Heel Pain

Heel pain is the most common complaint a podiatrist hears.  In fact, I don’t have to be at work to hear it.  My friends joke because at any given time a stranger can walk up to me waving their foot around asking me about the pain in their heel.  This article is a guide to the most common causes of heel pain.  I like to base the descriptions on location of the pain because not all heel pain is plantar fasciitis.

The bottom of the heel:

Plantar fasciitis:
The most common diagnosis given to heel pain.  The problem is inflammation of the small muscles in the foot where they attach to the heel.  This is caused by an unstable foot and is most often described as deep sharp pain when you get out of bed in the morning or after sitting for a prolonged period of time.  It can extend into the arch and will get worse if left untreated.

Heel spur:
A growth of bone on the bottom of the heel along the attachment of the small muscles in the foot.  This is the same problem as plantar fasciitis.  The best way to think of this is your muscles are pulling away from the bone because your foot is unstable.  The spur forms when the bone tries to hold onto the muscles to keep them from pulling away.  The spur does not cause the pain, it is the plantar fasciitis that is causing your pain.

Systemic arthritis:
Yes, that’s right your heel spur might not be related to plantar fasciitis at all.  Systemic arthritis such as Systemic Lupus, Reiter’s Syndrome, or Psoriatic arthritis cause inflammation along the attachment points of tendons.  This is called enthesopathy.  The heel is a common spot for this to occur, but the spur is different.  With enthesopathy the spur is not crisp at the margins.  We call this “whispering”.  If you have pain in other joints or your low back, your heel pain might not be plantar fasciitis.

Nerve entrapment:
Heel pain that is described as electrical or shooting is more likely to be from nerves.  There are nerves in the heel that can become entrapped or pinched as they cross muscles and fascia.  This pain can mimic plantar fasciitis, but when I press along the side of your heel  and run my finger over the nerve you will have the pain.  The low back is a common area to have pinched nerves that send pain to the heel.  If you tell me you also have pain in your low back I will test your spine to see if the heel pain occurs with stress.

The back of the heel:

Achilles tendonitis:
The Achilles tendon runs from the muscles in your calf to the back of the heel.  This is one of the strongest tendons in the body.  Inflammation of the tendon occurs either around the tendon or within the tendon.  With inflammation around the tendon there is sharp and stabbing pains with activity, but this might be improved in heels.  Inflammation within the tendon is worse, but hurts less.  You will notice swelling of the tendon.  If left untreated the tendon will weaken.  Everyone has heard of a friend of family member who was playing sport and suddenly without warning ruptured (broke) their Achilles tendon.

Pump Bump or Haglund’s deformity:
The heel bone can form a lump on the back side usually the outside edge of the Achilles tendon area.  This area is a pressure point in shoes, especially women’s shoes, therefore was given the name of pump bump.  Avoiding shoes that apply pressure to that area is the easiest treatment of all, but many people need to wear dress shoes for work.  Prominent bone can only be removed by surgery.

Bursitis:
The Achilles tendon attaches to the back of your heel bone, but not at the top edge.  As the tendon passes the top edge working its way to the attachment in the center of the bone there is a fluid filled sack called a bursa.  This allows the tendon to slide over the top edge of the bone as you walk.  This fluid filled sack can become irritated causing pain and swelling.  Relieving the inflammation and stretching your Achilles tendon usually make this problem go away completely.

Heel pain is very common and as you can see there are many reasons your heel can hurt.  Think about where the pain is and when it hurts.  You might not be suffering from plantar fasciitis.