Discussed on this Page:
to the Arch
to the Heel Bone
Bone Bruise (Periostitis)
Bone Spur on the Bottom of the Heel (Infracalcaneal Exostosis)
Bone Spur on the Back of the Heel (Retrocalcaneal Exostosis)
Heel Pain in Children (Apophysitis)
Heel and Arch Problems
Tarsal Tunnel Syndrome
and Treatment of Common Causes of Heel Pain
Injuries to the Arch
bone is the largest of the 26 major bones in the human foot. But
while it is a large, strong bone, it is often injured, and this pain
can be quite disabling at times. Heel pain can occur in the front, back,
sides or bottom of the heel.
That the heel is commonly injured is not surprising, perhaps,
given the amazing amount of stress it must endure during a day.
Indeed, it is one of the most common injuries of the foot; we see some
variation of heel
pain in our offices an average of 5 or 6 times per day.
There are many possible causes of heel pain. Most
commonly it is a chronic, long-term pain that results of some
type of faulty biomechanics (abnormalities in the way you walk) that place
too much stress on the heel bone and the soft tissues that attach to it.
Chronic pain is a common result of standing or walking too many hours in
the course of a day, working on concrete, being overweight, wearing
poorly-constructed shoes, having an overly-pronated foot type (where the arch
collapses excessively) or the opposite--having too high an arch. For
more on this, see our web page on
seem to get this slightly more often than men, and while any age can be
affected, it usually occurs between 30 and 50 years of age.
The other type of heel pain is the sort you get from an
acute injury--a bruise to the bone or soft tissue strain resulting from a
strenuous activity, like walking, running, or jumping, or from some degree
While there are dozens of possible causes to heel pain,
review some of the more common causes.
One of those often-painful soft tissue that attaches to heel
spurs at the bottom of the foot is called "plantar fascia".
Fascia, located throughout the body, is a fibrous connective tissue
similar to a ligament. You can see fascia when you handle meat. It
is the white, connective
tissue separating layers of meat or attaching to bones.
The "plantar" fascia in our bodies is that fascia
which is seen on the bottom (or plantar portion) of the foot,
extending from the heel bone to the ball of the foot. Compared to other
fascia around the body, plantar fascia is very thick and very
strong. It has to be strong
because of the tremendous amount of force it must endure when you walk, run or
But while the
plantar fascia is a strong structure, it can still get
injured, most commonly when it is stretched beyond its normal length over long
periods of time.
When plantar fascia is injured, the condition is
called "plantar fasciitis", which is usualy pronounced either "plan-tar fash-I-tis"
to the end of a word means that structure is inflamed.) It is sometimes
known more simply as 'fasciitis'.
is the most common type of arch pain.
of plantar fasciitis may occur anywhere along the arch, but it is most
common near its attachment to the heel bone.
|Symptoms of plantar fasciitis vary, but the classic symptom is
pain after rest--when you first get out of bed in the morning, or when you get
up after sitting down for a while during the day. This is known as "post-static
The pain usually
diminishes after a few minutes of walking, sometimes even disappearing, but the
pain is commonly felt again the longer you're on the foot.
Fasciitis can be aggravated by shoes that lack appropriate
support, especially in the arch area, and by the chronic irritation of
long-periods of standing, especially on concrete, and by being overweight. Other
factors which influence this condition are gender (females
get this more than men), age (30s to 50s are most common),
and those with flatter-than-normal feet.
It doesn't help that fascia doesn't heal particularly quickly.
