Heel Pain: What Causes it in Adults and Children

Heel pain is a fairly common problem. It mainly affects adults, however, children can also complain.

Most of the time it has a non-serious basis.

Although it tends to be heterogeneous, two diseases are most frequently described. These are plantar fasciitis and heel spur (i.e. a growth on the heel).

Diagnosis based on pain site?

Depending on the location of the pain, it is possible to partly distinguish what the problem may be. 

An example is if it occurs in the bottom, back or front of the heel, or laterally, on the outside of the foot. 

It can radiate from the heel to the foot, ankle area and Achilles tendon.

Also important in recognizing the underlying problem is whether...

Does heel pain occur mainly in the morning after waking up or when sitting?
Does moving and walking alleviate it?
It will probably be an inflammation of the plantar tendon.

Or is it the other way around?

Does walking worsen heel pain?
or increased load on the area?
And does the pain get worse when you step on the foot, the heel? 
It is probably the heel spur. 

However, there may be many causes. 
Read on to find out. 

The plantar fascia and the heel spur are common causes

What causes heel pain?

It is largely represented by plantar fasciitis and heel spur.

When the cause is plantar fasciitis...

When the heel is painful and if it moves and radiates to the foot, it is probably an inflammation of the tendon that is located at the bottom of the foot, that is, the sole of the foot. We are talking about plantar fascia.

It is a ligamentous band that runs through the bottom of the foot. It attaches to the heel and runs down to the toes. 

Plantaris, plantar = related to the foot, hindlimb. 
Fascia = band, sheet. 

Minor injuries, tears of this tendon, that is, microtraumas, arise on the basis of long-term and repeated damage due to excessive and disproportionate load.

However, it also arises suddenly, in acute injury.

The result is inflammation, which is referred to as plantar fasciitis. 

Also called: 
aponeurosis plantaris

The inflamed area is painful and is sharp and uncomfortable.

Mostly occurs in the morning after waking up. After moving and walking around, the pain subsides.

However, in people who have a sedentary job and at times of prolonged rest again pain sets in. Similarly, this happens when standing for long periods of time.

Certain risk factors are involved in the development of plantar fasciitis:

• age over 40 to 60 years
• obesity
• sedentary lifestyle and sedentary work
• being on your feet for a longer period of time
• defective foot structure, hence a high arch of the foot or a flat foot
• poor movement mechanisms and incorrect posture
• inappropriate footwear, too hard or too soft 
• high heels
• tight shoes
• excessive overload, acute or prolonged
• arthritis of the lower limbs
• vascular problems

With the symptoms, of course, pain is common, which the affected person describes as sharp and stabbing. The pain is localized at the bottom part of the heel. 

Heel pain radiates from the inside of the heel to the toes.

The pain is directed and moves through the foot to the toes, mostly from the inside. The pain can be relieved by stepping on the outer, lateral part of the foot. 

A typical sign is that the pain occurs in the morning after waking up and at times of prolonged rest.

After history taking and performing a palpation examination, the doctor complements the diagnosis with imaging methods such as X-ray, CT or ultrasound.

What helps and what needs to be done against heel pain?

The first-choice treatment is exercise, stretching exercises, ice, shoe modification.

Taping can help, and orthotics (prosthetics) and shoe inserts are also available. A night splint is also suitable. 

In the acute phase, it is important to avoid walking barefoot and temporarily limit excessive leg loads.

Lifestyle changes, magnetotherapy, massage or shock wave treatment will complement the regimen. 

Medications to alleviate pain and inflammation, such as analgesics and non-steroidal anti-inflammatory drugs, are helpful. And also in topical form such as ointment or gel.

Don't medicines, ointments, creams, gels, herbs or teas help?

In some cases, surgical treatment is necessary, especially if the conservative approach fails.  

Calcaneal heal spur and bony outgrowths

The Latin name is Calcar calcanei.

The basis is calcification and ossification at the site of inflammation.

Damage to the plantar tendon attachment to the heel >
subsequent deposition of calcium (calcification) >
transformation of functional tissue (healing of tendon or muscle damage) into bone (ossification).

The result is deformities of the heel in the area of the tendon attachment = bony outgrowths on the heel.

Have you heard of osteophytes? These are bony outgrowths that also form on the spine, for example.

