Baton Rouge, LA​

6141 ParkForest Dr

Gonzales, LA

​826 West Hwy 30 Ste A

Common Causes of Heel Pain:
Diagnosis, Treatment, and Prevention

Heel pain is a common foot problem that affects people of all ages and genders. When a person with this condition tries to use the affected heel, it usually causes excruciating pain.

 

As a result of avoiding placing weight on the affected heel, some people may limp or develop an abnormal walking style.


People with heel pain often describe the pain as worse when they get up in the morning or after they’ve been sitting for long periods. After a few minutes of walking the pain decreases, because walking stretches the fascia. For some people, the pain subsides but returns after (American College of Foot and Ankle Surgeons, 2004)

What causes heel pain?

To be able to effectively treat heel pain, you need to know the root cause. The longer you have heel pain, the more time it will take for it to heal.

 

The most common causes of heel pain are pain that occurs on the bottom of the heel (plantar fasciitis) and pain that occurs at the back of the heel (Achilles tendinitis).Heel pain is usually mild at first but it can become severe with time.

 

While mechanical factors are the most common causes, other causes include;

Pain on the Bottom of the Heel

The most common causes for pain on the bottom of the heel are biomechanical abnormalities that lead to pathologic stress of the plantar soft tissues (1-7, pg 329 ACFAS).

 

Plantar fasciitis, heel spurs, and tarsal tunnel syndrome are some of the causes of pain on the bottom of the heel  (Dr. Nicole G. Freels, FACFAOM, 2011.)

 

According to Podiatry Today, Plantar fasciopathy affects about 10% of the people in America and 1 to 2 million people in America every year.

 

A consensus is that the majority of patients with heel pain have changes of the plantar fascia. 

 

Those who suffer from chronic pain have more damage. Heel thickening, swelling, and calcification are examples of changes. 

 

Because there are fewer cells and less blood flow to this area of the foot, chronic changes can make healing difficult.

 

It could be nerve entrapment or a type of tissue that is not healing. New technologies are being tested to see if they can pinpoint the source of the problem.

Plantar Fasciitis or Heel Spur Syndrome

A heel spur is a calcium deposit causing a bony protrusion on the bottom of the heel bone. (Rick Ansorge, WebMD, 2020, August 28)

 

Plantar fasciitis is where the thick band of tissue that connects the heel bone(calcaneum) with the rest of the foot (the plantar fascia) becomes damaged and thickened.

 

Heel spurs are not painful but they can cause heel pain when the plantar fascia is inflamed. 

 

People usually experience pain when they first stand up in the morning or get up after sitting for a long time. When people first begin to walk, they often feel pain in their heels. 

 

The pain may subside after a few minutes, but it will return if people stand for extended periods. The person’s weight can play a role in this. 

 

Other factors, such as tight Achilles tendons and ill-fitting shoes, can worsen the situation.

Questions about pain are important.

  • Is there a history of trauma? 
  • What are the current shoe wear and current activity levels at work and leisure? 
  • Are there occupational or recreational activities with daily, prolonged weight-bearing or walking on hard surfaces?

WANT MORE INFORMATION ON HEEL PAIN?

DOWNLOAD YOUR FREE HEEL PAIN GUIDE FROM FORMANEK, DPM

Revised Monday, January 31, 2022

Diagnosis

A doctor will check the foot and ask about the pain, the amount of walking and standing the patient does, the type of footwear they use, and their medical history.

The doctor will also check for abnormalities in the movement of the joints. 

Other physical exams may include 

  1. Passive ankle dorsiflexion, Passive ankle dorsiflexion can cause discomfort in the proximal plantar fascia.
  2. Palpation on the bottom of the heel.
  3. The occurrence of symptoms bilateral and angle and base of gait evaluation. 

 

These may be enough to determine a diagnosis, although blood tests or imaging scans may be required in some severe cases.

Treatment

Initial treatment options focus on relieving pressure on the plantar fascia’s insertion at the calcaneus.

 

these options include patient-guided stretching exercises of the calf muscles which include;

 

  • Tapping
  • Heel pads
  • Heel lifts
  •  Strapping of the foot
  • Avoiding flat, non-supportive shoes and barefoot walking
  • Over-the-counter arch supports
  • Heel cushions and limitation of prolonged physical activities and use of plantar fascia night splints.

Other therapies focus on

  • Inflammation reduction such as cryotherapy, nonsteroidal anti-inflammatory drugs (NSAIDS).
  • Corticosteroid injections in appropriate patients
  • Grastin to stretch the plantar fascia ligament mechanically 
  • Deep tissue needling to relax the musculature and allow for increased stretching.
  • Self-massage, foam rolling, or therapy balls. (Manual therapy helps facilitate flexibility, improving tolerance and range of motion when performed in conjunction with stretching exercises (3,7,30 Podiatry Today page 44). )

Usually, there’s an improvement within 6 weeks of initial treatment and the continuation of the therapy session usually heals the pain However, if there’s little or no improvement, the patient should be referred to a podiatrist or foot specialist.

The second phase of treatment includes the continuation of initial treatment plus additional therapy.

