The heel is the largest bone in the foot. Heel pain is the most common foot problem and affects 2 million Americans every year. It can occur in the front, back, or bottom of the heel. Types of heel pain include:
- Achilles tendinitis
- Bursitis of the heel
- Excess pronation
- Haglund's deformity
- Heel spur syndrome
- Plantar fasciitis
Each type of heal pain is described in more detail below. General treatment guidelines are as follows:
- The American Orthopaedic Foot and Ankle Society (AOFAS) suggests shoe inserts, medications, and stretching as a first line of therapy for heel pain. One study found that 95% of women who used an insert and did simple stretching exercises for the Achilles tendon and plantar fascia experienced improvement after 8 weeks.
- If these treatments fail, the patient may need prescription heel orthotics and extended physical therapy. Surgery may be an option if other methods have failed.
Achilles tendinitis is an inflammation of the tendon that connects the calf muscles to the heel bone. It is caused by small tears in the tendon from overuse or injury. This condition is most common in people who engage in high-impact exercise, particularly jogging, racquetball, and tennis.
Of the people who engage in these activities, those at highest risk for this disorder are the ones with a shortened Achilles tendon. Such people tend to roll their feet too far inward when walking, and may bounce when they walk. A shortened tendon can be due to an inborn structural abnormality, or it can develop from regularly wearing high heels.
An inflamed Achilles tendon causes intense pain and affects mobility. With conservative treatment, most people with Achilles tendinitis recover in about 12 weeks.
Evidence is inconclusive about the best way to treat either acute or chronic Achilles tendinitis. Some approaches include:
Treatments to Relieve Pain and Reduce Inflammation. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin or ibuprofen (Advil), may help ease pain and reduce inflammation. It is also helpful to apply ice for 20 to 30 minutes, four or five times a day. (Note: Corticosteroid injections should not be used, because they increase the risk for rupture of the tendon.)
Gentle Stretching. Gentle calf muscle stretches may also help reduce pain and spasms. Called eccentric exercises, they involve standing on the balls of your feet at the edge of a low stool or block, raising the heels and then gently allowing one heel at a time to reach toward the floor. Do 3 sets of 15, 2 times per day every day for 6-12 weeks. If the calf is swollen, elevate the leg. Exercise is safe when the heel is no longer swollen or tender, even if pain is still present. If pain increases with exercise, stop immediately.
Shock Wave or Laser Therapy. Low level shock wave or laser therapy was shown to help improve recovery when added to an exercise regimen. During this procedure, waves of energy are delivered to the calf and ankle area.
Topical Glyceryl Trinitrate. This patch may be used in addition to exercises; however more research is necessary to assess its benefits.
Surgery vs. Nonsurgical Treatment. Chronic inflammation may lead to rupture of the Achilles tendon. Rupture most commonly affects men in their 40’s and 50’s. If pain continues, the ruptured tendon will require a cast and perhaps surgery, called tendon transfer. Although some experts believe a cast without surgery is a sufficient treatment for such rupture, there is a chance the tendon may rupture again in the future, even after it heals. Some experts suggest surgery for active people and nonsurgical treatment for older people.
Surgery requires a long incision with a postoperative period of immobilization that can average 6 weeks. Complications can include a significant surgical scar, infection, and muscle atrophy, although surgery reduces pain and preserves foot function in the long term.
Bursitis of the Heel
Bursitis of the heel is an inflammation of the bursa, a small sack of fluid beneath the heel bone. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin or ibuprofen (Advil), and steroid injections will help relieve pain from bursitis. Applying ice and massaging the heel are also beneficial. A heel cup or soft padding in the heel of the shoe reduces direct impact when walking.
Pronation is the normal motion that allows the foot to adapt to uneven walking surfaces and to absorb shock. Excessive pronation occurs when the foot has a tendency to turn inward and stretch and pull the fascia. It can cause not only heel pain but also hip, knee, and lower back problems.
Haglund's deformity, known medically as posterior calcaneal exostosis, is a bony growth surrounded by tender tissue on the back of the heel bone. It develops when the back of the shoe repeatedly rubs against the back of the heel, aggravating the tissue and the underlying bone. It is commonly called pump bump because it's often linked to wearing high heels. (It can also develop in runners, however.)
Treatment for Haglund's Deformity. Applying ice followed by moist heat will help ease discomfort from a pump bump. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin or ibuprofen (Advil), will also reduce pain. Your doctor may recommend an orthotic device to control heel motion. Corticosteroid injections are not recommended because they can weaken the Achilles tendon.
In severe cases, surgery may be necessary to remove or reduce the bony growth. Studies show, however, that recovery from surgery is very long, and success rates vary. Experts advise patients to try all conservative measures before choosing surgery.
Plantar Fasciitis and Heel Spur Syndrome
Plantar fasciitis is a common foot problem that accounts for 1 million office visits per year. Plantar fasciitis occurs from small tears and inflammation in the wide band of tendons and ligaments that stretches from the heel to the ball of the foot. This band, much like the tensed string in a bow, forms the arch of the foot and helps serve as a shock absorber for the body.
