Heel Pain

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Introduction

Heel Pain

Heel pain is a common foot condition. It's usually felt as an intense pain when using the affected heel.

Heel pain usually builds up gradually and gets worse over time. The pain is often severe and occurs when you place weight on your heel.

In most cases, only one heel is affected, although estimates suggest that around a third of people have pain in both heels.

The pain is usually worse first thing in the morning, or when you first take a step after a period of inactivity. Walking usually improves the pain, but it often gets worse again after walking or standing for a long time.

Some people may limp or develop an abnormal walking style as they try to avoid placing weight on the affected heel.

What causes heel pain?

Most cases of heel pain are caused when a band of tissue in the foot, known as the plantar fascia, becomes damaged and thickens.

Plantar fasciitis is the medical term for the thickening of the plantar fascia.

The plantar fascia

The plantar fascia is a tough and flexible band of tissue that runs under the sole of the foot. It connects the heel bone with the bones of the foot, and acts as a kind of shock absorber to the foot.

Sudden damage, or damage that occurs over many months or years, can cause tiny tears (microtears) to develop inside the tissue of the plantar fascia. This can cause the plantar fascia to thicken, resulting in heel pain.

The surrounding tissue and the heel bone can also sometimes become inflamed.

Read more about the causes of heel pain.

When to see your GP

See your GP or a podiatrist (foot problems specialist) if you've had persistent heel pain for a number of weeks and it hasn't cleared up.

They should be able to diagnose the cause of your heel pain by asking about your symptoms and medical history and examining your heel and foot.

Further tests will only usually be needed if you have additional symptoms that suggest the cause of your heel pain isn't inflammation, such as:

  • numbness or a tingling sensation in your foot, which could be a sign of nerve damage in your feet and legs (peripheral neuropathy)
  • your foot feels hot and you have a high temperature (fever) of 38°C (100.4°F) or above, which could be a sign of a bone infection
  • your heel is stiff and swollen, which could be a sign of arthritis

Possible further tests that may be recommended include blood tests, X-rays, a magnetic resonance imaging (MRI) scan or an ultrasound scan.

Who gets heel pain?

Heel pain is a common foot condition. An estimated one in 10 people will have at least one episode of heel pain at some point in their life.

People who run or jog regularly, and older adults who are 40-60 years of age, are the two main groups affected by heel pain.

Treating heel pain

There are a number of treatments that can help relieve heel pain and speed up your recovery. These include:

  • resting your heel - avoiding walking long distances and standing for long periods
  • regular stretching - stretching your calf muscles and plantar fascia
  • pain relief - using an icepack on the affected heel and taking painkillers, such as non-steroidal anti-inflammatory drugs (NSAIDs)
  • wearing well fitted shoes that support and cushion your feet - running shoes are particularly useful
  • using supportive devices - such as orthoses (rigid supports that are put inside the shoe) or strapping

Around four out of five cases of heel pain resolve within a year. However, having heel pain for this length of time can often be frustrating and painful.

In about one in 20 cases, the above treatments aren't enough and surgery may be needed to release the plantar fascia. 

Read more about treating heel pain.

Preventing heel pain

Being overweight can place excess pressure and strain on your feet, particularly on your heels. Losing weight and maintaining a healthy weight by combining regular exercise with a healthy, balanced diet can be beneficial for your feet.

Wearing appropriate footwear is also important. Ideally, you should wear shoes with a low to moderate heel that supports and cushions your arches and heels. Avoid wearing shoes without heels.

Read more about preventing heel pain.


Causes

Causes

Plantar fasciitis is the most common cause of heel pain, accounting for around four out of five cases.

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

Damage to the plantar fascia is thought to occur following:

  • sudden damage - for example, damaging your heel while jogging, running or dancing; this type of damage usually affects younger people who are physically active
  • gradual wear and tear of the tissues that make up the plantar fascia - this usually affects adults who are 40 years of age or over

Increased risk

You're at an increased risk of gradual wear and tear damaging your plantar fasciitis if you:

  • are overweight or obese - if you have a body mass index (BMI) of 30 or over you're considered obese  
  • have a job that involves spending long periods of time standing
  • wear flat-soled shoes - such as sandals or flip flops

Less common causes

Some less common causes of heel pain are described below.

Stress fracture

A stress fracture (crack in the bone) can occur if your heel bone is damaged following repeated stress over time.

Fat pad atrophy

Fat pad atrophy is where the layer of fat that lies under the heel bone, known as the fat pad, starts to waste away due to too much strain being placed on it.

Women who wear high-heeled shoes for many years have an increased risk of developing fat pad atrophy.

Bursitis

Bursitis is inflammation of one or more bursa. Bursa are small fluid-filled sacs under the skin that are usually located over the joints and between tendons and bones.

It's possible to develop bursitis anywhere inside the body, not just in the foot.

Tarsal tunnel syndrome

The nerves in the sole of your foot pass through a small tunnel on the inside of the ankle joint called the tarsal tunnel.

If a cyst forms or the tunnel is damaged, the nerves can become compressed (squashed). This can cause pain anywhere along the nerve, including beneath your heel.

