Heel Pain: Information and Doctors for Heel Pain

Heel pain (ICD code: M79.67) can manifest in various ways. Some patients experience start-up pain that occurs after sitting or lying down for a long time. It improves with movement. This start-up pain can be mild or so severe that the first few steps can only be taken with a limp.

However, heel pain can also manifest as

• pressure pain or
• a stabbing pain that radiates into the midfoot,

. Some patients report dull or pressing heel pain while at rest. The possible causes of this pain can vary widely.

Overuse and improper weight distribution on the feet are a common cause of heel pain. Other causes may include:

Inflammation of the tendons

Of particular note here is the Achilles tendon (Achillodynia), which is most commonly affected and can lead to pain at its attachment point on the heel. The plantar fascia (plantar fasciitis), which stabilizes the sole of the foot and attaches to the heel, is also one of the (though significantly rarer) causes of heel pain.

Heel spur (calcaneal spur)

A heel spur (calcaneal spur) is a bony protrusion on the heel that can be painful, especially when pressure is applied, but later also at rest. An inflamed tendon attachment to the heel bone also leads to heel pain. This inflammation often occurs in combination with what is known as an upper heel spur. The upper heel spur forms on the upper part of the heel bone at the attachment site of the Achilles tendon. In this condition, the inflamed tendon attachment calcifies.

Haglund’s heel

A characteristic feature of Haglund’s heel is the formation of a bone spur in the heel area, which can be congenital (e.g., due to foot deformities such as pes cavus) or acquired (e.g., due to excessive running training). This results in inflammation at the attachment site of the Achilles tendon, which can lead to ossification. Haglund’s heel is also referred to as a superior heel spur, since the ossification points upward (toward the Achilles tendon). 

Foot Deformities

These include, in particular, common deformities such as valgus foot, fallen arch, and flatfoot.

Rheumatic and Metabolic Disorders

Rheumatic conditions as well as metabolic disorders such as gout or diabetes mellitus often lead to joint and bone pain, which is particularly pronounced in the morning and improves as the day progresses.

Circulatory Disorders

With the most common type of circulatory disorder—known as intermittent claudication—the situation is reversed. Here, the pain occurs primarily during physical exertion and subsides again at rest. The cause of this circulation-related pain is narrowed or blocked arteries in the leg, which are still able to maintain blood supply at rest. However, during physical exertion, the pain intensifies, forcing the patient to take frequent short breaks from standing or sitting. This is where the term “intermittent claudication” comes from.

What could be the cause if the upper part of the heel hurts?

The most common cause of pain in the upper part of the heel is inflammation of the Achilles tendon, known as achillodynia. Heel pain associated with achillodynia usually occurs at the upper edge of the heel bone, since this is where the tendon attaches. Therefore, achillodynia is often seen in combination with Haglund’s heel (i.e., a superior calcaneal spur). 

Achillodynia is primarily caused by overuse. Ill-fitting shoes can also contribute to the development of Achilles tendonitis.

Inflammation of the Achilles tendon manifests as sharp heel pain that worsens with physical activity. The affected tendon is also thickened and tender to the touch, and may be red in some cases. 

What are the symptoms of heel pain associated with plantar fasciitis? 

In plantar fasciitis, the tendon sheet on the sole of the foot (plantar fascia) is inflamed. The heel pain originates at the bottom, toward the sole of the foot, and becomes particularly severe when stepping down. Plantar fasciitis is often accompanied by a lower heel spur, since the plantar fascia attaches to the heel from below. Similar to an upper heel spur—which is a bony growth associated with Achilles tendinitis—a lower heel spur in plantar fasciitis refers to bony growths on the lower part of the heel.

When the foot is overloaded or subjected to improper stress, the tissue in the sole of the foot around the heel spur can become inflamed. Women between the ages of 50 and 60 are particularly prone to this type of heel pain. Typically, the symptoms occur in the morning after getting out of bed. 

What are flat-footed and fallen-arch feet?

Flat feet can vary in severity. Collapsed and flat feet are congenital or acquired foot deformities. Causes include

• a shortened Achilles tendon
• excess weight, or
• weakness of the ligaments, muscles, and connective tissue

Depending on the severity and cause, mobility limitations can develop quite early on. Foot or heel pain may then occur when walking or running.

