The most common causes of pain in the back of the heel are plantar fasciitis, Achilles tendonitis, and Haglund’s syndrome. The pain can be throbbing, stabbing, burning, or aching depending on the underlying cause and its severity. The pain can come from behind or beneath the heel.
The heel pain is often worse first thing in the morning when you start to walk around but tends to improve with movement. Excessive walking or standing can make the pain worse. Treatments include rest, pain medications, immobilization, physical therapy, and occasionally surgery.
This article explores the common and uncommon causes of heel pain, as well as what can be done to diagnose and treat this common orthopedic symptom.
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Common Causes of Heel Pain
Heel pain is usually caused by any injury or infection to the heel bone (calcaneus) or surrounding structures. It can also be caused by injury to nerves that service the ankle or foot.
The heel bone lies at the back of the foot beneath the ankle. Along with connective tissues and a small bone called the talus, the heel provides balance and side-to-side movement of the back of the foot.
The two most common causes of heel pain involve the connective tissues that link the heel to either the base of the foot (called plantar fasciitis) or the bottom of the calf muscle (called Achilles tendonitis).
Plantar Fasciitis
Plantar fasciitis is the inflammation of the band of connective tissue that forms the arch of the foot and connects your heel bone to the base of your toes.
Plantar fasciitis causes stabbing or throbbing pain on the bottom of the heel when weight is placed on the heel after rest. The pain is usually worse during the first few steps of the morning but can also be triggered by long periods of standing.
If plantar fasciitis persists for a long time, a bony protrusion called a heel spur can form where the fascia connects to your heel bone. The pain from a heel spur is often described as "cutting" or "stabbing."
In rare cases, the plantar fascia can rupture (tear), causing excruciating pain along with swelling and bruising.
Achilles Tendonitis
Achilles tendonitis isinflammation of the Achilles tendon, the large, cord-like tendon that attaches the back of your heel bone to the calf muscle.
Achilles tendonitis causes tightening or burning pain in the tendon just over the heel. Mild swelling and morning stiffness of the heel and calf are also common.
Achilles tendonitis is usually due to overuse, such as from long-distance running. Wearing ill-fitting shoes, not warming up your calf muscles before exercise, or having arthritis may also contribute to Achilles tendonitis.
In rare cases, the Achilles tendon can rupture. This typically occurs during vigorous physical activity when the foot suddenly pivots (such as with basketball or tennis). Besides severe heel pain, some people report hearing a “popping” or “snapping” sound when the tendon tears.
Uncommon Causes of Heel Pain
There are other less common causes of heel pain that range in severity from mild to debilitating:
Heel Pad Bruise
A heel pad bruise causes sharp pain over the bottom of the heel. It is a relatively minor injury that can occur after landing hard on your heel or stepping hard on a stone. It can also happen with excessive weight-bearing exercises.
Tarsal Tunnel Syndrome
Tarsal tunnel syndrome is a nerve disorder in which a large nerve in the back of the foot, called the posterior tibial nerve, becomes pinched. Although tarsal tunnel syndrome can cause aching or burning heel pain, the pain is more often felt in the bottom of the foot and near the toes.
Tarsal tunnel syndrome is a counterpart to carpal tunnel syndrome of the wrist, causing numbness and tingling with pain that worsens at night.
Stress Fractures
Stress fractures of the heel commonly occur in athletes (such as long-distance runners) who overtrain or intensify their workouts over a short period of time. Repeated stress on the heel bone eventually causes a break.
A stress fracture causes significant heel pain that worsens with activity and improves with rest. In addition to pain, swelling and tenderness may be experienced at the fracture site.
Fat Pad Atrophy
In older adults, the cushioning fat of the heel can break down and thin over time. This is referred to as fat pad atrophy. With this condition, the pain is generally absent in the morning but worsens with activity as the day progresses.
Heel pad syndrome is a related condition in which the thinning of the fat pad is caused by repetitive trauma. Marathon runners and people with obesity are at special risk of this. Heel pad syndrome causes a deep, aching pain in the middle of the heel that worsens with weight-bearing activities.
