Home > Foot Problems > Heel Pain
Heel Pain
| * Explanation | * Symptoms | * Diagnosis | * Duration |
| * Prevention | * Treatment | * Call your Doctor | * Prognosis |
Heel pain is a common symptom that has many possible causes. Although heel pain may sometimes be caused by a systemic (total body) illness, such as arthritis or gout, in most cases the cause 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 support the arch. Plantar fasciitis occurs when the plantar fascia is overloaded or overstretched. This produces small tears in the fibers of the fascia, especially where the fascia meets the heel bone. Plantar fasciitis tends to occur in the following groups of individuals: obese persons, pregnant women, runners, volleyball players, tennis players and persons who participate in step aerobics or stair climbing. You may also trigger the pain of 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 suddenly push themselves to run longer distances.
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 persons, runners or joggers. As in plantar fasciitis, the problem may be aggravated by shoes that are worn out, poorly fitting or poorly constructed.
Calcaneal apophysitis — In this condition, the apophysis (center of bone growth) in the calcaneus (heel bone) becomes irritated as a result of traction forces from the Achilles tendon. 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 may 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 fluid-filled sac that cushions a tendon as the tendon passes near bone. In the heel, bursitis may cause pain at the underside of the heel (intracalcaneal bursitis) or at the back of the heel (posterior calcaneal bursitis). In some cases, heel bursitis is related to structural abnormalities of the foot that produce an abnormal gait. In other cases, it may be triggered by wearing shoes with poorly cushioned heels.
Pump bump — This condition, medically known as posterior calcaneal exostosis, is an abnormal bony growth at the back of the heel near the insertion of the Achilles tendon. It is especially common in young women, in whom it is often related to long-term bursitis caused by pressure from women's shoes (pumps).
Local bruises — Like other parts of the foot, the heel can be accidentally bumped and bruised. Typically, this happens as a "stone bruise," an impact injury caused by stepping on a sharp object while walking barefooted.
Achilles tendinitis — In most cases, Achilles tendinitis (inflammation of the Achilles tendon) is triggered by overuse, especially by excessive jumping during sports. However, it may also be related to poorly fitting shoes, if the upper back portion of a shoe digs into the Achilles tendon above the heel. Less often, it is caused by an inflammatory illness, such as ankylosing spondylitis, Reiter's syndrome, gout or rheumatoid arthritis.
Trapped nerve — Compression of a small branch from the lateral plantar nerve (which is one of two major branches of the posterior tibial nerve) can cause pain, numbness or tingling in the heel area. In many cases, this nerve compression is related to a sprain, fracture or large varicose vein near the heel.
Heel pain comes in many variations, depending on the cause:
Plantar fasciitis — Plantar fasciitis commonly causes intense heel pain during the first few steps after getting out of bed in the morning. This heel pain often subsides once you've begun to walk around, but it may return in the late afternoon or evening.
Heel spur — Although X-ray evidence suggests that about 11 percent of the general population has heels spurs, many of these individuals are totally asymptomatic (have no symptoms). In others, heel spurs produce pain and tenderness on the undersurface of the heel that progressively worsen over several months.
Calcaneal apophysitis — In a child, this condition causes pain and tenderness at the lower back portion and posterior undersurface of the heel. The affected heel is often tender to the touch but not obviously swollen.
Bursitis — Heel fat pad atrophy causes pain in the middle of the undersurface of the heel. This pain typically worsens with prolonged standing and is usually most intense at the end of the day. Posterior calcaneal bursitis causes pain at the back of the heel that worsens if you flex your foot up or down.
Pump bump — This condition causes a painful enlargement at the back and lateral portion of the heel.
Local bruises — Heel bruises, like bruises elsewhere in the body, may cause pain, mild local swelling, tenderness and a black and blue discoloration of the skin.
Achilles tendinitis — This condition causes pain at the back of the heel near the end of the Achilles tendon. The pain typically becomes worse if you exercise or play sports, and it is often followed by tenderness, 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 has been caused by a sprain, fracture or other injury.
What Your Doctor Looks For
After you have described your foot symptoms, the doctor will want to know more specific details about your pain, your medical and orthopedic history and lifestyle, including:
After reviewing your symptoms, history and risk factors for heel injury, your doctor will perform a physical examination. This examination will include:
An examination of your shoes — Signs of excessive wear in certain parts of the shoe can provide valuable clues to gait problems and poor bone alignment.
An evaluation of your gait — While you are barefooted, your doctor will ask you to stand still and to walk in order to evaluate the mechanics of your foot.
An examination of your feet — First, your doctor will compare both your feet for any signs of asymmetry. Then your doctor will examine your painful foot for signs of tenderness, swelling, discoloration, muscle weakness and decreased range of motion.
Sometimes, depending on the results of your physical examination, foot X-rays or other diagnostic tests may be necessary.
The duration of heel pain depends on the cause. For example, any type of heel pain that is related to obesity should gradually improve as a patient loses weight.
If your heel pain is related to a specific sport or exercise regimen, a period of rest may bring relief. Then once your heel is pain-free, you may need to make some modifications in your training program to prevent your pain from returning.
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 and cushion the heel. If you are prone to episodes of plantar fasciitis, exercises that stretch the Achilles tendon (heel cord) and plantar fascia may help to prevent re-injury. Ice massage can also be used on the sole of your foot after stressful athletic activities.
If you participate in sports that require a lot of running, the American Orthopaedic Foot and Ankle Society (AOFAS) and the American Academy of Podiatric Sports Medicine (AAPSM) recommend that you replace your old running shoes with a new pair every 350 to 500 miles. This may help prevent plantar fasciitis, heel spurs and other foot problems.
Treatment of heel pain depends on its cause:
Plantar fasciitis — Most doctors recommend an initial six- to eight-week program of conservative treatment, which includes a 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 nonsteroidal anti-inflammatory drugs (NSAIDs) 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. Surgical treatment is rarely necessary, except as a last resort.
Heel spur — Conservative treatment includes the use of shoe supports (either a heel raise or a donut-shaped heel cushion) and local corticosteroid injections. As in plantar fasciitis, surgery is a last resort.
Calcaneal apophysitis — This is usually a self-limited condition that the child outgrows after age 13 or 14. In the meantime, conservative treatment includes the use of heel pads and heel cushions, but no local injections.
Bursitis — Treatment is similar to the treatment of heel spurs. Injection with corticosteroids may cause the Achilles tendon to atrophy (shrink) or rupture.
Pump bump — Treatment is similar to the treatment of bursitis and heel spurs. In rare cases, the exostosis (bony growth) at the heel may need to be surgically removed.
Local bruises — Heel bruises can be treated by applying an ice pack for the first few minutes after injury.
Achilles tendinitis — This condition is treated conservatively with rest, NSAIDs and physical therapy.
Trapped nerve — If the trapped nerve has been caused by a sprain, fracture or other injury, then this underlying problem must be treated first. In rare cases, surgical release of the trapped nerve may be necessary.
Make an appointment to see your family doctor, orthopaedic surgeon or podiatrist if you have a foot problem that makes walking painful or if you have foot pain at rest.
Although the prognosis depends on the specific cause of the heel pain, most patients respond to conservative, nonsurgical therapy. For example, at least 90 percent of patients with plantar fasciitis heal after six to eight weeks of conservative therapy, or conservative therapy followed by six to eight weeks of night splints. Less than 5 percent of patients with plantar fasciitis require surgery.
As with many other orthopedic problems, heel pain may return if you do not follow your doctor's plan of conservative therapy, or if you return too soon to your previous level of exercise or sports participation.