This is because it has
relatively poor circulation, which is why it's white in colour.
are many treatments for fasciitis. The most common initial treatment
provided by the family doctor are
medications. They may
take the edge off the pain, but they don't often resolve the condition
injections, which deliver the medication directly to the
most painful area, are usually more effective. Rest, ice, weight loss,
taping, strapping, immobilization, physiotherapy, massage, stretching, heel
cushions, acupuncture, night splints and
shock wave therapy all help some
note: We are pleased to announce that as of January
2004, we have the newest in technology in the field of
extra-corporeal shock wave therapy in our main Surrey
office. The Piezoson 100 machine, a
German-made machine that has been used in Europe for several
years has just been approved for use in Canada, and ours is
the first and only machine in western Canada. For the
first time true extra-corporeal shock wave therapy can be
offered without anesthesia with success rates of 83% reported
in German medical journals on difficult-to-treat heel
considering shock-save therapy should note that not all
shock-wave machines are the same or have the same success
rates. For more information on this, please visit our
partner, Shockwave Therapy - BC's website on
shock wave therapy.
patients, however, have a biomechanical cause to their complaint, such as
This may mean many of the treatments listed above will only provide temporary
relief of fasciitis symptoms. When you stop the treatment, the pain often
returns. This is why many cases of fasciitis respond well to
inserts that control the mechanical cause of the complaint.
you're considering orthoses, it's very important to have a podiatrist examine you.
Ideally it should be a podiatrist who specializes in the field of
biomechanics. There are many biomechanical
factors to consider when assessing the need for literally dozens of types of
devices available, so you need to have an expert to properly assess
Unfortunately, as is the case in many jurisdictions, there is no
minimum standard of training required in British Columbia to make orthoses,
and there are many fly-by-night operations around that employ salesmen with
little, if any, training in understanding anatomy or foot function.
The emphasis with these groups is on selling you some sort of device, rather
than providing proper assessment, treatment and follow-up.
the Heel Bone
When the fascia
is not the source of heel pain, the next most commonly injured
tissue is the heel bone itself.
affliction is when the heel bone simply becomes bruised.
This is usually known as "periostitis."
This is more common
in sudden, acute injuries. Rest, ice, compression, and
cushioning (with innersoles, heel cups, and gel materials) may be
helpful. In more severe cases, immobilization to fully rest the tissue
may be necessary.
may also cause heel pain. This is more common as a chronic,
ongoing injury. The good news is that with rest
and conservative care, the heel bone is usually one of the
quickest-healing bones in the foot.
chronic fascial strain occurs over a long-enough
period of time, it may be a result of excessive growth of bone to develop
where it attaches to the heel bone, something known as a "heel
spur". This growth usually develops on the underside of the heel bone.
are caused by a constant, excessive pull on the heel bone by the muscles
and fascia. They often take years to develop, and may be
associated with a variety of factors, including a biomechanical imbalance,
working on concrete, excessive running or jogging,
improperly-fitted or excessively-worn shoes, genetics, age factors, or obesity.
chronic strain that results causes a repeated tearing away of the lining or
membrane that covers the heel bone (a tissue known as "periosteum"),
which causes bleeding and bone growth in the direction of the
spur that develops is visible by X-ray, and appears as a protrusion of
bone that can extend forward as much as half an
The notion of heel spurs can be a bit misleading, however, as
the spurs, themselves, are not usually the thing that hurts. This is
because the heel bone has relatively few pain fibres compared to the soft
tissues that attach to it. This is why you may often have a heel spur
with no pain. What typically hurts are the soft tissues that attach to
that spur. Thus, you can have a tremendous amount of pain in the heel, yet have no spur show up on x-ray.
Thus, treatment is usually aimed more at the painful soft
tissues around the heel than it is at the heel spur itself.
may also occur on the back of the heel. This is known as a
"Posterior Heel Spur," a "Haglund's
Deformity," a "Pump Bump", or a "Retrocalcaneal
Exostosis. " The
term "Retrocalcaneal Exostosis" literally translates to
a "bony bump on the back of the heel bone" and is
discussed in more depth on a
Heel pain can also occur in children, most commonly between ages 8 and
13, and in this age group the most common tissue to be injured isn't the fascia
or a heel spur, but the growth plate of the heel. This is known as "Calcaneal
apophysitis," or simply "apophysitis".
Often simply dismissed as "growing pains", pediatric heel pain is
as children become increasingly active in sports activity in and out of
school. This physical activity, particularly jumping, inflames the growth center
of the heel (the apophysis. The
more active the child, the more likely the condition will occur.
