The heel is located at the back of the foot, just below the ankle, and behind the arch of the foot. It comprises the heel bone, called the calcaneus, which is the largest bone in the foot.
The Achilles tendon is the lower part of the calf muscle, which attaches to the back of the heel bone.
The plantar fascia is a band of tissue (also a tendon) that runs along the bottom of the foot (the sole). It is attached to the planter surface of the heel bone posteriorly and to the base of your toes anteriorly. It supports the arch of the foot.
The attachments of these two tendons to the heel bone get inflamed due to certain reasons and cause pain in the heel. This post discusses the various causes and related symptoms of heel pain.
What is heel pain?
Heel pain is physical discomfort and pain on the back or the underside of the heel that may make walking painful, uncomfortable, or hard.
Several reasons can make both these attachments of the Achilles tendon and plantar fascia to the heel bone inflamed and painful.
Heel pain is a fairly common problem that affects many people worldwide. Some studies indicate that about 10% of the population experience heel pain at some point in their lives.
Each foot of yours has to bear a stress of 60 tons every time you walk a mile, which your feet can normally handle. However, too much stress can overstrain the tendons and fascia and cause inflammation and heel pain.
In most cases, heel pain resolves with rest and supportive care, but sometimes, it can persist and become chronic.
For heel pain, you should see a podiatrist. He is a specialist in medicine who deals with and treats heel pain and conditions that affect the foot, ankle, and lower leg. He is also known as a doctor of podiatric medicine (DPM) or podiatric surgeon.
This article explores the common and uncommon causes of heel pain, the diagnostic procedures, and the treatment options available.
Risk factors that make you prone to heel pain
A lifestyle that involves too much walking, especially on uneven surfaces such as those who frequently go trekking.
Running or jogging, jumping on hard surfaces as in skipping can strain your plantar fascia
Long-distance runners and ballet dancers are prone to strain the plantar fascia
An occupation that consistently involves standing for long periods such as teachers, nurses, and factory workers
Being overweight and obese. This puts excessive weight and stress on your foot ligaments and can strain them.
Heel pain can occur at any age, but is seen more in older people. Aging is a natural process in which there is weakening of the ligaments and fascia and what activities once seemed okay to do, now the aging foot can no longer support and bear. Heel pain is common over the age of 60 years.
Certain conditions that you are born with such as flat feet or high arches increase the risk of excessive strain on the plantar fascia.
An injury that may bruise or strain the ligament of the fascia can cause heel pain.
Wearing footwear that is tight, does not support the arch of the foot, and is uncomfortable to walk in can strain the plantar fascia. Choosing the right walking shoes is important.
Those with walking gait abnormalities put too much stress on the heel bone and strain the ligament and fascia of the foot.
Causes and Symptoms
There are several causes of heel pain each with its own etiology and presenting symptoms. Most of these causes are not due to trauma.
However, a calcaneal fracture can be due to constant stress on the plantar fascia and the Achilles tendon.
Fractures of the heel bone can be due to trauma from great force, such as when people land on their feet after falling from a height (such as falling off a ladder) or car crashes.
Plantar fasciitis
Plantar fasciitis is one of the most common causes of heel pain and is seen in about 10% of the general population. More than 2 million persons present with plantar heel pain in the US every year.
The plantar fascia has the capacity to absorb heavy stresses and strains we place on our feet when walking, running, and playing sports.
However, too much pressure beyond its normal range of extension can stretch the fascia too much and cause damage or tear its tissues. When this happens, the natural response to injury is inflammation, which results in heel pain and plantar fasciitis.
Similarly, when walking too vigorously or extensively, the pain in the heel develops due to overuse and excessive stretching of the plantar fascia causing micro-tears of the plantar fascia leading to its inflammation.
What can cause planter fasciitis?
Wearing high-heeled shoes or shoes with poor arch support or worn-out soles
Starting an intense running or walking exercise suddenly
Sudden weight gain
A sudden change in the occupation that requires prolonged standing
Excessive pronation—excessive inward motion—can cause too much stretching and pulling on the ligaments and tendons attached to the bottom back of the heel bone.
Heel pain of plantar fasciitis
Symptoms of plantar fasciitis
The pain of plantar fasciitis is sharp, localized, and of a stabbing type in the undersurface of the heel. The pain is felt in the arch and heel of the foot, becomes worse when you start walking, and is relieved with rest. There is difficulty in raising the front part of the foot off the floor.
It often comes on with the first steps in the morning. This is because the plantar fascia is tight and contracted after the night’s sleep. As time passes and you move around, the pain usually decreases because the plantar fascia gradually relaxes, leading to pain relief.
However, it can return when you stand for long periods or it can return if you stand up after you have been sitting for a long period.
Heel pain, when you bend, can also occur due to plantar fasciitis and Achilles tendonitis.
Plantar fasciitis can also cause pain and discomfort in other parts of the body, including the knee, hip, and back.
Besides pain, plantar fasciitis can also cause swelling of the feet and ankles.
About 30% of the cases are bilateral, meaning it is present in both the legs. About 50% of patients with plantar fasciitis will also have heel spurs.
