Heel pain is usually focused on the underside or the back of your heel. If your pain is on the underside of your heel, its likely cause is plantar fasciitis. Pain on the back of your heel, where the Achilles tendon attaches to the heel bone, is Achilles tendinitis. Although heel pain is rarely a symptom of a serious condition, it can interfere with your normal activities, particularly exercise.
Fast facts on Heel pain
Here are some key points about heel pain. More detail and supporting information is in the main article.
- Heel pain is usually felt either under the heel or just behind it.
- Heel pain has a prevalence of 3.6%.
- US studies estimate that 7% of older adults report tenderness under the heel.
- Plantar fasciitis is estimated to account for 8% of all running-related injuries.
- There are 26 bones in the human foot, of which the heel is the largest.
- Pain typically comes on gradually, with no injury to the affected area. It is often triggered by wearing a flat shoe.
- In most cases the pain is under the foot, towards the front of the heel.
- The majority of patients recover with conservative treatments within months.
- Home care such as rest, ice, proper-fitting footwear and foot supports are often enough to ease heel pain.
- To prevent heel pain, it’s recommended to reduce the stress on that part of the body.
What Are Common Causes of Heel Pain?
Heel pain has a number of causes that are typically associated with overuse of the heel bone. You can strain your heel by pounding your feet on hard surfaces, being overweight, or wearing shoes that do not fit properly.
These strains can irritate the heel’s bones, muscles, or tendons. Other common causes of heel pain include the following.
- Heel Spurs: A bony growth on the underside of the heel bone. The spur, visible by X-ray, appears as a protrusion that can extend forward as much as half an inch. When there is no indication of bone enlargement, the condition is sometimes referred to as “heel spur syndrome.” Heel spurs result from strain on the muscles and ligaments of the foot, by stretching of the long band of tissue that connects the heel and the ball of the foot, and by repeated tearing away of the lining or membrane that covers the heel bone. These conditions may result from biomechanical imbalance, running or jogging, improperly fitted or excessively worn shoes, or obesity.
- Plantar Fasciitis: Both heel pain and heel spurs are frequently associated with plantar fasciitis, an inflammation of the band of fibrous connective tissue (fascia) running along the bottom (plantar surface) of the foot, from the heel to the ball of the foot. It is common among athletes who run and jump a lot, and it can be quite painful.
The condition occurs when the plantar fascia is strained over time beyond its normal extension, causing the soft tissue fibers of the fascia to tear or stretch at points along its length; this leads to inflammation, pain, and possibly the growth of a bone spur where the plantar fascia attaches to the heel bone. The inflammation may be aggravated by shoes that lack appropriate support, especially in the arch area, and by the chronic irritation that sometimes accompanies an athletic lifestyle.
Resting provides only temporary relief. When you resume walking, particularly after a night’s sleep, you may experience a sudden elongation of the fascia band, which stretches and pulls on the heel. As you walk, the heel pain may lessen or even disappear, but that may be just a false sense of relief. The pain often returns after prolonged rest or extensive walking.
- Excessive Pronation: Heel pain sometimes results from excessive pronation. Pronation is the normal flexible motion and flattening of the arch of the foot that allows it to adapt to ground surfaces and absorb shock in the normal walking pattern.
As you walk, the heel contacts the ground first; the weight shifts first to the outside of the foot, then moves toward the big toe. The arch rises, the foot generally rolls upward and outward, becoming rigid and stable in order to lift the body and move it forward. Excessive pronation—excessive inward motion—can create an abnormal amount of stretching and pulling on the ligaments and tendons attaching to the bottom back of the heel bone. Excessive pronation may also contribute to injury to the hip, knee, and lower back.
- Achilles Tendinitis: Pain at the back of the heel is associated with Achilles tendinitis, which is inflammation of the Achilles tendon as it runs behind the ankle and inserts on the back surface of the heel bone. It is common among people who run and walk a lot and have tight tendons. The condition occurs when the tendon is strained over time, causing the fibers to tear or stretch along its length, or at its insertion on to the heel bone. This leads to inflammation, pain, and the possible growth of a bone spur on the back of the heel bone. The inflammation is aggravated by the chronic irritation that sometimes accompanies an active lifestyle and certain activities that strain an already tight tendon.
Other possible causes of heel pain include:
- rheumatoid arthritis and other forms of arthritis, including gout, which usually manifests itself in the big toe joint;
- an inflamed bursa (bursitis), a small, irritated sac of fluid; a neuroma (a nerve growth); or other soft-tissue growth. Such heel pain may be associated with a heel spur or may mimic the pain of a heel spur;
- Haglund’s deformity (“pump bump”), a bone enlargement at the back of the heel bone in the area where the Achilles tendon attaches to the bone. This sometimes painful deformity generally is the result of bursitis caused by pressure against the shoe and can be aggravated by the height or stitching of a heel counter of a particular shoe;
- a bone bruise or contusion, which is an inflammation of the tissues that cover the heel bone. A bone bruise is a sharply painful injury caused by the direct impact of a hard object or surface on the foot.
Symptoms of Plantar fasciitis
The symptoms of plantar fasciitis are:
- Pain on the bottom of the heel
- Pain in the arch of the foot
- Pain that is usually worse upon arising
- Pain that increases over a period of months
People with plantar fasciitis often describe the pain as worse when they get up in the morning or after they’ve been sitting for long periods of time. After a few minutes of walking the pain decreases, because walking stretches the fascia. For some people the pain subsides but returns after spending long periods of time on their feet.
Diagnosis of Heel Pain
To arrive at a diagnosis, the foot and ankle surgeon will obtain your medical history and examine your foot. Throughout this process the surgeon rules out all the possible causes for your heel pain other than plantar fasciitis.
In addition, diagnostic imaging studies such as x-rays or other imaging modalities may be used to distinguish the different types of heel pain. Sometimes heel spurs are found in patients with plantar fasciitis, but these are rarely a source of pain. When they are present, the condition may be diagnosed as plantar fasciitis/heel spur syndrome.
Treating Heel pain
There are a number of treatments that can help relieve heel pain and speed up your recovery. These include:
- resting your heel – avoiding walking long distances and standing for long periods
- regular stretching – stretching your calf muscles and plantar fascia
- pain relief – using an icepack on the affected heel and taking painkillers, such as non-steroidal anti-inflammatory drugs (NSAIDs)
- wearing well fitted shoes that support and cushion your feet–running shoes are particularly useful
- using supportive devices – such as orthoses (rigid supports that are put inside the shoe) or strapping
Around four out of five cases of heel pain resolve within a year. However, having heel pain for this length of time can often be frustrating and painful.
In about one in 20 cases, the above treatments aren’t enough and surgery may be needed to release the plantar fascia.