Heel pain can be so severe that many will limp or grab onto a wall to go to the bathroom. After thirty minutes or so, the pain tends to work itself out.
This is classically described as morning heel pain. Pain will also occur upon standing after long periods of sitting. Plantar fasciitis is essential, the tearing and inflammation and subsequent deterioration of a long ligament type structure in the bottom of the foot.
12 Main Causes of Heel Pain
1. Plantar Fasciitis
The most common cause of heel pain is plantar fasciitis. This condition is known for causing pain at the bottom of the heel and sometimes in the arch.
Plantar fasciitis is characterized by heel pain at the first step in the morning, which can sometimes be so severe that many will limp or grab onto a wall to make their way to the bathroom. After 20-30 minutes, the pain tends to work itself out. Read more on how to cure plantar fasciitis.
2. Plantar Fascial Rupture
The plantar fascia is a long ligament on the bottom of the foot which helps to support the arch. A complete tear of this ligament at the heel is rare but can happen.
Generally, individuals have some dull pain in the heel before the injury but are not severe enough to seek medical attention. Acute pain can develop after jumping and landing on foot or taking off quickly in a sprint.
This is common in games like tennis or soccer or when running on a soft surface, like a sandy beach. It is also possible to have a rupture of the ligament after receiving a steroid injection to treat plantar fasciitis, but this is uncommon.
Pain develops suddenly and is commonly followed by bruising and swelling. The pain is worsened with walking and better with rest. X-rays should be taken but will be negative because soft tissue is not well visualized on an X-ray.
Treatment should be a 4-8 week period of immobilization. This may require a below-the-knee cast but usually involves a removable walking cast. You may need crutches during the first few weeks to assist in ambulation.
3. Calcaneal Spur Fracture
A spur can develop on the bottom of the heel in response to traction from the plantar fascia. The spur is rarely a cause of pain, but heel spur fracture outlines larger spurs that can be broken and the events leading up to a broken heel spur (calcaneal spur fracture) are very similar to those described above for a plantar fascial rupture. Mouse over X-ray to see the spur fracture outlined.
Acute pain that develops after jumping and landing on the foot or taking off quickly in a sprint may indicate a heel spur fracture. Although quick sprints, common in games like tennis or soccer, can cause a heel spur fracture, it is more likely to occur from jumping and landing on the heel.
4. Calcaneal Stress Fracture
The heel bone is called the calcaneus and is under tremendous impact when walking. Although not joint, in some cases, the heel bone can crack. The crack in the bone is an incomplete break, called a stress fracture.
Generally, there is a deep, dull pain in the heel, at the bottom, and on both sides. The pain will slowly increase in intensity and worsen after walking or standing. The heel may become swollen but is generally not bruised.
The pain may develop after a change in activity, shoes, or a change in job, which may require more walking or standing. It may develop after a simple change in the walking surface, but stress fractures in the heel generally do not happen after an injury or traumatic event.
An initial X-ray may not show anything – this is common with most stress fractures. Another X-ray at four weeks will most likely show the area of the partial break in the bone.
A bone scan will show the stress fracture in its initial phase, but repeat X-rays may be more beneficial to evaluate the overall structure of the heel bone and to evaluate for potential collapse. Further evaluation of overall bone density to rule out osteopenia is also essential.
Treatment involves a weight-bearing removable below the knee cast for 4-6 weeks. Exercises such as swimming may be beneficial to maintain fitness during the recovery period.
Related: Treating heel pain
5. Low Back Pain/Sciatica
Although it is unlikely to have isolated pain at the heels originating from the back, it is a possible cause of heel pain. Pain at the heels arising from the back may be burning, tingling, or cause numbing pain.
There is generally no pain when taking those first few steps in the morning (which is common with plantar fasciitis), and pain may worsen with sitting and driving.
The pain may also worsen at rest or when lying down to sleep. Evaluation by a general physician, orthopedist, or neurologist is recommended.
6. Nerve Entrapment
Pinching off a nerve in the heel classically develops after the initial phases of plantar fasciitis. Small tears in the plantar fascia can cause inflammation and thickening of the fascia, which can place pressure on the nerve running just beneath the fascia.
Initially, pain at the first step in the morning, which seems to work itself out, is a common complaint, and this is why nerve entrapment can be easily confused with plantar fasciitis.