Sever's disease

Sever's disease is a common cause of heel pain in children. It's caused by the muscles and tendons of the hamstrings and calves stretching and tightening in response to growth spurts.

The stretching of the calf muscle pulls on the Achilles tendon. This pulls on the growing area of bone at the back of the heel (the growth plate), causing pain in the heel.

The pain is further aggravated by activities such as football and gymnastics. The pain often develops at the side of the heel, but can also be felt under the heel.

Calf and hamstring stretches and, if necessary, heel pads are usually effective treatments for Sever's disease.

Bone spurs

Bone spurs are an excess growth of bone that forms on a normal bone. They can develop on the heel (a heel spur), and are more common in people with heel pain. However, they can also occur in people without heel pain, and a heel spur itself doesn't cause heel pain.


Treatment

Treatment

Treatment for heel pain usually involves using a combination of techniques, such as stretches and painkillers, to relieve pain and speed up recovery.

See your GP or another suitably qualified healthcare professional, such as a podiatrist, if you've had persistent heel pain for a number of weeks and it hasn't cleared up. They'll be able to diagnose the problem and give you specific advice about a suitable exercise programme.

Most cases of heel pain get better within 12 months. Surgery may be recommended as a last resort if your symptoms don't improve after this time. Only one in 20 people with heel pain will need surgery.

Rest

Rest the affected foot whenever possible. Avoid walking long distances and standing for long periods. However, you should regularly stretch your feet and calves using exercises such as those described below.

Pain relief

Non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, can be used to help relieve pain.

Some people also find applying an ice pack to the affected heel for five to 10 minutes can help relieve pain and inflammation.

However, don't apply the ice pack directly to your skin. Instead, wrap it in a towel. If you don't have an ice pack, you can use a packet of frozen vegetables.

Exercise

Exercises designed to stretch both your calf muscles and your plantar fascia (the band of tissue that runs under the sole of your foot) should help relieve pain and improve flexibility in the affected foot.

A number of stretching exercises are described below. It's usually recommended that you do the exercises on both legs, even if only one of your heels is affected by pain. This will improve your balance and stability as well as relieving your heel pain.

Towel stretches

Keep a long towel beside your bed. Before you get out of bed in the morning, loop the towel around your foot and use it to pull your toes towards your body, while keeping your knee straight. Repeat three times on each foot.

Wall stretches

Place both hands on a wall at shoulder height, with one of your feet in front of the other. The front foot should be about 30cm (12 inches) away from the wall.

With your front knee bent and your back leg straight, lean towards the wall until you feel a tightening in the calf muscles of your back leg. Then relax.

Repeat this exercise 10 times before switching legs and repeating the cycle. You should practise wall stretches twice a day.

Stair stretches

Stand on a step of your stairs facing upstairs, using the banister for support. Your feet should be slightly apart, with your heels hanging off the back of the step.

Lower your heels until you feel a tightening in your calves. Hold this position for about 40 seconds, before raising your heels back to the starting position. Repeat this procedure six times, at least twice a day.

Chair stretches

Sit on a chair, with your knees bent at right angles. Turn your feet sideways so your heels are touching and your toes are pointing in opposite directions. Lift the toes of the affected foot upwards, while keeping your heel firmly on the floor.

You should feel your calf muscles and Achilles tendon (the band of tissue that connects your heel bone to your calf muscle) tighten. Hold this position for several seconds and then relax. Repeat this procedure 10 times, five or six times a day.

Dynamic stretches

While seated, roll the arch of your foot (the curved bottom part of the foot between your toes and heel) over a round object, such as a rolling pin, tennis ball or drinks can. Some people find that using a chilled can from their fridge has the added benefit of helping to relieve pain.

Move your foot and ankle in all directions over the object for several minutes. Repeat the exercise twice a day.

Footwear

Your GP or podiatrist may advise you to change your footwear.

You should avoid wearing flat-soled shoes because they won't provide your heel with support and could make your heel pain worse.

Ideally, you should wear shoes that cushion your heels and provide a good level of support to the arches of your feet.

For women, wearing high heels, and for men wearing heeled boots or brogues, can provide short- to medium-term pain relief. This is because they help reduce pressure on the heels.

However, these types of shoes may not be suitable in the long-term because they can lead to further episodes of heel pain. Your GP or podiatrist will be able to advise you about suitable footwear.

Orthoses

Orthoses are insoles that fit inside your shoe to support your foot and help your heel recover. You can buy orthoses off-the-shelf from sports shops and larger pharmacies. Alternatively, your podiatrist should be able to recommend a supplier.

If your pain doesn't respond to treatment and keeps recurring, or if you have an abnormal foot shape or structure, custom-made orthoses are available. These are specifically made to fit the shape of your feet.

However, there's currently no evidence to suggest that custom-made orthoses are more effective than those bought off-the-shelf.

Strapping and splinting

An alternative to using orthoses is to have your heel strapped with sports strapping (zinc oxide) tape, which helps relieve pressure on your heel. Your GP or podiatrist can teach you how to apply the tape yourself.

In some cases, night splints can also be useful. Most people sleep with their toes pointing down, which means tissue inside the heel is squeezed together.