  • the use of custom orthotic devices (especially for the biomechanically malaligned patient)
  • The use of night splints to maintain an extended length of the plantar fascia during sleep (15-22) pg 330 (ACFAS)
  • A limited number of corticosteroid injections (23,24 pg 330 ACFAS)
  •  the use of a fixed ankle walker-type device to immobilize the foot during activity(25) pg 330 ACFAS) or cast immobilization for 4-6 weeks.
  • Appropriate weight-loss management consultation
  • A referral should be considered in patients with a high body mass index.

It will take about 2- 3 months for 85-90% of patients to respond to treatment in this second phase (26-30), pg 330 ACFAS).

 For those who show improvement both in phase 1 and phase 2 therapy should continue the treatment until they are treated.

 If no improvement, other systemic diseases should be considered (31-37, pg 330 ACFAS).

During the third phase of treatment, cast immobilization should be added if not already done.  

Other treatment options include surgical plantar fasciotomy. Plantar fasciotomy is a surgical procedure that separates your fascia from your heel bone to reduce strain.

Note that in the majority of cases, removal of the plantar heel spur does not treat plantar heel pain (48, 59-61) page 330 ACFAS).  

Long-term biomechanical control of excessive pronation through orthotics is important to permanently treat the condition.

Heel Bursitis

There are several fluid-filled sacs behind the heel bone that act as a cushion and a lubricant between muscles and tendons sliding over bone. 

They are known as bursa. Repetitive or overuse of the ankle can cause the bursa to become inflamed or irritated leading to heel bursitis. 

 Symptoms include heel pain, when walking, running, or jumping, or when the area is touched.

The skin around the back of the heel may be red and warm to the touch, and standing on tiptoe may aggravate the pain. 

It is most common in people who are just beginning an aggressive exercise routine.

Common causes

 Causes for heel bursitis include:

 

  • Excessive stress
  • Direct trauma
  • plantar fascial strain relationship
  • posterior pulling effect with the Achilles tendon creating tightness and contracture.

 

Treatment measures can include cortisone injections directly into the inflamed bursa, heel padding, orthotics, physical therapy with deep friction massage to break up the bursa, ultrasound +/- phonophoresis with the addition of steroids.

Black Heel Syndrome

Bruising from rubbing irritation of the capillaries of the heel against the heel counter.  This is most commonly seen in runners.  Treatment best consists of protective padding and/or injection of the inflamed bursa with cortisone.  The asymptomatic bursa can also be removed surgically. 

Plantar Fat Pad Atrophy

As we mature the fatty tissue layer underneath our heels becomes thinner with less shock absorption for the heel which can lead to pain.

 

Cushioned insoles, orthotics with accommodation can be helpful

Pain on the Back of the Heel

The most common causes of posterior heel pain or pain on the back of the heel are;

 

  1.  Achilles Tendonitis, 
  2. Heel bursitis, often associated with ‘pump bumps’ (Haglund’s deformity). 

 

The Achilles tendon is the largest tendon (a band of tissue that connects muscle to bone) in the human body and is very strong (Dr. Nicole G. Freels, FACFAOM. (2011))

 

 X-ray scans show spurring or erosions in the tendon.  An MRI is the best way to find out the changes inside the tendon.

 

This condition is common with soccer players or after someone accidentally steps into a hole. The abrupt movement causes partial tears within the tendon which gradually fills with new bone formation.

 

Initial treatment is aimed at reducing pressure to the area such as heel lifts–for short term treatment– 

 

Other treatment options include;

 

  • Orthotics
  • Bracing
  • NSAID therapy
  • Physical therapy such as stretching exercises, Grastin, ultrasound to reduce scar tissue and increase vascularity, Deep Tissue Needling to relax musculature to allow for stretching, ice massage, night splints,  Immobilization, especially in acute cases.

 

Local corticosteroid injections are not recommended as they can weaken the tendon and cause rupture. In difficult cases, surgery may be required.

Heel bumps OR Haglund’s Deformity are a bone enlargement on the back of the heel bone. These usually happen to athletes when their shoes rub up against their heels, and they can be made worse by the height or stitches of a shoe’s heel counter.

 

As a result, the heel suffers from painful bumps or bumps, making exercise extremely difficult.

 

It is more common in women between the ages of 20-30 (66-69) pg 334( ACFAS).  Symptoms include acute pain and inflammation aggravated by shoe gear. 

 

Initial treatment includes open-backed shoes, NSAID therapy, injections aimed at eliminating pressure and inflammation in the symptomatic area.  Adjunctive physical therapy can be helpful. 

 

If symptoms do not improve surgery may be required.

How to prevent heel pain

Preventing heel pain entails reducing stress on that area of the body.

  • Do not walk barefoot on a hard floor.
  • Being overweight can place excess pressure and strain on your heels. Exercise regularly to maintain healthy body weight to reduce stress on the heels
  • Only wear shoes with heels made of  material that can absorb stress
  • Check that the shoes fit properly and that the heels and soles are not worn down.
  • Avoid wearing shoes that appear to cause pain.
  • If you are prone to heel pain, rest your feet rather than stand.
  • Warm-up properly before engaging in sports or activities that may put a lot of strain on the heels.
  • Wear appropriate sports shoes for each type of sporting activity.
References