How does heel pain manifest in rheumatic conditions?

The cause of heel pain is not always found directly in the foot. Morning heel pain in both feet, for example, is a key symptom of the rheumatic disease ankylosing spondylitis. Other rheumatic conditions can also affect the feet. Inflammatory processes underlie rheumatic pain in the foot and heel. Rheumatic heel pain is therefore always treated in conjunction with the underlying rheumatic condition.

Which metabolic disorders can lead to heel pain?

Metabolic disorders such as gout and diabetes mellitus can also cause heel pain. Gout is characterized by elevated uric acid levels in the blood. Diabetes mellitus is characterized by high blood sugar levels.

Both conditions can

• tendon damage
• bone damage
• soft tissue damage, or
• skin problems

and thus lead to heel pain.

Most causes of heel pain are related to the musculoskeletal system. That is why trauma surgeons, orthopedic surgeons, and foot surgeons are the right specialists to consult for heel pain. They deal with deformities and disorders of the musculoskeletal system.

During a medical history interview, the exact nature and origin of the symptoms are assessed:

• Severity of pain 
• Triggers of the pain or 
• Factors that alleviate the symptoms
• Injuries or 
• pre-existing conditions affecting muscles, tendons, and joints

The subsequent physical examination assesses:

• Body build 
• Gait and posture 
• Muscle reflexes in the legs and feet
• Foot pulses and
• neurological tests

What other diagnostic procedures can be helpful in establishing a diagnosis? 

Ultrasound and X-ray examinations can be used to assess the structures of the foot more precisely. Magnetic resonance imaging (MRI) is also suitable for evaluating heel pain. An MRI is particularly helpful when inflammation of the soft tissues is suspected and the bone appears normal on an X-ray. 

Doctors who specialize in heel pain originating from the bones or joints are trauma surgeons or orthopedic surgeons. However, if an underlying systemic disease is suspected, you may need to be referred to another specialist. Depending on the suspected underlying condition, this could be, for example, a

• neurologist (a specialist in nervous system disorders)
• internist (a specialist in diseases of the internal organs), or
• rheumatologist (specializing in diseases of the immune system)

.

In general, exercise and stretching can relieve heel pain, regardless of the cause. Physical therapy is particularly recommended for chronic symptoms.

• physical therapy
• massages, or other 
• physiotherapy treatments (e.g., special stretching exercises, application of fango, etc.)

are beneficial and helpful.

Further treatment of heel pain depends primarily on the cause of the symptoms:

• Acute overuse: Take it easy and avoid prolonged and physically demanding activities. Cooling compresses can further reduce the pain. 
• Foot misalignment: Treatment with special orthotics. These correct the misalignment and thus provide pain relief. Heel cushions, heel pads, or foot sleeves relieve pressure not only on the painful heel but on the entire foot.
• Tendonitis: Anti-inflammatory pain medications and reducing the strain on the affected area can help. In addition to taking a break from exercise, gentle but regular stretching of the calf muscles and tendons is also beneficial.
• Heel spur: In addition to the measures mentioned above, shock wave therapy or injections of local anesthetics—or, in very rare cases, cortisone—may also be tried.
• Rheumatism: Heel pain caused by a rheumatic condition is primarily treated with medication. Depending on the cause, various drug therapies may be considered. These include, for example, anti-inflammatory drugs such as cortisone or pain relievers from the group of nonsteroidal anti-inflammatory drugs (NSAIDs).
• Metabolic disorders: In cases where heel pain is caused by a metabolic disorder such as diabetes mellitus or gout, it is also advisable to adjust your diet. If you have diabetes, for example, you should avoid easily digestible carbohydrates, such as those found in white flour products. If you have gout, avoiding foods high in purines can help prevent symptoms. These include meat, legumes, and organ meats.

If none of the conservative treatment measures described above are sufficient for a heel spur, surgery may be necessary. During the procedure, the bony protrusion is completely removed using endoscopic techniques. The procedure itself is minimally invasive and falls under the field of foot surgery. The patient then receives comprehensive follow-up care to prevent the heel spur from recurring.