Dr Tariq Jagnarine
Fam Med, Endocrinology/Diabetes
Heel pain can result from factors like inflammation, bone changes, and nerve compression. It occurs under or behind the heel, where the Achilles tendon connects to the heel bone. Sometimes, it can affect the side of the heel. Pain that occurs under the heel is known as plantar fasciitis. In most cases, heel pain resolves itself without treatment, but sometimes it can persist and become chronic.
Risk factors
The following are some of the risk factors for heel pain:
• Tight calf muscles
• High arches
• Running excessively
• Older adult
• Extra weight
• having a job that requires a lot of standing or walking
• Low arches
CAUSES
Heel pain may occur due to a single injury, such as a twist or fall, or from repetitive stress and pounding of the heel. Flat footwear may also stretch the plantar fascia until the area becomes swollen or inflamed, causing pain and discomfort. Common causes of heel pain include:
• Plantar fasciitis
This is inflammation of the plantar fascia. The plantar fascia is a strong, bowstring-like ligament that runs from the calcaneum or heel bone to the tip of the foot. This type of pain often results from a person’s foot anatomy. For example, if the arches are particularly high or low, this can lead to plantar fasciitis.
• Heel bursitis
Inflammation can occur at the back of the heel, in the bursa, which is a fibrous sac full of fluid. This condition can result from landing awkwardly or hard on the heels, or from pressure from footwear. A person may feel this pain deep inside the heel, or at the back of the heel.
• Haglund’s deformity
Haglund’s deformity is a bony enlargement on the back of the heel. It occurs when footwear rubs against the back of the heel, irritating the bony enlargement and surrounding tissue. Hard-backed shoes and pumps can place pressure on the back of the heel, irritating Haglund’s deformity. This is why people often refer to this condition as “pump bump.”
• Tarsal tunnel syndrome
In tarsal tunnel syndrome (TTS), tissue compresses the large nerve in the back of the foot, resulting in pain. This type of compression neuropathy can occur either in the ankle or foot.
• Stress fracture
Repetitive stress, strenuous exercise, sports, or heavy manual work can cause injury. For instance, runners are at a higher risk of a stress fracture in the metatarsal bones of the foot. Osteoporosis can also cause stress fractures.
• Sever’s disease
This is the most common cause of heel pain in children and young adults. It results from overuse and repetitive microtrauma of the growth plates of the heel bone. Sever’s disease most commonly affects children aged 7–15 years.
• Achilles tendinitis
Achilles tendinitis occurs when the large tendon in the back of the heel becomes inflamed. Overuse and injury are the most common causes of Achilles tendinitis. People may also refer to tendinitis as tendinosis or tendinopathy.
• Other causes
Other causes of heel pain include:
• Achilles tendon rupture
• Plantar fascia tear
• Baxter’s nerve entrapment
• Calcaneal stress fracture or cysts
• Soft tissue mass
• Short flexor tendon tear
• Systemic arthritis
• Bone bruise
• Problems with circulation
• Poor posture when walking or running
• Bone cyst, which is a solitary fluid-filled cyst in a bone
• Gout
• Neuroma, or Morton’s neuroma
• Osteomyelitis, an infection of the bone or bone marrow
Symptoms
People usually feel heel pain under the foot, toward the front of the heel. The pain typically starts gradually and becomes more severe. Pain may be severe, however, if there is a tear. A person may have noticed a popping sound at the time of the injury, and pain will be immediate.
• Sites of heel pain
A person may experience heel pain at specific sites. These may have different causes and treatments:
Bottom of the heel: Health experts typically refer to this as plantar fasciitis. Pain may occur here when too much pressure damages or tears the tissues, leading to inflammation.
Achilles tendon: Pain in this tendon on the back of the lower leg may result from repetitive stress, such as from tight calf muscles or suddenly increasing exercise activity and intensity.
Side of the foot: Lateral foot pain affects the outside of the heel or foot, and medial foot pain affects the inside edge. It may result from stress fractures, sprains, TTS, and other conditions.
Treatment
Most people recover with conservative treatments within months. Treatment options include the following:
• Nonsteroidal anti-inflammatory drugs (NSAIDs) can reduce pain and swelling.
• Corticosteroid injections may work if NSAIDs are not effective.
• Physical therapy can teach exercises that strengthen the lower leg muscles.
• Athletic taping gives the bottom of the foot better support.
• Orthotics, or assistive devices, and insoles can help correct foot deformities.
• Surgery
For most people with plantar fasciitis, treatment will resolve heel pain within 6 weeks. However, surgery may be necessary if pain persists after several months of treatment. A surgeon may detach the plantar fascia from the heel bone during surgery. There is a risk that this may weaken the arch of the foot.
Home remedies
Home care can help get rid of heel pain that is not severe. This includes:
• Rest: Avoid running or standing for long periods, walking on hard surfaces, and engaging in any activity that may stress the heels.
• Ice: Place an ice pack wrapped in cloth on the affected area, not directly onto the skin, for about 15 minutes.
• Footwear: Shoes that fit well and provide good support are crucial, especially for athletes.
• Foot supports: Wedges and heel cups can help relieve symptoms.
Some studies suggest that Botox may help treat plantar fasciitis. According to another study, delivering a standard dose of external beam radiation therapy like that doctors use in cancer treatment may help.
Prevention
Prevention of heel pain involves reducing the stress on the affected part of the body. Tips include the following:
• Wearing shoes when on hard ground, and not going barefooted
• Reaching or maintaining a moderate body weight to reduce stress on the heels
• Choosing footwear with heels made of material that can absorb some stress, or using inserted heel pads
• Ensuring that shoes fit properly and do not have worn-down heels or soles
• Resting the feet rather than standing, when possible
• Warming up properly before engaging in sports and activities that may place a lot of stress on the heels
When to contact a doctor
A person should consult a doctor if the heel pain persists for over 2 weeks, or if they experience:
• Severe pain with swelling near the heel
• Pain, numbness, or tingling in the heel, as well as fever
• Difficulty walking as usual
• Difficulty bending the foot downward or tiptoeing
A person should contact a doctor if the heel pain continues for more than 1 week, or if it persists when they are not standing or walking.
