Table of ContentsView AllTable of ContentsCommon CausesUncommon CausesRare CausesSymptomsWhen to Seek CareDiagnosisTreatmentPrevention
Table of ContentsView All
View All
Table of Contents
Common Causes
Uncommon Causes
Rare Causes
Symptoms
When to Seek Care
Diagnosis
Treatment
Prevention
The most common cause of pain in the back of the heel isplantar fasciitis. The pain can be throbbing, stabbing, burning, or aching depending on the underlying cause and its severity. Pain that comes from behind or beneath the heel is more likely to be a case of Achilles tendonitis.
There are other causes, and location (pain on the side of the heel, for example) is a clue when diagnosing the pain.So is the activity that leads to pain, such as running or standing a long time, as well as the time of day, like first thing in the morning or pain that worsens hours later.
Common Causes of Heel Pain
The heel bone lies at the back of the foot beneath the ankle. Along with connective tissues and a small bone called thetalus, the heel provides balance and side-to-side movement of the back of the foot.
The two most common causes of heel pain involve the connective tissues that link the heel to either the base of the foot (calledplantar fasciitis) or the bottom of the calf muscle (calledAchilles tendonitis).
1. Plantar Fasciitis
Plantar fasciitisis the inflammation of the band of connective tissue that forms the arch of the foot and connects your heel bone to the base of your toes. It causes stabbing or throbbing pain on the bottom of the heel when weight is placed on the heel after rest.
Risk factors include:
The condition is also referred to as plantarfasciopathybecause it’s a degenerative process that leads to secondary inflammation. It usually affects one foot, allowing you to bear weight on the other.
BMI is a dated, flawed measure. It does not take into account factors such asbody composition, ethnicity, sex, race, and age. Even though it is a biased measure, BMI is still widely used in the medical community because it’s an inexpensive and quick way to analyze a person’s potential health status and outcomes.
If plantar fasciitis persists for a long time, a bony protrusion called a heel spur can form where the fascia connects to your heel bone. The pain from a heel spur is often described as “cutting” or “stabbing.”In rare cases, the plantar fascia can rupture (tear), causing excruciating pain along with swelling and bruising.
2. Achilles Tendonitis
Achilles tendonitisis inflammation of the Achilles tendon, the large, cord-like tendon that attaches the back of your heel bone to the calf muscle.
Achilles tendonitis causes tightening or burning pain in the tendon just over the heel. Mild swelling and morning stiffness of the heel and calf are also common.
Achilles tendonitis is usually due to overuse, such as from long-distance running. Wearing ill-fitting shoes, not warming up your calf muscles before exercise, or having arthritis may also contribute to Achilles tendonitis.
In rare cases, theAchilles tendon can rupture. This typically occurs during vigorous physical activity when the foot suddenly pivots (such as with basketball or tennis). Besides severe heel pain, some people report hearing a “popping” or “snapping” sound when the tendon tears.
3. Sever Disease
Sever disease is the most common cause of heel pain in children and adolescents. Calledcalcaneal apophysitis, it typically occurs between the ages of 8 and 12 when children are running, jumping, or otherwise active. It can be worse during a growth spurt.
The injury involves bone swelling or inflammation, often due to playing sports like soccer or basketball. Conservative treatment (rest, icing, pain medication) is usually successful.
4. Peroneal Tendonitis
Conditions affecting theperonealtendonare a common cause of pain on the outside of the heel, where the tendons connect the calf muscles to the foot. These tendons can rupture, dislocate, or stretch in ways that cause tendonitis.
It’s common for peroneal tendonitis to occur due to overuse injuries. Damage to the peroneal nerve also can cause symptoms, including numbness, tingling, and pain. Some people experience a foot drop with this injury, leading to gait (walking) changes and weakness.
Uncommon Causes of Heel Pain
There are other less common causes of heel pain that range in severity from mild to debilitating:
1. Heel Pad Bruise
A heel padbruisecauses sharp pain over the bottom of the heel.It is a relatively minor injury that can occur after landing hard on your heel or stepping hard on a stone. It can also happen with excessive weight-bearing exercises.
2. Tarsal Tunnel Syndrome
Tarsal tunnel syndromeis a nerve disorder in which a large nerve in the back of the foot, called theposterior tibial nerve, becomes pinched. Although tarsal tunnel syndrome can cause aching or burning heel pain, the pain is more often felt in the bottom of the foot and near the toes.
Tarsal tunnel syndrome is a counterpart tocarpal tunnel syndromeof the wrist, causing numbness and tingling with pain that worsens at night.
3. Stress Fractures
Stress fracturesof the heel commonly occur in athletes (such as long-distance runners) who overtrain or intensify their workouts over a short period of time. Repeated stress on the heel bone eventually causes a break.
A stress fracture causes significant heel pain that worsens with activity and improves with rest. In addition to pain, swelling and tenderness may be experienced at the fracture site.
4. Fat Pad Atrophy
In older adults, the cushioning fat of the heel can break down and thin over time. This is referred to as fat pad atrophy, with wear on the heel causing pain. The condition can arise due to steroid treatments for co-occurring plantar fasciitis, too, but has a different cause.
As the soft tissue surrounding the bony bump gets irritated, a condition calledbursitismay develop. Bursitis is the inflammation of a fluid-filled sac between joints, called the bursa. It can occur at the top and side of the Achilles tendon (calcaneal bursitis) or where the Achilles tendon attaches to the back of the heel bone (retrocalcaneal bursitis).
