Heel pain is most commonly caused by plantar fasciitis, a chronic (ongoing) overuse injury of the thick band of tissue on the sole of the foot, which is known as the plantar fascia. The plantar fascia connects the heel bone to the toes and creates the arch of the foot, acting as a shock absorber when you walk or run.
Pain on the underside of the heel on weight-bearing is the main symptom of plantar fasciitis. This heel pain is often worse with the first few steps in the morning and can increase with standing and after exercising. The pain usually lessens with activity, such as when you get up and move about, but returns when you first stand up after a period of sitting. The pain may be recreated by dorsiflexion of the foot (bending back the foot so that the toes move towards the shin).
About a third of people with plantar fasciitis will have pain in both feet.
Causes of plantar fasciitis
With repeated activity on our feet, the plantar fascia can become tight and cause persistent traction (tugging) on its attachment point into the heel bone, and inflammation and pain may develop at this site. This painful condition is known as plantar fasciitis.
Biomechanical abnormalities that cause the foot to excessively pronate (roll in) on walking, tightness or weakness of the calf muscles, and abnormal functioning of the big toe, are the underlying contributors to many cases of plantar fasciitis.
Other causes of heel pain
Aside from plantar fasciitis, heel pain may be caused by a stress fracture of the calcaneus (heel bone), arthritis, irritation of a nerve or nerve entrapment (such as the posterior tibial nerve), Achilles tendinitis, or inflammation of the bursa (bursitis) between the Achilles tendon and the calcaneus.
Heel pain in children
The most common cause of heel pain in children is Sever’s disease (calcaneal apophysitis). This disease commonly arises when growth spurts are beginning and around the time of puberty. Sever’s disease is more common in boys. It is thought to occur when the growth plate at the back of the heel becomes inflamed due to a mismatch in development of the bone and the muscles and tendons. The pain is at the back of the heel where the Achilles tendon attaches to the heel bone.
Diagnosis of heel pain
To investigate the cause of your heel pain, a doctor, podiatrist or physiotherapist will examine your foot. They may ask you to walk about, stand on your toes, and ask you questions about the pain, such as when it is worse, how long you have had it, etc.
If you have classic symptoms of plantar fasciitis, you will usually not need any imaging to confirm the diagnosis. An X-ray may be necessary in some cases if a fracture is suspected, but X-rays are not routine in diagnosing heel pain. X-rays may also show a heel spur, but this may be an incidental finding (see below).
Ultrasound and MRI can show increased thickness of the plantar fascia if it is present.
Sometimes painful outgrowths of bone called heel spurs (also known as a calcaneal spur) form where the plantar fascia joins the heel bone, however, these are due to the pulling of the plantar fascia on the bone, and are not the primary source of the heel pain.
Heel spurs do not always cause pain and often are discovered incidentally on X-rays taken for other problems. Heel spurs can occur at the back of the heel and also under the heel bone on the sole of the foot, where they may be associated with plantar fasciitis.
The following factors will increase your risk of having plantar fasciitis:
- having problems with the arches of the foot, for example having flat feet (which leads to reduced shock absorption) or very high arches (with tighter plantar fascia), will predispose a person to have plantar fasciitis
- spending long periods of time in unsupportive footwear, on hard flat surfaces, will increase the risk of plantar fasciitis by putting strain on the plantar fascia
- wearing unsupportive shoes, or shoes with stiff soles
- being obese or overweight is a risk factor for plantar fasciitis
- having tight calf muscles
- having tight achilles tendons
- running, dancing, aerobics or other repetitive sport that impacts the heel
- sudden increase in training distance when running
- being pregnant – weight gain and hormonal changes put more strain on the plantar fascia
- being older – because the muscles become weaker.
Treatment of heel pain
Heel pain may be associated with a heel spur, however the heel pain is usually due to plantar fasciitis, rather than a heel spur, so treatment is usually directed at the plantar fasciitis itself.
