What Causes This Pain Under My Heel?

Pain under the heel can be caused by a number of different reasons. In this blog we will discuss the different causes and discuss how to determine which it might be. Careful Physiotherapy assessment will involve an in-depth assessment your particular set of symptoms to determine what might be causing your pain. Heel pain is very common with up to 10% of people feeling heel pain at some point in their lifetime.

What can I do about the pain under my heel?

Often the symptoms do not require surgery or intervention from a doctor and will respond well to conservative management that might include physiotherapy or podiatry.

What are common causes of pain under the heel?

 

Plantarfascial Cause 

Pain in the female foot

 

  • One of the most common causes of heel pain.
  • It involves irritation and pain from the plantar fascia, a thick band of connective tissue that inserts into the heel bone and runs forwards under the arch of the foot as a tough band of tissue. It splits about half way down its length to form bands that attach into each toe.
  • The function of the plantarfascia is to help with foot posture and in the spread and absorption of forces that affect the body via the foot when we walk. It tightens pulling the muscles together so that they form the arch of your foot.  This is important for normal walking and to protect the bones and other tissues from overload and damage.
  • Pain from a problem with the plantarfascia commonly presents in a particular area of the foot. It is particularly painful just in front of the heel bone and on the inner side where the arch of the foot is. pain may also spread down the plantarfascia towards the toes but will be most acute at the insertion to the heel bone.
  • People with this condition commonly report ‘start up pain’. This is pain that is particularly bad first thing in the morning when they first get out of bed and stand up. This is because this is the first time the fascia is stretched and used after a full nights rest. this pain commonly improved once up and around.
  • The pain from the plantarfascia also increases after heavy periods of activity such as a lot of running, walking (particularly in barefeet) and if particularly hard or heavy footwear has been used that you are not used to.
  • There is a link with obesity and plantarfascia problems as well as with people who do not do regular exercise. People with jobs that involve a lot of standing such as within the army are at higher risk.
Heel Fat Pad Cause
  • Another common source of heel pain.
  • It is the thick area of padding directly under the heel bone at the back of the foot.
  • It is commonly covered in thicker skin as this is where a lot of the weight of our body presses and so the skin thoughens up here.
  • This fat pad is perfectly designed to take the incredibly high forces that pass down through it from our body as we walk and move. A direct hit to the heels can injure this special tissue and cause pain.
  • Pain from the fat pad is usually directly under the heel bone and it may also be tender to feel along the edges of the heel bone either side. Pain rarely refers or travels anywhere else if this is the problem. There will be no tingling or numbness associated with this condition.
  • The risk factors for developing fat pad problems are similar to plantarfascial problems but the pain is in a slightly different area of the foot. This can be assessed by a physiotherapist to ensure the correct diagnosis is made.
Fibromatosis
  • A less common cause of heel pain
  • This is a condition where thickening develops in the mid foot area of the plantarfascia (sole of foot).
  • It looks and feels like a lump in the soft tissue under the foot about half way between the toes and the heel.
  • It can be tender but sometimes is painfree.
  • The reason they develop is unclear but can be more common in people who have had Duputrens contractures in their hands or if in the family history.
  • People who have diabetes can have a higher risk of developing them also.
Nerves
  • There are several spots in the heel where nerves can be a cause of heel pain.
  • Sometimes this can present as pain alone but often it is associated with tingling or numbness in the area too. The pain from nerve problems in the foot is more likely to be described as burning in quality.
  • The inferior calcaneal nerve runs down the inner heel area. It has to pass under a sheath of tissue on its way and sometimes it gets irritation if the space is too small or the way the foot is used irritates it. This can cause pain along the length of the nerve to where it travels. Commonly pain from this nerve travels along the inner heel area and half way forwards along the foot. This is variable from person to person as anatomy can vary.
  • Another cause of nerve related pain in the heel can be when the nerves are irritated up in the back but the pain from this irritation is sent along the whole length of the nerve to where it supplies the feeling in the leg. Sometimes this can happen to the S1 nerve from the back which supplies the skin over the heel. Commonly patients with this presentation of heel pain will also report some back pain or previous problems. They might describe the pain as burning or shooting and it might get worse with positions that tension the nerves such as reaching for your toes with your knees straight, sitting with both feet up on the sofa or prolonged sitting still. There may also be some associated numbness over the heel and the outer edge of the foot or little toe.
 Subtalar joint

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  • Sometimes the subtalar joint, the joint between the heel bone and one of the ankle bones can cause heel pain.
  • This might be due to an injury to the surfaced cartilage or  bony injury or osteoarthritis. Patients might report a limitation to the distance they can walk without pain and most commonly the pain will occur in weightbearing and standing.
  • There might be some crepitus (noises) from the foot when you move it that don’t occur in the other foot or you may have had a previous injury that has left your foot vulnerable.
 Other less common causes
  • Gout
  • Bony spur – small piece of bone that grows on the bones and can irritate tendons, nerves or other soft tissue making them inflamed and painful
  • Stress fractures
  • Inflammatory arthritis
  • Infection
  • Foreign bodies. It is worthwhile obtaining a full assessment of your heel pain as appropriate treatment can then be targeted to the correct cause.

What should I do about my heel pain?

A physiotherapist will be able to carry out a thorough assessment of your heel pain.  They will then be able to treat your pain with treatments that can include exercises, manual work, massage, taping or acupuncture.  If the physiotherapist feels that you need a specialist medical opinion or medical treatment we can help to organise this for you.