Heel Pain: Causes, Location Clues and Treatment

Heel pain by location

Where it hurts is the best guide to the cause.

Common causes of heel pain

Plantar fasciitis

The plantar fascia is a thick band of tissue running from the heel to the toes that supports the arch. Repeated strain causes small tears and degeneration where it attaches to the heel bone. It is most common between ages 40 and 60 and in runners. Risk factors include:

• excess body weight
• standing for long periods on hard surfaces
• a sudden increase in walking or running
• tight calf muscles and Achilles tendon
• flat feet or high arches
• worn-out or unsupportive shoes

Heel spurs

A heel spur is a small bony growth under the heel bone, seen on X-ray. Many people with spurs have no pain at all. When pain is present, it usually comes from the plantar fasciitis that often accompanies the spur, not the spur itself, and surgery to remove spurs is rarely needed.

Achilles tendinitis

The Achilles tendon connects the calf muscles to the heel bone. Overuse, especially in runners who increase mileage quickly or change to hill training, causes pain in the tendon, either a few centimeters above the heel or right where it attaches. The tendon may feel thickened or creak.

Achilles tendon rupture

A complete tear causes a sudden pop or feeling of being kicked in the back of the ankle, often during sprinting or jumping. Walking becomes weak and you cannot stand on tiptoe on that side. It needs prompt assessment; see Achilles tendon rupture.

Less common causes

• Inflammatory arthritis: spondyloarthritis, reactive arthritis and psoriatic arthritis can inflame the points where tendons attach to the heel, often in both heels, with back stiffness.
• Stress fracture in runners, military recruits and people with osteoporosis.
• Nerve entrapment: the small nerve to the little toe muscle (Baxter's nerve) can cause heel pain that mimics plantar fasciitis.
• Gout, bone infection and, rarely, bone tumors.

Heel pain in the morning

Pain that is worst with your first steps out of bed is the hallmark of plantar fasciitis. Overnight the fascia tightens as the foot points down. The first steps stretch it suddenly. Achilles tendinitis also causes morning stiffness at the back of the heel. Night splints and stretching before getting up target this directly.

How heel pain is diagnosed

Most heel pain is diagnosed from your history and an examination. The doctor will press on specific spots, check calf tightness, watch you walk, and squeeze the heel from both sides to test for a stress fracture. Imaging is used if pain does not improve, after an injury, or when another cause is suspected:

• X-ray: fractures, spurs, arthritis
• Ultrasound: thickened plantar fascia, Achilles tendon tears
• MRI: stress fractures and tendon damage
• Blood tests if inflammatory arthritis or infection is suspected

Treatment and home care

Most people improve with simple measures. Combining several works better than any one alone.

Stretching

• Plantar fascia stretch: sitting, pull your toes back toward your shin with one hand and hold 10 seconds, 10 times, ideally before your first steps in the morning.
• Calf stretch: hands on a wall, back leg straight and heel down, lean forward for 30 seconds, 3 times a day. Repeat with the knee slightly bent.
• Rolling the arch over a frozen water bottle for 5 minutes combines massage and ice.

Footwear and supports

• Wear supportive shoes with cushioned heels and arch support, even at home. Avoid walking barefoot on hard floors and flat sandals.
• Over-the-counter heel cups or arch supports help many people.
• Replace running shoes every 300 to 500 miles (500 to 800 km).
• A night splint holds the foot flexed overnight and reduces morning pain.

Activity and weight

• Cut back on running and long periods of standing. Swap to cycling or swimming while it settles.
• Losing excess weight reduces load on the heel.

Pain relief

Ice for 15 minutes after activity. Ibuprofen or naproxen for short periods can help, following the label dose (avoid with stomach ulcers, kidney disease or some heart conditions), or acetaminophen (paracetamol).

If it does not improve

• Physical therapy with strengthening and taping
• Custom orthotics
• A corticosteroid injection for plantar fasciitis (used sparingly, as it can weaken the fascia or fat pad). Injections are generally avoided around the Achilles tendon
• Extracorporeal shockwave therapy for persistent plantar fasciitis or Achilles tendinopathy
• Surgery, rarely, for pain lasting more than 6 to 12 months despite all treatments

Frequently asked questions

What is the most common cause of heel pain?

Plantar fasciitis. It causes sharp pain under the heel that is worst with the first steps in the morning or after sitting. It is linked to tight calves, excess weight, long periods standing and unsupportive shoes, and usually improves with stretching and footwear changes.

Why does my heel hurt in the morning?

Overnight, the plantar fascia and calf muscles tighten. Your first steps stretch them suddenly and cause pain, which typically eases after a few minutes of walking. Stretching your foot and calf before getting out of bed helps.

What causes pain at the back of the heel?

Usually Achilles tendinitis, retrocalcaneal bursitis or Haglund's deformity, a bony bump rubbed by shoes. In children aged 8 to 14, Sever's disease is common. Sudden pain with a pop may mean an Achilles rupture and needs prompt care.

How long does heel pain take to go away?

Plantar fasciitis often improves within a few weeks to months, and about 90% of people recover within a year with simple treatment. Starting stretching and supportive footwear early shortens recovery.

Should I walk with heel pain?

Gentle walking in supportive shoes is fine for plantar fasciitis, but reduce long walks, running and standing until it settles. Stop and get checked if you cannot bear weight, the pain is severe after an injury, or it is getting worse.