The heel is a cushion of fatty tissue that protects the structures of the foot, including the heel bone, muscles and ligaments. Heel pain is a common foot complaint. Complications include plantar fasciitis and heel spurs. Sever's disease is a common cause of heel pain in children. A podiatrist can help diagnose and treat heel pain.
Heel pain is a very common foot problem. The sufferer usually feels pain either under the heel (planter fasciitis) or just behind it (Achilles tendinitis), where the Achilles tendon connects to the heel bone. Even though heel pain can be severe and sometimes disabling, it is rarely a health threat. Heel pain is typically mild and usually disappears on its own; however, in some cases the pain may persist and become chronic (long-term).
There are 26 bones in the human foot, of which the heel (calcaneus) is the largest. The human heel is designed to provide a rigid support for the weight of the body. When we are walking or running it absorbs the impact of the foot when it hits the ground, and springs us forward into our next stride. Experts say that the stress placed on a foot when walking may be 1.25 times our body weight, and 2.75 times when running. Consequently, the heel is vulnerable to damage, and ultimately pain.
In the majority of cases heel pain has a mechanical cause. It may also be caused by arthritis, infection, an autoimmune problem, trauma, a neurological problem, or some other systemic condition (condition that affects the whole body).
Heel pain is an extremely common complaint, and there are several common causes. It is important to make an accurate diagnosis of the cause of your symptoms so that appropriate treatment can be directed at the cause. If you have heel pain, some causes include:
Plantar fasciitis is the most common condition that causes heel pain. Plantar fasciitis is due to irritation and inflammation of the tight tissue that forms the arch of the foot. Common symptoms of plantar fasciitis include heel pain with prolonged walking and standing.
A spur is commonly associated with plantar fasciitis. This problem is most commonly seen in patients who have long standing heel pain due to plantar fasciitis.
Tarsal tunnel syndrome causes a large nerve in the back of the foot to become entrapped, or pinched. Similar to carpal tunnel syndrome in the hand, tarsal tunnel syndrome can cause heel pain.
Stress fractures of the calcaneus are an uncommon cause of heel pain. Stress fractures should be considered especially in athletes such as long distance runners who have heel pain.
Posterior heel pain causes symptoms behind the foot, rather than underneath. Posterior heel pain causes include Achilles tendonitis and retrocalcaneal bursitis. Learn about causes of posterior heel pain and what treatments are available.
Common causes of heel pain include:
Achilles tendinitis
Achilles tendon rupture
Bone bruise
Bone cyst
Bone spurs
Bursitis
Fracture
Gout
Heel pad wear and tear
Neuroma
Osteomyelitis
Peripheral neuropathy
Pinched nerve
Plantar fasciitis
Problems with your gait
Rheumatoid arthritis
Stress fractures
Tarsal tunnel syndrome
Tendinitis
Treatment for heel pain usually involves trying a combination of techniques, such as painkillers and exercise, to relieve pain and speed up your recovery time.
Surgery is usually regarded as a ‘treatment of last resort’ if your symptoms fail to improve after 12 months. Only 1 in 20 people will need surgery.
Rest the affected foot whenever possible by avoiding standing for long periods of time or walking long distances. However, it is important to regularly exercise your feet and calves with stretching exercises.
Non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, are a type of painkilling medication that are usually effective in helping to relieve pain.
Some people also find that applying an ice pack to the affected heel for 5 to 10 minutes can help to relieve pain and inflammation. Ice packs are available from larger pharmacies and supermarkets.
Do not apply the ice pack directly to the skin because this can damage it. Instead, wrap the ice pack in a towel. If you do not have an ice pack, use a packet of frozen vegetables.
Regular exercises designed to stretch both your calf muscles and your plantar fascia (band of tissue that runs under the sole of the foot) should help relieve pain and improve flexibility in the affected foot.
A number of stretching exercises are described below. It is usually recommended that you do the exercises on both legs, even if only one of your heels is affected by pain. This will improve your balance and stability, as well as helping to relieve heel pain.
Keep a long towel beside your bed. Before you get out of bed in the morning, loop the towel around your foot and use the towel to pull your toes towards your body while keeping your knees straight. Repeat three times for each of your feet.
Place both of your hands on a wall at shoulder height with one of your feet in front of the other. The front foot should be 30cm (12 inches) away from the wall. With your front knee bent and your back knee straight, lean towards the wall until you feel a tightening in the calf muscles in your back leg. Then relax. Repeat this procedure 10 times, then switch legs and repeat the cycle. It is recommended that you carry out wall stretches twice a day.
Stand on your stairs facing upstairs while using your banister for support. Your feet should be slightly apart and your heels should be hanging off the back of the stair. Lower your heels until you feel a tightening in your calves. Hold this position for around 40 seconds, then raise your heels back to normal. Repeat this procedure six times, at least twice a day.