Pain generally worsens throughout the day. Tingling, burning, numbness, or electrical pain may or may not be present, further confusing the diagnosis.
7. Medial Calcaneal Nerve IllustrationHeel Neuritis
Neuritis is inflammation of a nerve. In the ankle, a branch from the nerve coursing down the leg can be rubbed and irritated at the inside of the heel. The rub and irritation are generally due to shoes or orthotics. The symptoms include pain, numbness, burning, tingling, and needle-like sensations.
X-rays are useful in ruling out other heel problems but will not show any changes related to the nerve. Unfortunately, specific nerve studies (electrodiagnostic studies) are not specific for this condition. Luckily, the initial plantar fasciitis and nerve entrapment treatment is very similar.
Decreasing stress on the heel and reducing inflammation are the most effective conservative therapies. But, aggressive stretching of the plantar fascia (cornerstone treatment for plantar fasciitis) can potentially worsen the nerve entrapment.
Steroid injections may be beneficial by decreasing the irritation and inflammation around the nerve. When conservative treatments fail, surgical release of the nerve may be necessary.
8. Tarsal Tunnel Syndrome
Another nerve problem affecting the heel is called tarsal tunnel syndrome. The sciatic nerve courses down the back of the leg and splits, giving off nerve branches along the way. Below the knee, the nerve becomes the posterior tibial nerve.
This is the main nerve supplying the bottom of the foot. The nerve courses down the back of the leg and around the inside of the ankle to the bottom of the foot.
At the inside of the ankle, the end of the leg bone has a knobby area called the medial malleolus. The posterior tibial nerve course right behind this knob, and as it heads towards the foot, it has the potential to be compressed in this area.
Pain generally radiates to the bottom of the foot but sometimes up the leg. It can be dull and burning at the ankle, heel, or bottom of the foot and may be sharp with walking. The pain usually worsens with activity and is only sometimes relieved by rest.
Tumours can cause compression of varicose veins, bone spurs, and inflamed tendons but are more commonly caused by strain on the tissue due to mechanical factors affecting the foot.
The treatment depends on the cause of the nerve compression. It generally starts with physical therapy, custom orthotics, home ice therapy, and injections. If conservative measures fail, a surgical release may be indicated. Any tumour or mass causing the nerve compression should be removed.
9. Bone Tumor
Bone tumours in the heel are fortunately rare and generally benign. The pain typically starts as dull, deep heel pain and then quickly worsens and is associated with swelling.
An X-Ray will show a bone tumour or cyst. Depending on the level of pain and swelling and what the X-rays show, a CT scan or MRI may be recommended. Treatment depends on the type of cyst or tumour in the heel.
Systemic arthritic diseases can cause heel pain. Although conditions like rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, or Reiter’s Disease can all cause heel pain, they are not common causes.
Typical treatments for plantar fasciitis may be helpful, but the underlying disease must be addressed. Read more about osteoarthritis.
11. Achilles tendonitis
the inflammation of the Achilles tendon results from small microscopic tears within the tendon caused by chronic overuse. Achilles tendonitis typically develops after an increase or change in a certain activity. More on Achilles tendonitis/ tendinosis.
12. Haglund Deformity
Bony enlargement on the back of the heel is common in high arched feet and aggravated by shoes. Haglund commonly leads to painful bursitis, the inflammation of a fluid-filled sac between the tendon and bone.
Haglund’s deformity is also known as “pump bump” because the condition is common in women who wear high heels (or pumps). The rigid heel counter of a high-heeled shoe aggravates the enlargement when walking.
The condition is more common in individuals with high arched feet (cavus feet) because as the heel bone tilts up in a high arched foot, the bone on the back of the heel becomes more prominent. It rubs on the Achilles tendon, and shoes place more pressure on the area, causing inflammation of the bursa and surrounding tissue.
13. Heel spur
Heel spurs will cause pain and tenderness on the lower of the heel that will get worse as time passes by.
Less common causes of heel pain include Behcet’s syndrome, shrinking of the fat pad (fat pad atrophy), gout, lupus, heel bone swelling (intraosseous calcaneal oedema), and fibromyalgia.
Heel pain at the back of the heel may be caused by Achilles tendonitis, heel spurs, bursitis, tenosynovitis, and Haglund’s deformity.