Learn more: Spondylosis: Spinal growths and why they form

Long-term, but also acute overloading of the foot leads to plantar fasciitis. The latter can subsequently result in the formation of heel spurs.

Heel spur and plantar fasciitis are related.

Risk factors:

• prolonged excessive and inappropriate loading of the foot
• bad footwear
• arch disorders and deformities of the foot, high or low arches of the foot
• injury
• obesity, overweight
• running, jumping on hard surfaces
• disorders at the level of the Achilles tendon and calf

Repeated damage to the abutment heals by calcification, forming a hook-shaped bony outgrowth on the calcaneal tuberosity.

It results in clinical symptoms.

Symptoms of heel spurs are:

• sharp stabbing pain
• mainly localised to the centre of the heel
• it is aggravated by stepping on the heel when walking
• restricts or makes walking impossible
• the person is stepping on the toes or the side of the foot
• touching the outgrowth and foot muscles is painful

In contrast to plantar fascia inflammation, pain occurs when walking and with exertion. It makes sports to normal walking impossible. 

The spur is found mostly on both heels. And in many cases one does not even know about it as it has an asymptomatic course. 

People are often unaware of heel spurs.
The reason is that it does not always present with pain.

The X-ray finding typically shows a pointed bony process at the front of the heel.

Diagnosis includes taking history and examining the heel with X-ray confirmation. Imaging methods such as CT or ultrasound can also be used.

Treatment is primarily conservative. A special shoe insert (and other prosthetics) can alleviate the pain, which cushions the heel during walking.

Pain killers and medicine to manage the inflammation, incuding sprays,are added to the repertoire of treatment options. 

Physical therapy, magnetotherapy, shock wave therapy may also be used. If nothing helps, surgery is chosen.

Types of pain in children

Children, too, are affected by heel pain. It commonly arises when the leg is overloaded or after an accident. 

Growing pains are a fairly common problem. It affects 10-20% of children aged approximately 3 to 14 years.

To a large extent, growing pains occur mainly at night and can wake the sufferer from sleep.

It can be aggravated by sports activity.

Children localize the pain to the groin, thigh, shin, or heel areas.

In cases of severe pain, pain killers, topical ointments, and gels can be administered.

The pain subsides over time until it disappears completely and the children "grow out of it". 

However, we also know of one disease that is directly related to heel pain...

Sever's disease

It occurs in children, especially in the period of rapid growth. 

Onset occurs between the ages of 7 and 15.
It is the most common cause of heel pain at this age and in adolescents.
It is more common in boys.

Difficulties are aggravated by prolonged physical stress. Mostly, the disease occurs in children that often play sports.

For example athletics, hockey, football, basketball and the like.

The basis is inflammation and osteochondrosis in the heel area and in the growth spurt.

It is also referred to as Sever's disease, Morbus Haglund, alcaneus apophysitis, or simply Severs.

Children will sometimes limp or tiptoe, especially after exercise, PE class, or jogging. Heel pain accompanies all of these activities.

The basic treatment includes lifestyle changes, i.e. limiting the load on the legs, prosthetic devices, and appropriate footwear.

Other causes of heel pain

There are other causes of this kind of pain. In differential diagnosis, it is advisable to exclude other disease states as well.

Other possible causes:

• Haglund's exostosis, when a growth develops on the back of the heel, due to prolonged irritation, mainly due to inappropriate footwear
• heel injury such as ankle sprain, fracture
• arthritis, reactive arthritis
• spinal and hip problems
• arthrosis
• other rheumatic diseases, rheumatoid arthritis
• osteoporosis
• gout - chronic metabolic disease with high blood uric acid levels = hyperuricaemia
• Achilles tendon bursitis
• Achilles tendinitis - inflammation
• injury or rupture of the Achilles tendon
• osteomyelitis - inflammation of the bone
• nerve disease, as well as neuropathy, polyneuropathy and peripheral neuropathy
• tarsal tunnel syndrome - pressure on the nerves passing from the shin to the leg
• and other conditions

Table: presumed cause by nature and location of pain

Tight muscles can also be a problem. Especially if the risk factors occur over a long period of time and repeatedly. Pain in this case radiates from another place to the heel. In this case, there may be a problem called Myofascial trigger points (MTrPs), or Trigger points.

Learn more: Trigger points - myofascial "knots" as an identifiable source of pain