Sit on a chair with your knees bent at right angles so that your feet are pointing in opposite directions. Lift the affected foot upwards while keeping the heel on the floor. You should then feel your calf muscles and Achilles tendon (band of tissue that connects the heel bone to the calf muscle) tighten. Hold this position for several seconds, then relax. Repeat this procedure 10 times, five or six times a day.
While seated, roll the arch of your foot (the curved bottom part of the foot between your toes and your heel) over a round object, such as a rolling pin, tennis ball or drink can (some people find that using a chilled can from their fridge has the added benefit of helping to relieve pain). Move your foot and ankle in all directions over the object. Continue the exercise for several minutes and repeat the exercise twice a day.
Depending on your usual choice of footwear, your GP or podiatrist (a healthcare professional who specialises in foot care) may advise you to change your footwear. Avoid wearing flat-soled shoes as these will provide no support to your heel and could make pain worse.
Ideally, you should be wearing shoes that provide good support to the arches of your feet while cushioning your heels, such as laced-up sport shoes.
Orthoses are in-soles that fit inside your shoe to support your foot and assist the healing of your heel. You can buy orthoses off the shelf at larger pharmacies or sports shops, or your podiatrist should be able to recommend a supplier.
If your pain keeps reoccurring, does not respond to simple treatment measures, or you have an abnormal foot shape or structure, custom-made orthoses are available. They are specifically made to fit the shape of your feet.
However, there is currently no evidence that the custom-made orthoses are more effective than those bought off the shelf.
An alternative to using orthoses is to have your heel strapped with sports strapping (zinc oxide) tape. The strapping will help to relieve pressure on your heel.
Your GP or podiatrist should be able to teach you how to apply the straps yourself.
Night splints can also be useful in some cases. Most people sleep with their toes pointing down, which means that the tissue inside the heel is squeezed together. Night splints, which look like a type of boot, are designed to keep the toes and feet pointing up during sleep. This will stretch both the Achilles tendon and your plantar fascia while you sleep, which should help speed up your recovery time. Night splints are usually only available from specialist shops and online retailers. Again, your podiatrist should be able to recommend a supplier.
If none of the treatments above help to relieve your pain symptoms, your GP may recommend that you have an injection of corticosteroids. Corticosteroids are a type of medication that have a powerful anti-inflammatory effect. They have to be used sparingly because overuse can cause serious side effects, such as weight gain and high blood pressure (hypertension).
As a result of this, it is not usually recommended that more than three corticosteroid injections are given within a year in any part of the body. Before having a corticosteroids injection, a local anaesthetic (painkilling medication) may be used to numb your foot so that the injection is not painful.
If all the treatments listed above and corticosteroid injections do not relieve your heel pain, your GP may refer you to either:
an orthopaedic surgeon – a surgeon who specialises in surgery that involves the bones, muscles and joints
a podiatric surgeon – a podiatrist who specialises in foot surgery
The most widely used type of surgery for heel pain is known as plantar release surgery. This is when the surgeon cuts the fascia to release it from the heel bone. This should reduce tension in your plantar fascia, which in turn should reduce inflammation and relieve your pain symptoms.
There are two ways that the surgery can be performed:
open surgery – the section of the plantar fascia is released by making a cut into your heel
endoscopic/minimal incision surgery – a smaller incision is made and special instruments are inserted through the incision to gain access to the plantar fascia
Endoscopic/minimal incision surgery has a quicker recovery time so you will be able to walk normally much sooner (almost immediately) compared with two to three weeks for open surgery. A practical disadvantage of endoscopic surgery is that it requires both a specially trained surgical team and specialised equipment, so you may have to wait longer for treatment than if you choose open surgery.
Endoscopic surgery also carries a higher risk of damaging nearby nerves, which could result in symptoms such as numbness, tingling or some loss of movement in the foot.
You should discuss the pros and cons of both approaches with your surgical team.
The results of both surgical techniques have been mixed. As a result, they are rarely performed.
As with all surgery, plantar release carries the risk of causing complications, such as:
infection after surgery
nerve damage
symptoms getting worse after surgery – although this is rare
A new type of non-invasive treatment (does not involve making any cuts in your body) is known as extracorporeal shockwave therapy (EST).
EST involves using a device to deliver high-energy sound waves into your heel. These waves can sometimes cause pain, so a local anaesthetic may be used to numb your heel.
It has been claimed that EST works in two ways:
the sound waves have a ‘numbing’ effect on the nerves that transmit signals of pain to the brain
the sound waves help stimulate and speed up the healing process
Neither claim has yet been definitely proven.
In 2009, the National Institute of Health and Clinical Excellence (NICE) issued guidance about EST. NICE reported that it believed the procedure was safe, but there were uncertainties about how effective EST was in the treatment of pain. Some studies had reported that EST was superior to both traditional surgery and non-surgical treatments, while other studies found that EST was no better than placebo treatment.
If you are considering EST, it is important that you understand the real uncertainties that surround EST. It is possible that EST works well for some people but has no effect on others.