If heel pain occurs in this 8 to 13 year old age group, there are a
large number of treatments available, so podiatric care can do a lot to protect
the growing bone and to provide pain relief. When the heel bone
matures, the "apophysitis" problem disappears, and the pain is not
likely to recur in exactly the same location. But at older ages, the pain may
move more to the region of the fascia (slightly forward from the original
location), or develop into a heel spur.
Causes of Heel Pain
Rheumatoid arthritis and other forms of arthritis,
including gout, which usually manifests itself in the
big toe joint, can cause heel discomfort in some cases.
Heel pain may also be the result of an inflamed bursa
a small, irritated sack of fluid behind the heel.
A neuroma (or inflamed nerve, which may involve scar
tissue) involving the so-called Baxter's
Nerve, (a nerve that courses under the
heel bone), may also cause heel pain that mimics the pain of a heel spur.
We have a separate web page on
neuromas that occur in the more common
location in the ball of the foot and into the toes, but many of
the symptoms and treatments discussed there are applicable to a
neuroma involving Baxter's Nerve.
Tarsal Tunnel Syndrome,
nerve beneath the inside ankle bone, too, can cause pain in the heel.
Tarsal Tunnel Syndrome, analogous to carpal tunnel syndrome in the
hand, is often associated with conditions like a
or flattened foot type,
tibial tendon dysfunction, and
Pain at the back of the heel is associated with inflammation of
the Achilles tendon as it runs behind the ankle and inserts on the back surface
of the heel bone. The inflammation is called
tendinitis. It is common among people who run and walk a lot and have tight tendons. The
condition occurs when the tendon is strained over time, causing the fibbers to
tear or stretch along its length, or at its insertion on to the heel bone. This
leads to inflammation, pain, and the possible growth of a bone spur on the back
of the heel bone. The inflammation is aggravated by the chronic irritation that
sometimes accompanies an active lifestyle and certain activities that strain an
already tight tendon.
On very rare occasions, there can be problems within the bone
structure itself that cause heel pain.
tumours, and other conditions can occur in the
heel causing pain, so it is important to be examined thoroughly.
Preventing Heel Pain
A variety of steps can be taken to avoid heel pain and accompanying
- Wear shoes that fit well — front, back, and sides — and have
shock-absorbent soles, rigid shanks, and supportive heel counters.
- Wear the proper shoes for each activity.
- Do not wear shoes with excessive wear on heels or soles.
- Prepare properly before exercising. Warm up and do stretching exercises
before and after running.
- Pace yourself when you participate in athletic activities.
- Try to avoid
standing on concrete for long periods.
- Don’t underestimate your body's need for rest and good nutrition.
- If you're heavier
than you should be, lose weight.
Treating Heel Pain
If pain and other symptoms of inflammation—redness, swelling,
heat—persist, you should limit normal daily activities and contact a
Your foot would be examined, and an X-ray may be taken to
out problems of the bone.
Early treatment might involve oral or injectable anti-inflammatory
medication, taping, padding, massage, stretching, exercise, shoe
recommendations, or physiotherapy. Over-the-counter shoe inserts can
provide cushioning and may help somewhat for support. Foam or Gel heel
cushions help more for bruising of the heel bone, less so than for a strained
arch. If the
condition is chronic and there is a biomechanical basis to the complaint,
devices) may be
used to permanently take strain off the fascia.
complaints may be able to be treated with a new form of therapy
known as extracorporeal shockwave therapy, or ESWT for short.
Analogous to lithotripsy, the treatment where sound waves are used
to break up kidney stones without surgery, ESWT uses similar
shockwaves to promote healing of certain causes of painful heels.
For more on this, visit our partner Shockwave Therapy - BC's
Only rarely is surgery required for heel
pain. If necessary, however, surgery may be considered, and may involve
treating the soft tissue structures, the bony structures, or both.
Common soft tissues procedures employed to
treat heel pain include releasing the plantar fascia or removing an abnormal
soft tissue structure causing the pain--like a neuroma, bursa, or tumor, for
When procedures to treat heel
pain involve bone, common treatments include removing a heel spur
or realigning the heel or other bones relative to each other to
correct abnormal bone position.