Night splints, which look like boots, are designed to keep your toes and feet pointing up while you're asleep. This will stretch both your Achilles tendon and your plantar fascia, which should help speed up your recovery time.

Night splints are usually only available from specialist shops and online retailers. Again, your podiatrist should be able to recommend a supplier.

Corticosteroid injections

If treatment hasn't helped relieve your painful symptoms, your GP may recommend corticosteroid injections.

Corticosteroids are a type of medication that has a powerful anti-inflammatory effect. They have to be used sparingly because overuse can cause serious side effects, such as weight gain and high blood pressure (hypertension).

As a result, it's usually recommended that no more than three corticosteroid injections are given within a year in any part of the body.

Before having a corticosteroid injection, a local anaesthetic may be used to numb your foot so you don't feel any pain.

Surgery

If treatment hasn't worked and you still have painful symptoms after a year, your GP may refer you to either:

  • an orthopaedic surgeon - a surgeon who specialises in surgery that involves bones, muscles and joints
  • a podiatric surgeon - a podiatrist who specialises in foot surgery

Surgery is sometimes recommended for professional athletes and other sportspeople who have heel pain that's adversely affecting their career.

Plantar release surgery

Plantar release surgery is the most widely used type of surgery for heel pain. The surgeon will cut the fascia to release it from your heel bone and reduce the tension in your plantar fascia. This should reduce any inflammation and relieve your painful symptoms.

Surgery can be carried out either as:

  • open surgery - where the section of the plantar fascia is released by making a cut into your heel
  • endoscopic or minimal incision surgery - where a smaller incision is made and special instruments are inserted through it to gain access to the plantar fascia

Endoscopic or minimal incision surgery has a quicker recovery time, so you'll be able to walk normally much sooner (almost immediately), compared with two to three weeks for open surgery.

A disadvantage of endoscopic surgery is that it requires a specially trained surgical team and specialised equipment, so you may have to wait longer for treatment than if you were to choose open surgery.

Endoscopic surgery also carries a higher risk of damaging nearby nerves, which could result in symptoms such as numbness, tingling, or some loss of movement in your foot.

As with all surgery, plantar release carries the risk of causing complications such as infection, nerve damage and a worsening of your symptoms after surgery (although this is rare).

You should discuss the advantages and disadvantages of both techniques with your surgical team. 

Extracorporeal shockwave therapy (EST)

Extracorporeal shockwave therapy (EST) is a fairly new type of non-invasive treatment. Non-invasive means it doesn't involve making cuts into the body.

EST involves using a device to deliver high-energy soundwaves into your heel. The soundwaves can sometimes cause pain, so a local anaesthetic may be used to numb your heel.

It's claimed that EST works in two ways. It's thought to:

  • have a "numbing" effect on the nerves that transmit pain signals to your brain
  • help stimulate and speed up the healing process

However, these claims haven't been definitively proven.

The National Institute for Health and Care Excellence (NICE) has issued guidance about the use of EST for treating plantar fasciitis.

NICE states that there are no concerns over the safety of EST, but there are uncertainties about the effectiveness of the procedure for treating heel pain.

Some studies have reported that EST is more effective than surgery and other non-surgical treatments, while other studies found the procedure to be no better than a placebo (sham treatment).

For more information, you can read the NICE guidance about using EST for treating plantar fasciitis (PDF, 96.4kb).


Prevention

Prevention

It's not always possible to prevent heel pain, but there are measures you can take to help avoid further episodes.

Healthy weight

Being overweight can place excess pressure and strain on your feet, particularly on your heels. This increases the risk of damaging your feet and heels.

If you're overweight, losing weight and maintaining a healthy weight by combining regular exercise with a healthy, balanced diet can be beneficial for your feet.

You can calculate your body mass index (BMI) to find out whether you're a healthy weight for your height and build.

To work out your BMI, divide your weight in kilograms by your height in metres squared. If your BMI is:

  • less than 18.5 you're underweight
  • 18.5-24.9 your weight is healthy
  • 25-29 you're overweight
  • 30-40 you're obese
  • over 40 you're morbidly obese

You can also use the BMI healthy weight calculator to work out your BMI. 

Read more about obesity.

Healthy feet

Always wear footwear that's appropriate for your environment and day-to-day activities.

Wearing high heels when you go out in the evening is unlikely to be harmful. However, wearing them all week at work may damage your feet, particularly if your job involves a lot of walking or standing.

Ideally, you should wear shoes with laces and a low to moderate heel that supports and cushions your arches and heels. Avoid wearing shoes without heels.

Don't walk barefoot on hard ground, particularly while on holiday. Many cases of heel pain occur when a person protects their feet for 50 weeks of the year and then suddenly walks barefoot while on holiday. Their feet aren't accustomed to the extra pressure, which causes heel pain.

If you do a physical activity, such as running or another form of exercise that places additional strain on your feet, you should replace your sports shoes regularly. Most experts recommend that sports shoes should be replaced after you've done about 500 miles in them.

Read more about choosing sports shoes and trainers and tips for new runners.

You should also always stretch after exercising, and make strength and flexibility training part of your regular exercise routine.