It is more common in women, people between the ages of 45 and 64 years, runners for exercise or athletes, and in overweight and obese people.
Though plantar fasciitis is treated conservatively, it is not easy to treat, and dissatisfaction among the patients is common with most treatments because this condition is primarily a degenerative process.
Achilles tendinitis
The Achilles tendon is the thickest, strongest, and largest tendon in the human body.
Causes
Achilles tendinitis develops when the Achilles tendon, a thick band of tissue that attaches the calf muscles to the heel bone, becomes inflamed, swollen, and painful.
It most commonly develops in runners who have suddenly increased the intensity or length of their running.
The Achilles tendon weakens with age and therefore middle-aged people who occasionally play tiring sports, such as tennis or basketball are prone to develop this condition.
The condition occurs because the Achilles tendon is over-strained with time, causing the fibers of the tendon to tear along its length or at its insertion onto the heel bone.
This leads to pain due to inflammation and the possible growth of a bone spur on the back of the heel bone.
Heel pain of Achilles tendinitis
Symptoms
The pain of Achilles tendonitis is felt just behind or beneath the heel bone and can also cause calf pain in the affected leg.
The pain and stiffness are more in the morning when you get up and improve with mild activity.
The inflammation is aggravated by activities that strain the already over-strained tendon such as after prolonged jogging, climbing stairs, or sprinting.
Heel Spurs
A heel spur is a bony growth on the base of the heel bone. The spur, which can clearly be seen on X-ray, appears as a forward projection from the bottom of the heel. It can extend as much as half an inch. Heel spurs are often associated with plantar fasciitis.
Heel spurs don’t cause heel pain by themselves but the pain occurs due to the strain on the plantar fascia and muscles and ligaments of the foot caused by running or jogging, improperly fitted or excessively worn shoes, or obesity.
Bursitis
Bursitis sitis is an inflammation of the fluid-filled sac (bursa) located in the heel between the Achilles tendon and heel bone. It is called heel bursitis.
It develops due to the excessive physical activity of the ankle, such as too much walking, running, or jumping.
The site of pain is tender to touch and the pain in the heel is aggravated on walking or running. There is swelling, redness, warmth, stiffness, sharp pain, and limitation of movement. Pain is aggravated on activity and the heel bursitis pain is typically more at night.
It is treated with rest, ice fermentation, and nonsteroidal anti-inflammatory drugs. Using heel wedges in your shoes helps to decrease the pressure on the heel. However, it may take months for recovery depending on the severity.
Bursitis heel pain is usually better in the morning and worsens throughout the day, while pain from plantar fasciitis is usually worse in the morning and improves during the day as the fascia warms up.
Achilles tendon rupture
A ruptured Achilles tendon can cause swelling and pain at the back of your affected foot near the heel.
The pain is aggravated by walking or any activity that causes strain on the Achilles tendon.
There will be a bruise on the back of the foot at the site of injury. You may not be able to stand on your toes.
Achilles tendon rupture is an emergency and you should seek immediate treatment from an orthopedic specialist.
Treatment consists of rest, ice packs, NSAIDs, specific exercises of the calf muscles, and physiotherapy. Surgery may be the last resort.
Recovery can take months, depending on the severity of the injury but you can still be conservatively active during the healing process.
Heel fracture
Heel stress fractures occur due to repetitive long-term stress on the heel such as regular intense jogging or severely physically active sports like football or basketball.
There can be one or more small cracks in the heel bone, also called the calcaneal bone.
Besides stress fractures, calcaneal fractures can also include a break in the bone due to trauma causing sometimes a piece of bone to stick out (compound fracture).
Calcaneal fractures are rare and account for 1% of all foot fractures. Stress fractures are more common in men between the ages of 30 and 50 years.
Symptoms include intense pain in the heel making standing on the affected foot almost impossible. Movement aggravates the heel pain. Besides pain, there is swelling at the site of the fracture.
Other causes of heel pain
Regularly walking in ill-fitting tight shoes or wearing shoes with worn-out heels leads to extra stress on the heels.
Another cause of heel pain is dry cracked heels, which occur when the skin on the bottom of the heel becomes dry, and develops cracks and splits. They can occur due to Vitamin C, vitamin B-3, and vitamin E deficiencies.
Besides the causes of heel pain explained above that can also cause heel pain in women, there are specific causes exclusive to women. They include:
Pregnancy
Certain hormonal changes take place during pregnancy. The body produces the hormone relaxin, which causes the ligaments to loosen and makes the heel more flexible resulting in heel pain.
Weight gain during pregnancy can also cause heel pain.
Fluid retention that occurs in pregnancy causes swelling of ankles and feet, which can cause pressure on the heels resulting in heel pain.
Wearing high-heeled shoes. Frequent use of high-heeled shoes can lead to the shortening of the calf muscles. The tightened calf muscles must then stretch more when walking with a flat shoe or barefoot. This leads to a pull at the heel where the calf muscles are attached through the Achilles tendon. This causes pain at the rear or bottom of the heel.
