Heel Pain

heel pain

Most causes of heel pain are gradual onset or chronic injuries caused by overuse. Here we explain the more common causes of under the heel and at the back of the heel, as well as some of the less common causes of heel pain.

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Pain under the heel

Gradual onset:

This is the most common type of heel pain and is usually of gradual onset where the patient is unable to identify an exact point of injury. The two most likely injuries are Plantar fasciitis and Bruised heel.

Plantar Fasciitis

Probably the most common cause of pain under the heel. A key sign of Plantar fasciitis is pain which is worse first thing in the morning. As the foot warms up the pain eases only for it to return again later in the day, especially in the more chronic cases. Pain may also radiate into the arch of the foot. Immediate first aid of rest and ice or cold therapy is important, although rest is not always an option if you have to be on your feet. A combination of treatment approaches is best including plantar fasciitis taping, heel pads, cushioning insoles, orthotic inserts, stretching exercises, a night splint, plantar fasciitis massage and more.

Read more on Plantar Fasciitis

Bruised Heel

Another common overuse heel injury with symptoms similar to plantar fasciitis with pain under the heel, however, the pain does not normally radiate into the arch of the foot. Also, bruised heel pain is reduced with rest and is not worse first thing in the morning, but does get gradually worse the longer you are on your feet. Symptoms usually occur gradually over time, however, the injury may also occur from an acute and severe impact like landing from a height on your heels. Rest is the key to recovery and a bruised heel taping technique can help by protecting the soft tissues under the heel.

Read more on Bruised Heel

Heel Spur

A heel spur is a bony growth on the heel which can occur alongside plantar fasciitis and has identical symptoms, with pain under the heel, radiating into the arch of the foot. However, it is a separate injury and a heel spur can occur without any symptoms, likewise, plantar fasciitis can occur without the presence of a heel spur. A foot Xray will be needed to confirm the diagnosis.

Read more on Heel Spur

Tarsal Tunnel Syndrome

Tarsal tunnel syndrome is caused by pressure on the posterior tibial nerve as it passes on the inside of the ankle. It can cause a burning pain in the heel that can radiate into the arch of the foot. The sole of the foot may feel numb or have pins and needles. Treatment involves rest and identifying the underlying cause of the condition. Most are treated with cold therapy, physical therapy, and biomechanical assessment, however, injections and surgery are required in some cases.

Read more on Tarsal Tunnel Syndrome

Calcaneal Stress Fracture

Less common than a bruised heel, this is a hairline fracture in the big heel bone or calcaneus as it is called. Pain will come on gradually over time and will get worse with weight-bearing activities like running or jumping. It is an overuse injury commonly seen in soldiers, road runners and dancers. Often a stress fracture cannot be seen on an X-ray until it has started to heel which occurs following a significant period of rest.

Read more on Calcaneal Stress Fracture

Calcaneal Fracture

A calcaneal fracture can be caused by a fall or jumping from a great height. Sudden heel pain at the time of impact, swelling and bruising are the main symptoms of this heel injury.

Lateral Plantar Nerve Entrapment

Pain is generally located on the inner heel and inner ankle but may radiate outwards into the lower heel. Numbness is not normally a symptom, unlike many nerve injuries.

Pain at the back of the heel

Sever's Disease

This largely affects children aged 8-15 years old, especially if they do a lot of sport. Pain and tenderness at the back of the heel which gets worse with exercise is the main symptom of this injury. Sometimes a lump is seen at the back of the heel. Squeezing the sides of the back of the heel will feel particularly tender. Sever's disease is often linked to a growth spurt when the muscles and tendons can't keep up with the bone changes.

Read more on Sever's Disease

Achilles Bursitis

Achilles bursitis, also known as Retrocalcaneal bursitis is a common cause of pain at the back of the heel in athletes, particularly runners. There will be tenderness and swelling at the back of the heel.

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Insertional Achilles Tendonitis

Insertional Achilles Tendonitis causes pain at the back of the heel at the point where the achilles tendon inserts into the heel bone. The injury is similar to Sever's disease in children but affects adults. The main symptom is pain at the back of the heel and sometimes a lump where the achilles tendon inserts into the calcaneus or heel bone.

Read more on Insertional Achilles Tendonitis

Heel pain - not to be missed!

Bone and tissue tumours, like osteoid osteoma, are rare and are less likely than the above injuries to be causing the pain. If the pain is persistent, however, medical advice should be sought.

After a knee or ankle injury, regional complex pain syndrome may cause pain in the heel.

Spondyloarthropathies are joint diseases that may cause pain in various body parts, including the foot.

Immediate first aid for heel pain

Heel pain should be treated using the P.R.I.C.E. principles (protection, rest, ice, compression & elevation).

Protection- Stop training or playing immediately to protect the heel from further damage. Stopping activity that exacerbates the heel pain is vital for recovery. Depending on the injury a sports taping technique such as plantar fasciitis taping or bruised heel taping can protect the heel and often provide instant relief from symptoms.

Rest - Resting the heel is important to treat the injury. Stopping activity like running and jumping that puts pressure on the heel will allow it to recover quicker. Continuing to train, even with a minor heel injury, can result in a more serious injury.

Ice - Apply ice or cold therapy to the heel to help reduce any pain and any inflammation. Use it for 10 minutes every hour initially for the first 24 to 48 hours, reducing frequency to 3 or 4 times a day as symptoms improve. Do not apply ice directly to the skin. Wrap ice in a wet tea towel or use a commercially available cold pack instead.

Compression - The use of a compression support or compression bandages on the lower leg and foot can help reduce swelling. Taping the heel and underneath the foot can also help relieve symptoms of pain.

Elevation - Elevating the foot and heel above heart level whenever possible can help reduce any symptoms of swelling.

Read more on PRICE principles.

When should I see a doctor about heel pain?

When should you see a doctor with your heel pain? Often people do not want to bother their GP or A&E department but if you have any of the following symptoms you should seek further medical assistance:

  • Severe pain, especially on walking
  • Severe swelling (oedema)
  • Altered sensation in the foot – such as a feeling of 'pins and needles'(paresthesia) or a 'loss of feeling' (anaesthesia) in the foot
  • Unable to complete normal daily activities after the initial 72 hours

Further medical assistance can be sought through either your local GP or a private clinician such as a podiatrist, physiotherapist, sports therapist, osteopath or chiropractor. If you have followed the P.R.I.C.E. principles (see above) and are still unable to walk after 72 hours, or still have severe pain that is not subsiding after the first 72 hours, you should visit your local A&E department for further assessment.

Secondly, if you have applied the P.R.I.C.E. principles and still have heel pain that lasts a long time (more than 2 weeks), or has ongoing discomfort in your foot or heel, you are highly recommended to seek advice from a specialist expert such as a podiatrist or physiotherapist, osteopath, or chiropractor. They can provide you with advice and an appropriate and effective recovery and rehabilitation program.