Haglund’s Syndrome
Haglund’s syndrome, also referred to as “pump bump,” occurs when a heel spur forms at the back of the heel. This typically occurs in people who wear rigid or poorly-fitted shoes. The pain can cause limping accompanied by swelling, warmth, and redness.
As the soft tissue surrounding the bony bump gets irritated, a condition called bursitis may develop. Bursitis is the inflammation of a fluid-filled sac between joints, called the bursa. It can occur at the top and side of the Achilles tendon (calcaneal bursitis) or where the Achilles tendonattaches to the back of the heel bone (retrocalcaneal bursitis).
Sinus Tarsi Syndrome
The sinus tarsi, referred to as “the eye of the foot,” is the space on the outside of the foot between the ankle and heel bone. This space, while small, contains several ligaments along with fatty tissues, tendons, nerves, and blood vessels.
Sinus tarsi syndrome is usually caused by a traumatic injury, leading to ongoing pain in the front and sides of the ankle. The heel pain tends to increase with weight-bearing activities. There may also be a sensation of ankle "looseness" and difficulty walking on uneven surfaces.
Rare Causes of Heel Pain
Rare causes of heel pain include:
- Piezogenic papules: These are painful bumps that develop when fat bulges from the heel capsule, most often due to connective tissue diseases like Ehlers-Danlos syndrome.
- Heel bone infection: This is a form of osteomyelitis (bone inflammation) that causes constant heel pain, often with fever and fatigue.
- Heel bone tumors: These typically benign (non-cancerous) growths can cause deep, boring heel pain that worsens at night
When to See a Healthcare Provider
If you are unsure of the cause of your heel pain or don't know the specific treatment for your condition, seek medical treatment.
You should most definitely see a healthcare provider if:
- You are unable to walk on your heel.
- The heel pain interferes with your sleep.
- The heel pain persists for more than a few days.
- There is visible discoloration or disfiguration of the heel.
- There are signs of an infection, including fever and increasing pain, warmth, swelling, and redness.
Diagnosing the Cause of Heel Pain
Most heel conditions can be diagnosed with a medical history and physical examination. In certain cases, imaging studies and blood tests may be needed.
Medical History
A detailed medical history is often the most important part of diagnosing heel pain.
Questions may include:
- Where is your pain located?
- When did your pain start?
- What does your pain feel like?
- Does your pain occur when you place weight on it?
- Is the pain worse at different times of day or night?
- Do you recall doing anything that might have injured the foot?
- Are there any other symptoms?
Physical Examination
During the physical exam, the healthcare provider will inspect and touch (palpate) your foot, ankle, and heel, checking for tenderness, swelling, bruising, rash, or deformity. They may also move (manipulate) your foot and ankle to see if and where it causes pain.
Additionally, the provider may want to evaluate your gait, checking the position and angle of your foot, ankle, and heel.
Blood Tests
While blood tests are not commonly ordered for the diagnosis of heel pain, your healthcare provider may order one or more if they suspect (or want to rule out) a particular condition.
Blood tests may include:
- Complete blood count (CBC): This blood test can help detect signs of infection.
- C-reactive protein (CRP): This blood test can detect general inflammation in the body.
- Erythrocyte sedimentation rate (ESR): This blood test also detects general inflammation.
Imaging Studies
An X-ray of the heel may be ordered to diagnose conditions like a stress fracture, heel spur, bone tumor, or Haglund’s syndrome. Less commonly, a magnetic resonance imaging (MRI) scan may be used to diagnose a soft-tissue injury or infection.
Differential Diagnoses
While it is reasonable to assume that heel pain must stem from your heel, this is not always the case. There are other conditions that can mimic plantar fasciitis, Achilles tendonitis, and other causes of heel pain.
These include:
- Radiculopathy: This is when a pinched spinal nerve causes referred pain in another part of the body. When the lower back is involved, the pain may shoot down the calf muscle into the heel.
