irritation of a nerve in the lower back (called radiculopathy) may cause pain of the calf muscle that moves down the leg into the heel. In addition, peripheral neuropathies associated with diabetes, alcohol abuse, or a vitamin deficiency can cause diffuse foot and heel pain.18
Besides a neurological exam, an MRI or nerve conduction studies may be ordered to diagnose nerve problems.
Skin Problems
Skin problems, like an infection of the hindfoot or ankle (cellulitis), plantar wart, diabetic ulcers, or fungal foot infection (e.g., chronic athlete's foot) can cause discomfort in the heel or sole of the foot.19 A medical history and physical exam are usually sufficient to diagnose a skin problem of the heel, although blood tests or a biopsy of the affected area may be needed.
Systemic Diseases
Whole-body inflammatory diseases like sarcoidosis, rheumatoid arthritis, or reactive arthritis may cause heel pain.20 Oftentimes, other symptoms are present with these systemic diseases, such as fever, rash, and joint pain and inflammation. Laboratory and imaging studies are also used to diagnose systemic diseases.
Treatment
Treatment depends entirely on the root cause of your heel pain. If you are unsure of your diagnosis, or how severe your condition is, be sure to seek medical advice before beginning any treatment plan.
Some common treatments are listed here—but keep in mind, not all of these are appropriate for every condition.
Rest
For more acute causes of heel pain, such as a heel bruise, avoiding the precipitating activity—for example, take a few days off jogging or prolonged standing/walking—may be all you need to feel better. In other instances, resting can help to eliminate the most severe pain until you are able to see your doctor or a podiatrist.
Icing
For most sources of heel pain, applying an ice pack over the heel for 20-minute intervals up to four times daily can help diminish swelling and soothe your pain. Be sure to place a thin towel between the ice pack and the skin of your heel.
Taping
Taping the foot with sports tape or hypoallergenic tape is useful for certain heel diagnoses like plantar fasciitis, heel pad bruise, and heel pad syndrome.21
For plantar fasciitis, your doctor may recommend a taping technique involving four strips of tape that get applied around the foot and heel. The tape should not be applied too tightly and can stay in place for one week.
Exercise/Physical Therapy
Exercises and stretches are designed to relax the tissues that surround the heel bone. Some simple exercises, performed in the morning and evening, often help patients feel better quickly.
For Achilles tendonitis, your doctor may refer you to a physical therapist who uses a specialized exercise program called the Alfred protocol, which focuses on eccentric loading of your Achilles tendon
Footwear Modification
Depending on the cause of your heel pain, various foot supports may be recommended by your doctor.23
For instance, for plantar fasciitis, your doctor may recommend wearing splints at night to keep your foot straight. Moreover, wearing sturdy, comfortable shoes (ones with a good arch and heel support) and/or wearing special shoe inserts (e.g., gel pad inserts or heel cups) may also be helpful for easing the pain of plantar fasciitis.
Likewise, heel wedges or shoe orthotics may be recommended for the treatment of Achilles tendonitis. For Haglund's syndrome, your doctor may recommend altering the heel height of your shoes.
Medications
Nonsteroidal anti-inflammatory medications (NSAIDs) are commonly prescribed for heel pain caused by problems such as plantar fasciitis,24 Achilles tendonitis, a heel pad bruise, Haglund's syndrome, heel bursitis, heel pad syndrome, and sinus tarsi syndrome.
For more severe heel pain, like that caused by a heel fracture, opioids may be prescribed for a short period of time.
Sometimes, cortisone—a steroid that reduces inflammation—may be injected into the heel to ease the pain temporarily (for a few weeks, usually).
Surgery
While immediate surgery is needed nearly all the time to treat an acute Achilles tendon rupture, for other causes of heel pain, surgery is generally only recommended if non-surgical therapies have not worked for a period of six to 12 months.25
For example, with plantar fasciitis, surgery to detach the plantar fascia from the heel bone (called plantar fascia release) may be performed if all other treatments have failed for one year.25 Another surgery called gastrocnemius resection in which the calf (gastrocnemius) muscles are lengthened may also be performed for persistent plantar fasciitis.
Prevention
Preventing symptoms of heel pain may be a critical component of the long-term treatment of your condition. Depending on the exact source of pain, prevention strategies may slightly differ. But in general, there are some steps that you can take to avoid a recurrence of heel pain symptoms.
Some of these steps include:
Gradually increasing activity levels: Increasing your athletic activities gradually over time and taking breaks can help prevent heel injury.
Maintaining ideal body weight: Excess body weight places increased stress on the lower extremities, including the heel.
Wearing the right footwear: Wearing appropriate, properly fitting footwear—shoes with adequate support and cushioning—is critical for the prevention of many types of heel pain.
Early identification of discomfort: Usually your body will let you know when you are doing some kind that is causing an aggravation. Listening to the symptoms, especially in the early stages, can give you an opportunity to address a problem before it becomes severe. Continuing to perform an activity that is causing worsening of symptoms can lead to a more significant problem that is harder to address.
A Word From Verywell
Some causes of heel pain are more serious than others. Regardless, your doctor can help you figure out what's causing the discomfort and craft a treatment plan that will help your specific situation. The upside is that most solutions are fairly simple—rest, ice packs, and footwear modifications—that you can do at home without any hassle.
Try to follow your doctor's plan as best as you can—your body, including your heel, deserves your attention and care so it can heal properly and you can be pain-free.
