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The heel bone is the largest of the 26 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. Women 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 of trauma.
While there are dozens of possible causes to heel pain, I will review some of the more common causes.
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 jump.
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.
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. 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, by being overweight. It doesn't help that fascia doesn't heal particularly quickly because it has relatively poor circulation (which is why it's white in colour).
There are many treatments for fasciitis. The most common initial treatment provided by the family doctor are anti-inflammatory medications. They may take the edge off the pain, but they don't often resolve the condition fully. Steroid 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 extra-corporeal shock wave therapy all help some patients.
Many patients, however, have a biomechanical cause such as excessively pronated feet to their complaint, and 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 orthoses--custom-made inserts that control the mechanical cause of the complaint.
Heel pain sometimes results from excessive pronation. Pronation is the normal flexible motion and flattening of the arch of the foot that allows it to adapt to ground surfaces and absorb shock in the normal walking pattern.
As you walk, the heel contacts the ground first; the weight shifts first to the outside of the foot, then moves toward the big toe. The arch rises, the foot generally rolls upward and outward, becoming rigid and stable in order to lift the body and move it forward. Excessive pronation—excessive inward motion—can create an abnormal amount of stretching and pulling on the ligaments and tendons attaching to the bottom back of the heel bone. Excessive pronation may also contribute to injury to the hip, knee, and lower back.
Ledderhose's Disease (Plantar Fibromatoses)
In some cases, the fascial strain can become so bad that a tear develops in the structure. This can mean a lumpy scar known as a fibromatosis, or several scars known as fibromatoses. This unpleasant lump can make weight bearing even more difficult.
Patients with multiple fibromatoses may have a condition known as Ledderhose's Disease.
If chronic fascial strain occurs over a long-enough period of time, it may cause an 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 where the fascia attaches to the heel bone, but it may develop behind the heel bone as well.
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.
For information on heel spurs on the bottom of the heel, please visit our web page on Heel Spurs. For information on heel spurs on the back of the heel, please visit our web page entitled Posterior Heel Spurs.
A variety of steps can be taken to avoid heel pain and accompanying
How can heel pain be treated?
If pain and other symptoms of inflammation—redness, swelling, heat—persist, you should limit normal daily activities and contact our office, or another doctor of podiatric medicine.
Your foot would be examined, and an X-ray may be taken to rule out problems of the bone.
Early treatment might involve oral or injectable anti-inflammatory medication, taping, padding, massage, stretching, exercise, shoe recommendations, physiotherapy, over-the-counter shoe inserts or, if the condition is chronic and there is a biomechanical basis to the complaint, orthoses (or orthotic devices) may be used to permanently take strain off the fascia.
Only rarely is surgery required for heel pain. If necessary, however, it may involve the release of the plantar fascia, removal of a spur, removal of a bursa, or removal of a neuroma or other soft-tissue growth.
Other Common 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 (bursitis), a small, irritated sack of fluid behind the heel.
A neuroma (a nerve growth) 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.
Tarsal Tunnel Syndrome, a pinched nerve beneath the inside ankle bone, too, can cause pain in the heel.
Haglund's deformity ("pump bump") is a bone enlargement at the back of the heel bone, in the area where the Achilles tendon attaches to the bone. This sometimes painful deformity generally is the result of bursitis caused by pressure against the shoe, and can be aggravated by the height or stitching of a heel counter of a particular shoe.
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 Achilles 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.
Bone bruises (Periostitis), are also common heel injuries. A bone bruise or contusion is an inflammation of the tissues that cover the heel bone. A bone bruise is a sharply painful injury caused by the direct impact of a hard object or surface on the foot.
Stress fractures of the heel bone also can occur, but these are less frequent.
On very rare occasions, there can be problems within the bone structure itself that cause heel pain. Paget's disease, cysts, bone tumours, and other conditions can occur in the heel causing pain, so it is important to be examined thoroughly.
Children’s Heel Pain
One note on children's heel pain. There is a common condition of the heel that is found in children between ages 8 and 13. Often simply dismissed as "growing pains", pediatric heel pain is seen 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), leading to the condition known as "Calcaneal apophysitis", or simply "apophysitis". 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.
For more information on this condition, please visit our webpage on Calcaneal apophysitis.