What causes pain in the heel?
Pain in the heel can be caused by many things. The commonest cause is plantar fascitis. Other causes include:
constantly being on your feet, especially on a hard surface like concrete and wearing hard- soled footwear
thinning or weakness of the fat pads of the heel
injury to the bones or padding of the heel
arthritis in the ankle or heel (subtalar) joint
irritation of the nerves on the inner or outer sides of the heel
fracture of the heel bone (calcaneum)
What is plantar fasciitis?
The function of the heel in walking is to absorb the shock of your foot striking the ground as it is put down and to start springing you forward on the next step. It contains a strong bone (the calcaneum). Under the bone are a large number of small pockets of fat in strong elastic linings, which absorb much of the shock (fat pads). The heel is attached to the front of the foot by a number of strong ligaments which run between the front part of the calcaneum and various other parts of the foot. The strongest ligament is the plantar fascia, which attaches the heel to the toes and helps to balance the various parts of the foot as you walk. It therefore takes a lot of stress as you walk.
In some people the plantar fascia becomes painful and inflamed. This usually happens where it is attached to the heel bone, although sometimes it happens in the mid-part of the foot. This condition is called plantar fasciitis. Causes include:
constant stress, and is therefore commoner in people who spend all day on their feet or are overweight.
stiffness of the ankle or tightness of the Achilles tendon increase the stresses on the heel. Most people with plantar fasciitis have a rather tight Achilles tendon.
people who have high-arched ("cavus") feet or flat feet are less able to absorb the stress of walking and are at risk of plantar fasciitis
sometimes it starts after an injury to the heel.
people who have a rheumatic condition such as rheumatoid arthritis or ankylosing spondylitis may get inflammation anywhere a ligament is attached to bone (enthesopathy), and plantar fasciitis in these people is part of their general condition.
Usually plantar fasciitis eventually gets better itself, but this can take months or even years. If you have it once you are more likely to get it again.
I've been told my pain is caused by a bone spur. Is this likely?
Near the inflamed plantar fascia attachment, but not in it, some extra bone may form, producing a small "spur". In fact, it is a shelf of bone, not a sharp spur. These "heel spurs" are commoner in people with plantar fasciitis, but they can be found in people with no heel pain. The heel spur is caused by the same process as the heel pain, but the spur is not itself the cause of the pain.
Can I do anything about heel pain myself?
You can try to avoid the things that cause heel pain to start:
avoid getting overweight
where your job allows, minimise the shock to your feet from constant pounding on hard surfaces
reduce the shocks on your heel by choosing footwear with some padding or shock-absorbing material in the heel
if you have high-arched feet or flat feet a moulded insole in your shoe may reduce the stresses on your feet
if you have an injury to your ankle or foot, make sure you exercise afterwards to get back as much movement as possible to reduce the stresses on your foot and your heel in particular.
If you start to get heel pain, doing the above things may enable the natural healing process to get underway and the pain to improve.
When should I take professional advice?
If your heel pain is affecting your normal activities and not getting better with simple self-treatment you may wish to consult your GP. (You may prefer to put up with it, knowing it will probably get better eventually.)
How will my doctor tell what is wrong?
Your doctor will listen to your complaints about your heel and examine you to see what is causing the pain, and whether anything else has started it off. If the cause of your pain seems obvious, your doctor may be happy to start treatment straight away.
However, some tests may be helpful in ruling out other problems. Blood tests may be done for arthritis. An Xray will show any arthritis in the ankle or subtalar joint, as well as any fracture or cyst in the calcaneum. (It will also show a spur if you have one, but as we know this is not the cause of the pain.) Occasionally a bone scan may be used to help spot arthritis or a stress fracture.
What can be done about heel pain?
As heel pain is basically a stress problem in the tissues of the heel, the main treatment is to reduce stress.
Your doctor will advise you about weight loss and appropriate footwear. A soft heel pad is useful to wear in your shoe to act as a shock-absorber when you walk.
If you have a stiff ankle or tight Achilles tendon a physiotherapist can advise on exercises for these. Stretching the Achilles tendon and plantar fascia is very effective general treatment for many patients.
if you have a high-arched or flat foot, a podiatrist may advise an insole to reduce stress.
Simple pain-killers such as paracetamol or anti-inflammatory medicines can help reduce the pain. Ask advice from your doctor or pharmacist before taking anti-inflammatory medicines as they can have troublesome side-effects in some people.
The simple measures above will help the majority of people with heel pain. If the pain continues, a splint to wear on your ankle at night to prevent your Achilles tendon tightening up while you are asleep is often very effective in improving the severe pain that many people get first thing in the morning and breaking the cycle of pain. Your GP or an orthopaedic foot and ankle surgeon or rheumatologist may inject some steroid into the attachment of the plantar fascia to damp down the inflammation. These measures will reduce the pain in most people who are not helped by simple treatment.
If you still have pain after one or two injections, your doctor may want to investigate your problem a bit further. If no other medical problem or cause of stress in your heel is found, a number of other treatments can be tried:
wearing a plaster cast to rest the inflamed tissues
pain control treatments such as transcutaneous nerve stimulation (TENS) or acupuncture
Only if all non-surgical treatments fail would an operation be considered.
Do I need an operation?
It is rare to need an operation for heel pain. It would only be offered if all simpler treatments have failed and, in particular, you are a reasonable weight for your height and the stresses on your heel cannot be improved by modifying your activities or footwear.
The aim of an operation is to release part of the plantar fascia from the heel bone and reduce the tension in it. Many surgeons would also explore and free the small nerves on the inner side of your heel as these are sometimes trapped by bands of tight tissue. This sort of surgery can be done through a cut about 3cm long on the inner side of your heel. Recently there has been a lot of interest in doing the operation by keyhole surgery, but this has not yet been proven to be effective and safe. Most people who have an operation are better afterwards, but it can take months to get the benefit of the operation and the wound can take a while to heal fully. Tingling or numbness on the side of the heel may occur after operation.
Wouldn't it be better to take out my heel spur?
As you will have seen from reading the section above "I've been told my pain is caused by a bone spur", the pain is not caused by the spur. Rather, both the pain and the spur are caused by inflammation in the plantar fascia. Simple removal of the spur has been known to be ineffective in relieving the pain since the 1960s.
However, if you are one of the rare people who do not respond to simple treatment and end up having an operation to release the plantar fascia, the surgeon may also remove any bone spur