Heel pain

What causes heel pain?

Heel pain is mostly a symptom of another underlying condition. In most cases these conditions originate directly in the heel area. However, in some cases systemic diseases may also affect the heel and cause pain.

The heel mainly consists of the heel bone – the calcaneus. It's the largest bone in the foot and is an important insertion site for various muscles and tendons. The most important attachments are the Achilles tendon, running from the calf, and the plantar fascia. The latter is a structure made of connective tissue that stabilizes the longitudinal arch of the foot.

Heel pain is mostly caused by overuse, which can trigger painful inflammatory reactions in the adjacent muscles, tendons, and soft tissues. This overuse may be exacerbated by various risk factors. These include deformities of the foot, high physical or athletic activity, instability of muscles, ligaments, or tendons, flat or overly hard footwear and advanced age.

Overweight is also becoming an increasingly important risk factor for heel pain as excess body weight continuously strains the foot. Moreover, some of the rare causes of heel pain include inflammatory conditions (e.g., rheumatoid arthritis), calcaneal injuries, tarsal tunnel syndrome, which is caused by nerve irritation.

How does inflammation in the heel develop?

Most people associate the term inflammation with a bacterial infection, such as through an open wound. However, in orthopaedics inflammation often develops as a consequence of overuse or irritation of soft tissues, without any involvement of bacteria or other pathogens.

In the heel region, overuse can lead to irritation of tendon insertions. If this stress persists for a long period of time, these cells start detecting tissue damage and release inflammatory mediators. As a result, the body increases the blood supply to the site of injury to transport more immune cells. This results in redness, warmth, and swelling.

If the inflammation becomes chronic, the body tries to protect the area through a process called tissue remodeling. Persistent irritation of tendon insertions can lead to progressive calcification. In the heel, it is known as a heel spur.

What can be done against heel pain?

When heel pain occurs, several measures can be taken to relieve pain. Firstly, the affected foot should be rested and relieved from strain. Moreover, cooling the heel may counteract the pain. A light massage of the heel area may also be helpful.

As a preventative measure, as well as in acute cases, proper footwear should be worn and custom-made insoles should be ordered, if necessary. Shoes should support the foot and provide cushioning, further relief may be given through a heel wedge.

Furthermore, pain-relieving and anti-inflammatory medications (e.g., ibuprofen) prescribed by a physician can be taken.

However, it is always recommended to treat the underlying cause of heel pain. This is the only approach for long-term relief.

Exercises for heel pain

There are certain stretching exercises that can be done from home to treat or prevent heel pain. Special attention is placed on stretching the calf muscles and the foot arch. These exercises should be practised over an extended period of time and should be repeated multiple times a day (3 times a day) for the best possible results.

Calf stretch exercises

Sit on the floor with extended legs. Place a towel or strap around the painful foot and pull the foot towards the body. Stay in this position for about 15 seconds and then relax. Repeat this exercise 10 times.

Foot arch stretch exercises

Sit on a chair and place the painful foot on the opposite knee. Grab the toes of the affected foot with the hand from the same side. Pull the foot towards the painful side. Hold the stretch for 10 seconds, relax, and repeat 10 times.

Plantar fascia stretch with a bottle 

Sit on a chair, the bottle should be in front of you on the floor. Roll the painful foot back and forth over the bottle. Do this stretch for about one minute.

When to see a doctor for heel pain?

Most cases improve with the above mentioned measures and exercises, without the need for medical attention. However, a doctor should be consulted if the heel pain is accompanied by fever or other signs suggestive of inflammation. These include warmth, swelling, and redness.

Furthermore, it is advisable to consult a doctor in sudden and acute heel pain, that makes walking impossible or if the pain persists for more than two weeks despite conservative treatment and selfcare. 

What diagnostic methods are used for heel pain?

When a patient suffers from severe or persistent heel pain and seeks medical care, the diagnostic process begins with a thorough medical history and clinical examination of the foot.

Important aspects of the medical history include a detailed description of the current symptoms, presence of risk factors, and any underlying conditions. The clinical examination can provide valuable insights into the causes of the heel pain. It is important that both feet are examined, and their alignment is assessed in both sitting and standing positions.

Usually, imaging studies are ordered after the physical examination. An X-ray of the heel is performed, which is useful for detecting heel spurs. An MRI scan allows evaluation of the muscles, ligaments, and tendons. 

If nerve irritation is suspected, for instance in the case of tarsal tunnel syndrome, a neurological consultation may become necessary. Systemic conditions such as rheumatic diseases would also require assessment by an appropriate specialist. 

How does a specialist treat heel pain?

Treatment can be symptomatic to relieve acute pain, but the primary aim should always be to treat the underlying cause.

As many conditions that cause heel pain, also lead to inflammatory reactions, anti-inflammatory medications are often prescribed. These can be taken for a few days in acute cases. In addition, the heel should be rested and cooled.  Many patients benefit from these general measures. Nevertheless, the underlying cause should always be treated.

Deformities of the foot are usually effectively treated with orthopedic insoles. Physiotherapy can also help patients stretch and strengthen specific muscle groups that can compensate for the misalignment.

A persistent inflammation of the plantar fascia, which can cause severe pain, can be treated with extra corporeal shockwave therapy (ESWT). This method uses strongly focused pressure waves on the area of maximal pain. The aim is to increase cellular turnover and help the connective tissue to heal more quickly. Typically, three to five sessions are required.

Surgical interventions are also an option. However, these should be only considered as a last resort if all conservative therapies have been exhausted without sufficient improvement.

How can heel pain be prevented?

Some general measures can be taken to prevent heel pain. For patients with pre-existing conditions, specific therapies can be applied to prevent the progression of symptoms.

General preventative measures include particularly regular physical activity to maintain muscular stability in the lower extremities. This includes wearing appropriate and cushioned footwear. Excessive activity on very hard surfaces should be avoided when possible. For instance, instead of jogging on hard asphalt, jogging on softer forest trails is preferable.

Another positive side effect of regular exercise is the prevention of overweight. Excessive weight puts additional stress on the heel and foot arch causing heel pain. Maintaining normal weight can therefore help prevent heel pain.

If foot deformities are present, a foot specialist should be consulted. Deformities can be treated through the prescription of insoles and physiotherapy, preventing the pain from developing. In moderate to severe pain, early medical care is recommended to initiate therapy quickly and prevent any worsening of heel pain.

What physicians and clinics are specialists in heel pain?

Patients with heel pain can first visit their primary care physician/ family physician. They can perform general examinations and prescribe initial pain relief measures. If the pain persists or requires further evaluation, a referral to an orthopaedic specialist is recommended.

We can help you find an expert for your condition. All listed physicians and clinics have been carefully reviewed for the outstanding specialisation in heel pain and ready to receive your consultation or treatment inquiry.