Treatment for plantar fasciitis may include:
- rest from aggravating activities such as long walks and running
- calf muscle stretching and strengthening
- stretches for the plantar fascia
- applying ice after activities that irritate the problem
- anti-inflammatory medicines (NSAIDs), and
- weight loss (if required) to reduce stress on the feet.
A corticosteroid injection into the attachment point of the plantar fascia may provide some pain relief in the short term.
Other forms of treatment for resistant cases of plantar fasciitis are available but currently there is no evidence to support them. These include ESWT (extracorporeal shock wave treatment) and PRP (platelet rich plasma) injections.
Surgery is very rarely recommended and only after other measures fail.
Can footwear help plantar fasciitis?
A podiatrist or physiotherapist should be able to advise you on footwear choices to help with plantar fasciitis/heel pain.
Supportive footwear such as running shoes that have a stiff heel counter and a good midsole support are recommended. If necessary, foot supports, strapping, night splints (which stretch the plantar fascia as you sleep) or orthotics may be recommended to temporarily correct biomechanical abnormalities of the foot.
Heel cups, cushions or heel pads that can be inserted into footwear may help. Don’t wear old, worn-out running shoes, as they will aggravate the problem. Keep track of the approximate mileage of your running shoes.
Are there exercises or stretches to help plantar fasciitis?
There are specific exercises that have been shown to help with plantar fasciitis. A physiotherapist or podiatrist will be able to teach you these exercises. They focus on stretching the plantar fascia and the calf muscles, and strengthening the muscles of the lower leg.
The calf stretch is a straight-legged calf stretch of the gastrocnemius muscle done leaning on a wall for support.
The plantar fascia stretch is done in a seated position, crossing the affected foot over the knee of the other leg. Take hold of the toes of the affected foot and slowly pull them back towards you. Hold the stretch for a few seconds. You can use a towel wrapped around the toes if you can’t reach. The important thing is to do this gently, in a controlled fashion. Some therapists advise to do this first thing each morning in bed before walking about on your feet. (Plantar fascia pain tends to be at its worst first thing in the morning). It will also be of benefit to do it if you have been sitting in a chair for a while, before walking about.
Myofascial release is a massage technique which uses pressure and feedback to increase mobility of the fascia – the connective tissue that wraps around muscles. The evidence for myofascial release is not clear, but some people find it effective in reducing heel pain due to plantar fasciitis.
Rehabilitation for heel pain
Your healthcare professional should be able to prescribe a 6-month rehabilitation programme. If the problem does not go away after that, you should be referred to a specialist.
Rehabilitation for plantar fasciitis usually involves stretching and strengthening the calf muscles, and stretches for the plantar fascia. You may be advised to wear a heel cushion or heel cup in your shoes and do icing/ice massage after any activity that aggravates the problem. You can do ice massage effectively by freezing a drinks bottle filled with water and rolling your foot over it. Taping or orthotics may also help.
Replace activities that aggravate the problem with swimming or cycling during the rehab period. Don’t return to any sport or activities until you are pain free, and make sure you stretch properly before and after. Don’t resume activity at the level you left off before the plantar fasciitis – you should only increase gradually until you work back up to your usual level.
How long does it take plantar fascia to get better?
Most cases of plantar fasciitis that are not due to an inflammatory arthritis will get better within a year.
Some measures that may help prevent you from developing plantar fasciitis, include:
- stay a healthy weight for your height
- avoid going barefoot on hard surfaces
- replace running shoes before they are worn out
- wear supportive shoes, avoiding flat shoes without a heel or stiletto heels
- warm up before sport
- do regular stretches for your calves and feet
- increase exercise intensity or time of exercise gradually – no sudden increases
- avoid high impact activities.
What healthcare professionals can help with heel pain?
Healthcare professionals that are involved in the treatment and care of plantar fasciitis include General Practitioners (GPs), Sports physicians (sports medicine doctors), Podiatrists and Physiotherapists.