The heel is the largest bone in the foot. Heel pain 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
Shoe inserts, medications, and stretching are generally first line of therapy for heel pain. If these treatments fail, prescription heel orthotics and extended physical therapy are recommended. Surgery may be an option if other methods have failed.
Achilles tendinitis, also called Achilles tendinosis, 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.
People who have a shortened Achilles tendon are at high risk for this disorder. 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. Tight calf muscles can also increase the risk for Achilles tendinitis.
Symptoms include pain in the heel and along the tendon when walking or running. The area may feel painful and stiff in the morning. The tendon may be painful to touch or move. The area may be swollen and warm. You may have trouble standing up on one toe.
The main treatments for Achilles tendinitis do not involve surgery. It is important to remember that it may take at least 2 to 3 months for the pain to go away.
Conservative treatments include:
- Decreasing activity (including walking) that causes you pain. You can switch to other activities (biking, swimming) that put less stress on the Achilles.
- Applying ice to the tendon.
- Using nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Advil, generic).
- Stretching exercises to work on increasing the flexibility of the tendon
Your health care provider may refer you to physical therapy. A physical therapist can prescribe exercises to help stretch and strengthen your calf muscles and Achilles tendon. The therapist may also apply modalities such as ultrasound to help break down any scar tissue.
The exercises used for Achilles tendinitis treatment are called eccentric training. 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.
It is important to wear shoes that give you good support. Shoes that are slightly raised in the back are helpful for people with Achilles tendinitis. Your provider may also give you a prescription for a custom-made orthotic to fit inside your shoe.
If these treatments do not improve symptoms, you may need surgery to remove inflamed tissue and abnormal areas of the tendon. Surgery also can be used to remove the bone spur that is irritating the tendon. Extracorporeal shock wave therapy (ESWT) may be an alternative to surgery for people who have not responded to other treatments. This treatment uses low-dose sound waves.
Achilles tendinitis may make you more likely to have an Achilles rupture. This condition usually causes a sharp pain, like someone hit you in the back of the heel with a stick. Surgical repair may be necessary, but it is difficult because the tendon is not normal.
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 is often linked to wearing high heels. (It can also develop in runners.)
Applying ice followed by moist heat will help ease discomfort. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin or ibuprofen (Advil), will also reduce pain. Your provider may recommend an orthotic device to control heel motion.
In severe cases, surgery may be necessary to remove or reduce the bony growth. Studies suggest, however, that recovery from surgery is very long, and success rates vary. It is best to try conservative measures before considering surgery.
The plantar fascia is the thick tissue on the bottom of the foot. It connects the heel bone to the toes and creates the arch of the foot. When this tissue becomes swollen or inflamed, it is called plantar fasciitis. Plantar fasciitis is one of the most common orthopedic foot complaints.
You are more likely to get plantar fasciitis if you:
- Have foot arch problems (both flat feet and high arches)
- Run long distances, downhill or on uneven surfaces
- Are obese or have had sudden weight gain
- Have a tight Achilles tendon (the tendon connecting the calf muscles to the heel)
- Wear shoes with poor arch support or soft soles
- Change your exercise routine
Plantar fasciitis was commonly thought to be caused by a heel spur. However, research has found that this is not the case. On x-ray, heel spurs are seen in people with and without plantar fasciitis.
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.
Treatment of plantar fasciitis focuses on relieving pain, reducing inflammation, and restoring flexibility. Initial treatments include:
- Rest and ice applications
- Pain reliever such as ibuprofen (Advil, generic)
- Heel and foot stretching exercises
- Wearing shoes with good support and cushions
- Night splints to keep the foot stretched while asleep
If these methods do not work, your health care provider may recommend other treatments such as corticosteroid injections into the heel, a boot cast, or custom-made orthotics. Sometimes, foot surgery may be needed.
Your provider may also refer you to a physical therapist. A physical therapist can show you exercises to help increase strength and flexibility. The therapist may also use treatments, such as ultrasound, to decrease inflammation. A typical stretching exercise involves:
- 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. You need to be careful not to overdo activity or reinjure yourself while your foot is healing. In rare situations, you may need surgery to address the problem.