Heel pain
What is heel pain?
The heel is a specialised part of the body designed to absorb the impact of your body weight when walking, running or undertaking any other form of physical exertion or weight-bearing exercise. When heel pain develops, it can be very disabling, making every step a problem, which in turn affects your overall posture.
What causes the problem?
Heel pain is a common occurrence. In most cases the pain is caused by some form of mechanical injury resulting from small repetitive injuries that occur at a rate faster than the body can heal them.
Heel pain can also be caused by lower back problems or inflammatory joint conditions.
The following types of heel pain are not exhaustive but may help you appreciate the complexity of heel pain and why specialist advice can be helpful.
Plantar fasciitis (or fasciopathy):
This is the most common form of heel pain, caused by damage to the fascia ‘band’ (similar to a ligament) which connects the heel bone to the base of the toes. This condition can be caused in various ways including extensive running, walking or standing for long periods of time, especially when you have a sedentary lifestyle. In particular, a change of surface (eg road to track), poor shoe support, being overweight, overuse or sudden stretching of your sole, as well as a tight Achilles tendon, can lead to this condition.
Heel bursitis (subcalcaneal bursitis):
This is an inflammation of a bursa (a fluid-filled fibrous sac) under the heel bone where the pain is typically more in the centre of the heel than that experienced with plantar fasciitis and significantly worsens during the day. This condition can be caused by a fall from a height on to the heel.
Heel bumps:
These are firm bumps on the back of the heel, usually caused by excessive shoe rubbing in the heel area, or the thickening of the tissues associated with a tight Achilles tendon.
Tarsal tunnel syndrome:
This can feel like a burning or tingling sensation under the heel within the arch of the foot with occasional loss of sensation on the bottom of the foot. This is caused by compression of the tibial nerve as it passes the inside of the ankle. Tapping of the nerve just behind the ankle bone (known as Tinel’s test) will stimulate the symptoms of the condition.
Chronic inflammation of the heel pad:
This is caused by a heavy heel strike or sometimes a reduction in the thickness of the heel pad which can give rise to a dull ache in the heel which increases during the day.
Fracture:
A fracture can be caused by falling from a height or landing on an uneven surface.
Sever’s disease (calcaneal apophysitis):
This painful condition affects young children, usually between the ages of 8 and 12, especially those who are physically active or undergoing a growth spurt. It results from inflammation of the Achilles tendon where it attaches to the heel.
Achilles tendonosis:
This condition occurs when the Achilles tendon is placed under more pressure than it can cope with and small tears develop, along with inflammation, which in some cases leads to tendon rupture. These tears become a source of further injury, which can lead to swelling within the tendon, hence the name ‘tendonosis’ (sometimes referred to in error as ‘tendonitis’).
Who gets it?
Heel pain can affect everyone, whatever your age, but those more commonly affected include people in middle age (over 40s age group), those who are overweight or stand for long periods of time, and athletes.
How do I know I have it?
With plantar fasciitis, there are often no visible features on the heel but deep localised painful spots found in or around the middle of the sole of the heel, and pain is usually worse on standing after long periods of rest, particularly first thing in the morning.
With bursitis, pain can be felt at the back of the heel when the ankle joint is moved and there may be a swelling on both sides of the Achilles tendon. Or you may feel pain deep inside the heel when it makes contact with the ground.
Is it serious?
Heel pain is a common condition and in most cases will diminish following some routine self-care measures. If the pain persists longer than three weeks, it is best to seek professional advice from a podiatrist, as there are many types of heel pain, each with their own different causes and separate forms of treatment.
What are the treatments?
If you experience heel pain, some simple self-care measures include:
- Avoid wearing ill-fitting or uncomfortable shoes
- Wear shoes with good heel cushioning and effective arch support
- Minimise walking or exercising on hard ground
- Rest regularly and try not to walk or run too fast
- Wear a raised heel (no more than 6-10 mm higher than normal)
- Lose weight if you are overweight
More specialist treatments include:
Plantar fasciitis (or fasciopathy):
Treatment can take many forms, from resting your foot as much as possible, stretching exercises and deep-heat therapy, to steroid injections and even medication or surgery to release the tight tissue ‘band’. In the acute stage, use ice compresses for 10 minutes twice a day, and ibuprofen (always check with your GP or pharmacist before taking any new medication). In some cases, padding and strapping is applied to alter the direction of stretch of the ligament to alleviate symptoms in the short term. However, for the long term, special insoles (orthoses) may be prescribed to help the feet to function more effectively and to make any possible recurrence less likely.
Heel bursitis (calcaneal bursitis):
Medication and ultrasound can give relief but for the long term, a shoe insert may be necessary. In addition, attention to the cause of any rubbing and appropriate padding and strapping will allow inflammation to settle.
Heel bumps:
Adjustments to footwear is usually enough to make them comfortable, although a leather heel counter and wearing boots may help. In more serious, recurring cases, surgery may be necessary.
Tarsal tunnel syndrome:
Special shoe inserts can reduce the pressures on the nerve and may be appropriate for certain foot types whereas, on other occasions, local injections of medication to the area where the tibial nerve is inflamed may be necessary.
Chronic inflammation of the heel pad:
A soft heel cushion can help this condition.
Fracture:
If this is suspected, an X-ray is required to confirm final diagnosis and to determine the extent of the injury and a follow-on treatment plan.
Sever’s disease (calcaneal apophysitis):
This condition is temporary and self-limiting but can be painful at the time. Rest and stretching exercises may help.
Achilles tendonosis:
Treatment involves special exercises that strengthen the tendon and increasing the height of the heel with an insole on a temporary basis.
How can I prevent it?
Follow the self-care measures above in the first instance.
When should I see a podiatrist?
If you experience any foot care issues that do not resolve themselves naturally or through routine foot care within three weeks, it is recommended that you seek the help of a healthcare professional.
