What Causes Heel Pain and How Is It Treated?

The most common cause of pain in the back of the heel is plantar fasciitis. The pain can be throbbing, stabbing, burning, or aching depending on the underlying cause and its severity. Pain that comes from behind or beneath the heel is more likely to be a case of Achilles tendonitis.

There are other causes, and location (pain on the side of the heel, for example) is a clue when diagnosing the pain. So is the activity that leads to pain, such as running or standing a long time, as well as the time of day, like first thing in the morning or pain that worsens hours later.

This article explores the common and uncommon causes of heel pain, as well as what can be done to diagnose this common orthopedic symptom. It discusses treatments that range from simple rest and pain medication to physical therapy and surgery, while offering tips to prevent heel pain.

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. It causes stabbing or throbbing pain on the bottom of the heel when weight is placed on the heel after rest.

Plantar fasciitis pain is usually worse during the first few steps of the morning but can also be triggered by long periods of standing.

Risk factors include:

• Higher body mass index (BMI), an imperfect but commonly used health metric to assess weight and obesity
• Occupations or activities that require a lot of weight bearing
• The size and shape of your foot, including foot arch issues
• The presence of bone spurs
  

The condition is also referred to as plantar fasciopathy because it's a degenerative process that leads to secondary inflammation. It usually affects one foot, allowing you to bear weight on the other.

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 is inflammation 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.

Sever Disease

Sever disease is the most common cause of heel pain in children and adolescents. Called calcaneal apophysitis, it typically occurs between the ages of 8 and 12 when children are running, jumping, or otherwise active. It can be worse during a growth spurt.

The injury involves bone swelling or inflammation, often due to playing sports like soccer or basketball. Conservative treatment (rest, icing, pain medication) is usually successful.

Peroneal Tendonitis

Conditions affecting the peroneal tendon are a common cause of pain on the outside of the heel, where the tendons connect the calf muscles to the foot. These tendons can rupture, dislocate, or stretch in ways that cause tendonitis.

It's common for peroneal tendonitis to occur due to overuse injuries. Damage to the peroneal nerve also can cause symptoms, including numbness, tingling, and pain. Some people experience a foot drop with this injury, leading to gait (walking) changes and weakness.

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 wear on the heel causing pain. The condition can arise due to steroid treatments for co-occurring plantar fasciitis, too, but has a different cause.

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 tendon attaches 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. People diagnosed with diabetes face a higher risk.
• Heel bone tumors: These typically benign (non-cancerous) growths can cause deep, boring heel pain that worsens at night.
  

Symptoms of Heel Pain

Pain is the common symptom among conditions that cause heel pain, but when and where it occurs help to differentiate the exact cause. So do other factors, like the activities that lead to heel pain.

Symptoms of heel pain include:

• Dull, sharp, or stabbing heel pain
• Aching or burning along the arch of the foot
• Pain that increases when you first stand up or after a time of rest
• Climbing stairs or other activities when pain increases with exercise
  

Sites of Heel Pain

Heel pain can occur on the inside of the foot or the outside of the foot. The pain of Achilles tendonitis is most likely felt at the back of the foot, but heel pain also occurs with other symptoms. Some examples of heel pain at specific sites include:

• Pain and tenderness on the inside of the heel with plantar fasciitis
• Bruise-like pain at the center of the heel with heel pad syndrome
• Pain affecting the Achilles tendon with Sever disease

In some cases, an accident or injury can damage nerves in the foot that contribute to heel pain.

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 occurs 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.

A common approach is the R.I.C.E. method. The acronym stands for rest, ice, compression, and elevation of an injured body part, like the heel.

Rest and Elevation

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 above heart level also can help. You can lie down and use a pillow to help elevate the injured limb.

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.

Compression

Compression or wrapping the injury site is an important treatment step. It helps to immobilize the site and support the heel with pressure. Avoid wrapping too tightly, though.

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, such as calf raises or rolling an ice-filled plastic bottle beneath the foot. 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.

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: Your 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.

• 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.

Be sure to listen to your body, because 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.

Summary

Heel pain can have a number of causes, and specific features of the pain can help a healthcare provider diagnose the pain. For example, pain on the side of the heel may be due to sinus tarsi syndrome, while pain behind the heel suggests Achilles tendonitis.

When and how the pain occurs also will help you to understand its cause. Once your healthcare provider makes a diagnosis, they can discuss treatment options with you. In many cases, conservative treatment options including rest or the use of shoe orthotics can bring relief. Physical therapy and, rarely, surgery also may be needed.