- Peripheral neuropathy: This is burning or pins-and-needle sensations caused by damage to the nerves serving the limbs. Causes include diabetes, alcohol abuse, and certain medications.
- Skin problems: Heel pain can also be caused by plantar warts, fungal foot infections (like athlete’s foot), and bacterial skin infections (like cellulitis).
- Systemic inflammatory diseases: These include "whole-body" diseases like sarcoidosis, rheumatoid arthritis, and reactive arthritis that can cause heel pain in some people.
Treating Heel Pain
Treatment depends entirely on the cause of your heel pain. If you are unsure of your diagnosis or how severe your condition is, seek medical advice before beginning any treatment.
Rest
For acute causes of heel pain, such as a heel bruise, avoiding the activity that caused it may be all you need to feel better. For example, take a few days off from jogging or avoid prolonged standing or walking. Elevating the leg also helps.
Ice Application
For most sources of heel pain, applying an ice pack over the heel in 20-minute intervals up to four times daily can help reduce swelling and pain. Be sure to place a thin towel between the ice pack and your skin to avoid frostbite.
Foot Taping
Taping the foot with sports tape is useful for certain conditions like plantar fasciitis, heel pad bruise, and heel pad syndrome.
For plantar fasciitis, your healthcare provider may recommend a taping technique involving four strips of tape that are applied around the foot and heel. The tape should not be applied too tightly and can stay in place for up to a week.
Immobilization
Many Achilles tendon ruptures are treated by placing the limb in a cast with the toes pointed down. Other injuries may require a removable orthopedic boot which helps stabilize the ankle and limits the movement of the foot.
Physical Therapy
There are specific exercises and stretches that are designed to relax the tissues that surround the heel bone. These are performed in the morning and evening as part of a physical therapy treatment plan.
For Achilles tendonitis, you may be referred to a physical therapist for a form of therapy called the Alfredson protocol. This involves strengthening the Achilles tendon with eccentric exercises that contract the tendon while stretching the supporting muscles.
Stretches for Plantar Fasciitis Relief
Footwear Modification
Depending on the cause of your heel pain, your healthcare provider may recommend various foot supports:
- For plantar fasciitis: A splint may be worn at night to keep your foot straight. Wearing sturdy, comfortable shoes with good arch and heel support can also help.
- For Achilles tendonitis Heel wedges or shoe orthotics can help stabilize the ankle and ease pain.
- For Haglund’s syndrome: Tour healthcare provider may recommend that the heel height of your shoes be altered.
Pain Medications
Nonsteroidal anti-inflammatory medications (NSAIDs) are commonly used to relieve pain caused by plantar fasciitis, Achilles tendonitis, Haglund’s syndrome, and other causes of heel pain. These typically involve over-the-counter NSAIDs like Advil (ibuprofen) and Aleve (naproxen).
For severe heel pain, like that caused by a heel fracture, opioid drugs may be prescribed for a short period of time. Sometimes, cortisone—a steroid that reduces inflammation—may be injected into the heel to temporarily ease the pain.
Surgery
For most causes of heel pain, surgery is only recommended if all other conservative options have failed to provide relief for six to 12 months.
In people with plantar fasciitis, a plantar fascia release may be used to surgically detach the plantar fascia from the heel bone. Another procedure called a gastrocnemius resection surgically lengthens the calf muscle to relieve plantar fasciitis pain.
Prevention
Whether you have had heel pain in the past or not, there are things you can do to avoid injuring your heel and supporting structures.
These include:
- Maintain a healthy body weight: Excess body weight places increased stress on the lower extremities, including the heels.
- Wear the right footwear: Wearing appropriate, properly fitting footwear with adequate support and cushioning is critical for the prevention of many types of heel pain.
- Warm-up before activities: This is especially true if you are engaging in vigorous sports or long-distance running.
- Listen to your body: Pain is never "normal." If there is heel pain you cannot explain, back off a little and see if it improves. If it recurs or gets worse, see a healthcare provider.