6. Sinus Tarsi Syndrome
Thesinus tarsi, referred to as “the eye of the foot,” is the space on the outside of the foot between the ankle and heel bone. This space, while small, contains several ligaments along with fatty tissues, tendons, nerves, and blood vessels.
Rare Causes of Heel Pain
Rare causes of heel pain include:
1. Piezogenic Papules
These are painful bumps that develop when fat bulges from the heel capsule, most often due to connective tissue diseases likeEhlers-Danlossyndrome.
2. Heel Bone Infection
This is a form ofosteomyelitis(bone inflammation) that causes constant heel pain, often with fever and fatigue. People diagnosed with diabetes face a higher risk.
3. Heel Bone Tumors
These typically benign (non-cancerous) growths can cause deep, boring heel pain that worsens at night.
Symptoms of Heel Pain
Pain is the common symptom among conditions that cause heel pain, but when and where it occurs helps to differentiate the exact cause. So do other factors, like the activities that lead to heel pain.
Symptoms of heel pain include:
Sites of Heel Pain
Heel pain can occur on the inside of the foot or the outside of the foot. The pain of Achilles tendonitis is most likely felt at the back of the foot, but heel pain also occurs with other symptoms. Some examples of heel pain at specific sites include:
In some cases, an accident or injury can damage nerves in the foot that contribute to heel pain.
When to See a Healthcare Provider
If you are unsure of the cause of your heel pain or don’t know the specific treatment for your condition, seek medical treatment.
You should most definitely see a healthcare provider if:
Diagnosing the Cause of Heel Pain
Most heel conditions can be diagnosed with a medical history and physical examination. In certain cases, imaging studies and blood tests may be needed.
Medical History
A detailed medical history is often the most important part of diagnosing heel pain.
Questions may include:
Physical Examination
During the physical exam, the healthcare provider will inspect and touch (palpate) your foot, ankle, and heel, checking for tenderness, swelling, bruising, rash, or deformity. They may also move (manipulate) your foot and ankle to see if and where it causes pain.
Additionally, the provider may want to evaluate your gait, checking the position and angle of your foot, ankle, and heel.
Blood Tests
While blood tests are not commonly ordered for the diagnosis of heel pain, your healthcare provider may order one or more if they suspect (or want to rule out) a particular condition.
Blood tests may include:
Imaging Studies
An X-ray of the heel may be ordered to diagnose conditions like a stress fracture, heel spur, bone tumor, or Haglund’s syndrome. Less commonly, amagnetic resonance imaging (MRI)scan may be used to diagnose a soft-tissue injury or infection.
Differential Diagnoses
While it is reasonable to assume that heel pain must stem from your heel, this is not always the case. There are other conditions that can mimic plantar fasciitis, Achilles tendonitis, and other causes of heel pain.
These include:
Treating Heel Pain
Treatment depends entirely on the cause of your heel pain. If you are unsure of your diagnosis or how severe your condition is, seek medical advice before beginning any treatment.
A common approach is theR.I.C.E. method. The acronym stands for rest, ice, compression, and elevation of an injured body part, like the heel.
Rest and Elevation
For acute causes of heel pain, such as a heel bruise, avoiding the activity that caused it may be all you need to feel better. For example, take a few days off from jogging or avoid prolonged standing or walking.
Elevating the leg above heart level also can help.You can lie down and use a pillow to help elevate the injured limb.
Ice Application
For most sources of heel pain,applying an ice packover the heel in 20-minute intervals up to four times daily can help reduce swelling and pain. Place a thin towel between the ice pack and your skin to avoid frostbite.
Foot Taping
Taping the foot with sports tape is useful for certain conditions like plantar fasciitis, heel pad bruise, and heel pad syndrome.
For plantar fasciitis, your healthcare provider may recommend ataping techniqueinvolving four strips of tape that are applied around the foot and heel. The tape should not be applied too tightly and can stay in place for up to a week.
Compression
Compression or wrapping the injury site is an important treatment step. It helps to immobilize the site and support the heel with pressure. Avoid wrapping too tightly, though.
Physical Therapy
Specific exercises and stretches are designed to relax the tissues that surround the heel bone, such as calf raises or rolling an ice-filled plastic bottle beneath the foot. These are performed in the morning and evening as part of a physical therapy treatment plan.
For Achilles tendonitis, you may be referred to aphysical therapistfor a form of therapy called theAlfredson protocol. This involves strengthening the Achilles tendon with eccentric exercises that contract the tendon while stretching the supporting muscles.
Footwear Modification
Depending on the cause of your heel pain, your healthcare provider may recommend various foot supports:
Pain Medications
Surgery
For most causes of heel pain, surgery is only recommended if all other conservative options have failed to provide relief for six to 12 months.
In people with plantar fasciitis, aplantar fascia releasemay be used to surgically detach the plantar fascia from the heel bone. Another procedure called agastrocnemius resectionsurgically lengthens the calf muscle to relieve plantar fasciitis pain.
Whether you have had heel pain in the past or not, there are things you can do to avoid injuring your heel and supporting structures.
Be sure to listen to your body, because pain is never normal. If there is heel pain you cannot explain, back off a little and see if it improves. If it recurs or gets worse, see a healthcare provider.
Summary
Heel pain can have a number of causes, and specific features of the pain can help a healthcare provider diagnose the pain. For example, pain on the side of the heel may be due to sinus tarsi syndrome, while pain behind the heel suggests Achilles tendonitis.
When and how the pain occurs also will help you to understand its cause. Once your healthcare provider makes a diagnosis, they can discuss treatment options with you. In many cases, conservative treatment options including rest or the use of shoe orthotics can bring relief. Physical therapy and, rarely, surgery also may be needed.
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