What causes heel pain? Heel pain is a common complaint, especially amongst those who spend a lot of their time on their feet for work, or who are involved in repetitive impact sports.
The cause of this pain can be varied and should be thoroughly investigated to ensure the right course of treatment is undertaken. Firstly, there are two separate areas which are often termed ‘heel pain’:
- Underneath the heel – the bit we stand on.
- At the back of the heel – the Achilles region.
Pain underneath the heel
Plantar fasciitis is probably the most common heel pain causes. Symptoms come on gradually and are often worse first thing in the morning but usually ease after a short period of walking around. The plantar fascia is the tissue under the foot which forms the arch. Pain under the heel may radiate forwards into the foot and there may be tenderness under the sole of the foot and on the inside of the heel when pressing in. Pain is usually worse first in the morning because the foot has been in a relaxed position all night and the plantar fascia temporarily shortens.
Bruised heel, also known and Policeman's Heel is a contusion or bruising to the tissues under the heel causing pain. Symptoms consist of pain under the heel bone which usually comes on gradually, although can result instantly from jumping onto the heels from a height. Walking will be uncomfortable or painful and the athlete may put up with a painful heel for some time before it becomes so bad it prevents them training. Pressing in directly under the heel may trigger pain. Symptoms can be similar to those of plantar fasciitis, however a bruised heel is not usually worse first thing in the morning and doesn't usualy radiate forwards into the arch of the foot like plantar fasciitis can. Pain often improves with rest alone.
Calcaneal fracture or broken heel bone is usually caused by falling or jumping from a height. It can also occur from road accidents or bike accidents. It is also possible for the calcaneus or heel bone to suffer a stress fracture in athletes such as long-distance runners which may come on more gradually. Sudden pain in the heel at the time of injury with rapid swelling and bruising developing shortly after. With an acute calcaneal fracture the athlete will have difficulty weight bearing.
Calcaneal stress fracture - A fracture of the calcaneus (heel) bone, either caused by a direct trauma, or repetitive pounding resulting in a stress fracture. Symptoms may be similar to that of a bruised heel where pain comes on gradually over time and be made worse with weight bearing activity such as running and jumping. A therapist may help diagnose the injury by squeezing the back of the heel from both side which should reproduce the pain.
Tarsal tunnel syndrome is a painful condition of the foot caused by pressure on the posterior tibial nerve as it passes along a passage called the tarsal tunnel just below the bony bit on the inside of the ankle. Symptoms include pain which is often described as a burning pain radiating into the arch of the foot, heel and sometimes the toes. Pins and needles or numbness may be felt in the sole of the foot. Pain may be worse when running or when standing for long periods of time and often worse at night. The area under the medial malleolus on the inside of the ankle may be tender to touch.
Heel spur - A heel spur is a growth of bone under the heel which can (but doesn't always) cause pain. Symptoms may be similar to those of plantar fasciitis and include pain and tenderness at the base of the heel, pain on weight bearing and in severe cases difficulty walking. The main diagnosis of a heel spur is made by X-ray where a bony growth on the heel can be seen. A heel spur can occur without any symptoms at all and the athlete would never know they have the bony growth on the heel. Likewise, Plantar fasciitis can occur without the bone growth present.
Back of heel pain
Painful heels can occur at the back of the heel ajd are often attributed to the Achilles tendon and related structures.
Achilles Tendinopathy - is a degenerative condition of the Achilles tendon which is a common running injury and causes pain, stiffness and often a creaking feeling in the tendon. If not caught early this can be a difficult injury to cure but with the right treatment and particularly eccentric strengthening exercises a full recovery can usually be achieved.
Achilles tendon tears - a partial achilles tendon rupture can occur in athletes from all sports but particularly running, jumping, throwing and racket sports. Symptoms include a sudden sharp pain in the achilles tendon. Sometimes though, the athlete may not feel pain at the time of the tear but later on or the next day when the tendon has cooled down and stiffened up.
Achilles bursitis - sometimes also called retrocalcaneal bursitis and is difficult to distinguish from insertional tendinopathy. Symptoms include pain at the back of the heel, especially when running uphill or on soft surfaces. There will be tenderness and swelling at the back of the heel which may make it difficult to wear certain shoes. When pressing in with the fingers both sides are the back of the heel a spongy resistance may be felt. One of the more common heel injuries amongst runners.
Sever’s disease - an osteochondroses similar to Osgood Schlatters disease, occurs in young athletes. The main symptom of sever's disease is pain and tenderness at the back of the heel which is made worse with physical activity. There may be a lump over the painful area and the athlete may have tight calf muscles resulting with reduced range of motion at the ankle. Pain may go away after a period of rest from sporting activities only to return when the young person goes back to training.
Once the cause of heel pain has been established, a suitable treatment plan should begin. Whilst reducing pain and inflammation are the first step, it is important to consider, and then correct, the cause of the injury, especially in overuse injuries such as Plantar fasciitis or tendinopathy. Common causes include:
- Tight calf muscles.
- Faulty foot biomechanics – such as overpronation or oversupination.
- Sudden increases or changes to training.
- Unsupportive footwear.
- Wearing high heels frequently.
- Without correcting the cause of the injury, the pain will more than likely return once normal activities are resumed.