Most causes of heel pain are gradual onset or chronic injuries caused by overuse. Here we explain the most 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.
On this page:
- Pain under the heel
- Pain at the back of the heel
- Rare conditions not to be missed
- Emergency tips for relieving heel pain
- When should I see a doctor?
Pain under the heel
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.
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
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
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
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. This is a serious heel injury and needs urgent medical care.
Read more on Calcaneal fracture.
Lateral Plantar Nerve Entrapment
Lateral plantar nerve entrapment causes pain that radiates to the inside of the ankle and lower into the heel, along the path of the nerve. Treatment involves rest and identifying and correcting the underlying cause of the injury.
Symptoms include pain originating from the nerve which radiates into the lower heel on the inside, as well as the inner ankle area. Numbness in the heel is not normally a symptom plantar nerve entrapment.
Patients with poor foot biomechanics are more susceptible to this injury. Athletes who overpronate where the foot rolls in or flattens will increase the likelihood of causing the nerve to be compressed.
Treatment: Rest is important. Avoid using the foot as much as possible. If the injury is minor then adjusting training methods by reducing running mileage or substituting swimming or cycling for running until the injury has healed may be sensible. For a more severe injury, complete rest may be advised. A doctor may prescribe anti-inflammatory medication or NSAID's (e.g. ibuprofen), or apply a simple arch taping technique (play video). Orthotics may also be prescribed to correct biomechanical problems of the foot such as overpronation.
Read more on Lateral plantar nerve entrapment.
Medial calcaneal nerve entrapment
Medial calcaneal nerve entrapment, often called 'Baxter's nerve' has similar symptoms to that of tarsal tunnel syndrome. Pain will radiate from the inside of the heel out towards the centre of the heel. Resting and icing the ankle are effective ways to help ease the pain and recover from this injury.
Symptoms of a medical calcaneal nerve entrapment include a burning pain below the medial malleolus (bony bit on the inside of the ankle). The pain may radiate under the sole into the arch of the foot. Activities such as running will usually aggravate the condition and there may be tenderness over the medial malleolus. A positive sign for tinels test (play video) will be seen on examination. This involves tapping the foot with a rubber hammer just behind the medial malleolus. Repeated tapping will reproduce symptoms of burning pain, known as Tinel's sign.
The Medial Calcaneal Nerve is a branch of the Posterior Tibial nerve which is involved in cases of Tarsal Tunnel Syndrome. Symptoms of the two are often very similar and so they may be easily confused. When there is excessive overpronation or pressure from shoes then the medial calcaneal nerve can become trapped.
Treatment should initially consist of rest from aggravating activities and application of cold therapy. Ice should not be applied directly to the skin as it may cause ice burns. Use a wet tea towel or a commercially available cold wrap. Cold can be applied for 10 to 15 minutes every hour if the injury is painful reducing as required to 3 or 4 times per day.
A doctor may prescribe anti-inflammatory medication to reduce pain and inflammation. Electrotherapy such as ultrasound can help reduce pain and inflammation. Once symptoms settle down then a full rehabilitation program of ankle mobility and strengthening exercises can begin but they should only be done if pain allows.
If conservative treatment fails then a corticosteroid injection may be administered and in rare cases which fail to respond to treatment surgery may be indicated to decompress the nerve.
Pain at the back of the heel
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
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.
Chronic insertional Achilles tendonitis in teens is usually due to an issue like sever’s disease where traction forces pull the tendon away from the bone at the site of insertion. This is due to growth where the tendon or muscles become tight and can be painful on activity or touch. Treatment is similar to Sever's disease with the most important aspect being rest.
Read more on Insertional achilles tendonitis.
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.
Read more on Achilles Bursitis
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.
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 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.