What are some common heel pain causes?

The feet are complex structures that contain a large number of bones, muscles, tendons and ligaments. That means a lot can go wrong with them.

A common issue people experience is heel pain. We have a lot of patients come to the clinic believing that their heel pain is caused by plantar fasciitis. Often they believe this because after a quick Google search, they saw that plantar fasciitis was the top result.

However, it’s not always the cause of the heel pain. There are quite a number of other conditions that can occur in the heel region, and be the reason for the pain.

When diagnosing heel pain causes, we like to split the heel up into 2 parts.

• The posterior aspect – the back of the heel
• The plantar aspect – bottom of the heel, the part that touches the ground

Posterior Heel – The Back of the Heel

Some common conditions that can affect and cause pain in the posterior heel include:

Haglund’s Deformity

A Haglund’s deformity is a painful bump at the back of your heel and is often referred to as a retrocalcaneal exostosis. It can cause heel pain when wearing shoes, where the heel counter of the shoe rubs against it. A number of factors have been linked to the formation of a Haglund’s deformity including those with high arches, a tight achilles tendon or placing more pressure to the outside of the heel when walking.

A Haglund’s deformity can often present as or with:

• a noticeable hard bump on the back of your heel
• redness or blistering of the skin on the back of the heel
• the formation of callus on the back of the heel
• pain when wearing shoes that are too tight across the heel

Due to the fact that it often occurs in conjunction with other factors, treatment is aimed at addressing every factor. This may include:

• Footwear modifications – such as choosing heels with a softer heel counter or applying felt to the inside of the shoe to reduce friction.
• Using a heel lift to raise the height of the heel
• Icing
• Stretching of the calves and achilles
• Non-steroidal anti inflammatories (NSAIDs).
• Surgery may be required in severe cases, however this is relatively rare as other conservative treatments are often able to manage any heel pain or discomfort effectively.

Achilles Tendinopathy

Achilles tendinopathy involves injury and inflammation to the achilles tendon. The calf muscles attach onto the back of the heel via the achilles tendon and it is a very powerful tendon. It stores energy to allow you to walk, run and jump. Injury to the achilles can be quite debilitating and if not treated properly, can lead to chronic pain. You can learn more about achilles tendinopathy causes and treatment in our blog post all about it – “Condition Spotlight: Achilles Tendinopathy“.

Retrocalcaneal Bursitis

Retrocalcaneal bursitis is an inflammation of the bursa that sits at the back of the heel.

Bursa are small fluid-filled sacs that sit between the bone and soft tissue (muscles, tendons and ligaments). Their role is to essentially cushion the bone and reduce friction between the structures.

The bursa that sits at the back of the heel sits in between the calcaneus (heel bone) and the achilles tendon. It is often irritated in those who also have a Haglund’s deformity.

Similarly to a Haglund’s deformity, treatment is aimed at offloading the area and strengthening the achilles tendon to reduce pressure and improve the functionality of the achilles tendon. These can include heel lifts, icing and stretching.

Heel Spurs

Heel spurs tend to get a bad wrap when it comes to heel pain. They are essentially an outgrowth of bone and are common within joints where 2 bones are in close proximity to one another. They are very common at the heel, with most of the population having a calcaneal bone spur! Bone spurs occur due to stress placed on the bone, forcing it to produce new bone to cope with this. Heel spurs themselves are rarely the cause of your heel pain – just because your X-ray says that you have one, it doesn’t mean it’s the culprit. Heel spurs are usually only the cause of pain if the spur fractures or if the soft tissues that attach to the bone are torn off it.

The main treatment of heel spurs is to offload the area and reduce inflammation of the nearby soft tissue structures. This may include:

• heel lifts
• cushioned heel pads
• taping
• orthotics
• In severe cases, surgery may be required to remove the spur, however this is rare.

Plantar Heel – The Bottom of the Heel

Conditions that can affect the bottom of the heel or the plantar heel include:

Fat Pad Atrophy and Inflammation

Located on the bottom of the heel is a fat pad which is responsible for providing cushioning to the heel.

It acts as a shock absorber as we are standing or walking to protect the structures of the heel. Those with inflammation of the heel fat pad often present with an aching pain in the heel which feels similar to a bruise.

Over time, this fat pad undergoes what we call atrophy, meaning that it becomes thinner. Risk factors for developing pain in the heel fat pad include age, trauma, obesity and incorrect footwear. Treatment for heel fat pad atrophy and inflammation involves:

• cushioning the heel using gel or poron heel pads
• heel lifts
• orthotics
• icing
• taping
• NSAIDs (non-steroidal anti-inflammatories)
• footwear changes – avoiding shoes that have a very thin or flat sole, or those that provide very little cushioning.

Injury to the Quadratus Plantae and Abductor Hallucis Muscles

Within the feet, there are 4 layers of small muscles and tendons. 2 of the muscle that are commonly associated with or can be the cause of heel pain include:

Abductor hallucis

This muscle sits in the 1st layer and its role is to assist with movements of the big toe including the abduct the toe, which means to move the toe away from the midline of the body. It also works to flex the big toe.

Quadratus plantae

This muscle sits in the 2nd layer and its role within the foot is to assist with flexion of the lesser toes. Injury to this muscle is commonly misdiagnosed as plantar fasciitis.

Treatment of the to these muscles is very similar to that of plantar fasciitis. The aim is to also strengthen these muscles. Treatment can include:

• icing
• massage
• dry needling
• NSAIDs (non-steroidal anti-inflammatories)
• orthotics
• strengthening program – aimed at strengthening not only these muscles but also the other small muscles within the feet.
• trigger point dry needling

Baxter’s Neuropathy

Baxter’s neuropathy is a common cause of heel pain and research suggests that it accounts for approximately 20% of heel pain cases. It involves entrapment and inflammation of the nerve that runs under the heel called the inferior calcaneal nerve, or ‘Baxter’s nerve’. It typically sits between the abductor hallucis and quadratus plantae muscles of the foot. Those suffering with Baxter’s neuropathy will often describe burning, numb or tingling sensations under the heel, which are typical neurological symptoms. They may also say that the heel pain is worse after exercise and does not always seem to settle with rest. It is often misdiagnosed as plantar fasciitis, however can be confirmed using imaging such as an MRI.

Causes of Baxter’s neuropathy can include:

• pes planus foot type (flat feet)
• poor footwear
• chronic overuse
• injury to the heel, causing swelling in the area

Treatment of Baxter’s neuropathy can include:

• ice
• taping
• NSAIDs (non-steroidal anti-inflammatories)
• taping
• orthotics
• in severe cases, you may require a moon boot, cortisone injection or surgery, however conservative treatments are often enough to relieve the pain

How can you fix your heel pain?

If you’re in Melbourne’s North East suburbs, around Watsonia, come see us at our clinic. As podiatrists, we’re trained to diagnose these conditions and will be able to create a tailored management plan just for you.

You can book in to see us by calling us on 03 9432 2689 or make an appointment online here.