The term plantar means the sole of the foot, and fascia refers to any fibrous connective tissue in the body. Most people with plantar fasciitis experience pain in the heel with their first steps in the morning. The pain also often spreads to the arch of the foot. The condition can be temporary, or it may become chronic if ignored. Resting can provide relief, but only temporarily.
Heel spurs are calcium deposits that can develop under the heel bone as a result of inflammation. Heel spurs and plantar fasciitis are sometimes blamed interchangeably for pain, but plantar fasciitis can occur without heel spurs, and spurs commonly develop without causing any symptoms at all.
Causes of Plantar Fasciitis. The cause of plantar fasciitis is often unknown. It is usually associated with overuse during high-impact exercise and sports. Plantar fasciitis accounts for up to 9% of all running injuries. Because the condition often occurs in only one foot, however, factors other than overuse are likely to be responsible in many cases. Other causes of this injury include poorly-fitting shoes, lack of calf flexibility, or an uneven stride that causes an abnormal and stressful impact on the foot.
Treatment Goals. The three major treatment goals for plantar fasciitis are:
- Reducing inflammation and pain
- Reducing pressure on the heel
- Restoring strength and flexibility
Embarking on an exercise program as soon as possible and using NSAIDs, splints, or heel pads, as needed, can help relieve the problem. Pain that does not subside with NSAIDs may require more intensive treatments, including leg supports, shock wave therapy, injections, and even surgery.
Exercises to Restore Strength and Flexibility. Stretching the plantar fascia is the mainstay therapy for restoring strength and flexibility. One exercise involves the following:
- Put the hands on a wall and lean against them.
- Place the uninjured foot on the floor in front of the injured foot.
- Raise the heel of the injured foot.
- Gently stretch the injured leg and foot.
With stretching treatments, the plantar fascia nearly always heals by itself but it may take as long as a year, with pain occurring intermittently. A moderate amount of low-impact exercise (such as walking, swimming, or cycling) also seems to be beneficial.
Treatment. Inflammation and pain is most commonly treated with ice and over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin or ibuprofen. NSAIDs reduce pain and disability in people with plantar fasciitis when used with other techniques, such as night splints and stretching.
Corticosteroids are powerful anti-inflammatory agents. An injection of a steroid plus a local anesthetic (such as Xylocaine) may provide relief in severe cases of plantar fasciitis. (Steroid injections are not used for pain that is only due to heel spurs). For athletes or performers who need immediate relief, an effective method is to administer the steroid dexamethasone using a procedure called iontophoresis, which introduces the drug into the foot's tissue using an electrical current. It provides effective pain relief for up to four weeks and reduces swelling for up to 3 months.
Several non-drug approaches can relieve pressure on the heel, including:
Sturdy Shoes and Insoles. It is important to wear comfortable but sturdy shoes that have thick soles, rubber heels, and a sole insole to relieve pressure. (An insole with an arch support might also be helpful.) Cutting a round hole about the size of a quarter in the sole cushion under the painful area may help support the rest of the heel while relieving pressure on the painful spot. Heel cups are not very useful. When combined with exercises that stretch the arch and heel cord, over-the-counter insoles may offer the same relief as prescribed orthotics.
Night Splints. Some evidence suggests that splints worn at night may be helpful for some people. One device, for example, uses an Ace bandage and an L-shaped fiberglass splint to keep the foot stretched while the patient is sleeping. This allows the muscle to heal. Although patient compliance may be better with custom-made prescribed orthotics than with tension night splints, it is believed that they are equally effective in improving pain. In addition, evidence suggests that nearly any splint, regardless of cost, is equally effective in about three-quarters of patients.
Elevated Heels. Some people report relief from mild symptoms with the use of shoes or cowboy boots that have elevated heels. This approach, however, may not work in some people and is not recommended for anyone with a moderate-to-severe condition. (Heel cups have not been proven to be very useful.)
Orthotics. For severe conditions, such as fallen arches or structural problems that cause imbalance, special insoles, called orthotics, may help. Custom orthotics are made to fit the patient's foot and individual clinical needs. (See "Insoles and Orthotics" section).
Extracorporeal Shock Wave Therapy (ESWT). ESWT may be used as an alternative to surgery for patients who have not responded to other treatments. The therapy uses low-dose sound waves to injure the surrounding tissues in the heel, which is believed to trigger healing of the tissues that are causing the pain. Studies show that the treatment provides a very small reduction in heel pain without side effects. It can be considered as an option for patients who haven't responded well to extensive conservative treatment.
Surgery. Surgery may be needed for some patients, typically those who have disabling heel pain that does not respond to other treatments for at least a year. A typical surgery is called instep plantar fasciotomy. It relieves pressure on the nerves that are causing pain by removing and therefore releasing part of the plantar fascia. A less invasive method uses a procedure called endoscopy, which requires smaller incisions. Wearing a below-the-knee walking cast after surgery for 2 weeks may reduce the need for pain relief and speed recovery time compared to the use of crutches.
Botox. Studies show that injections of botulinum toxin (Botox), a protein used to temporarily paralyze certain muscles, reduce pain and improve patients' future ability to walk. More research is needed on this treatment.