Heel Pain

Senior Consultant Orthopaedic Surgeon

Heel pain is a common condition affecting the back or underside of the heel, often causing discomfort during walking, standing, or other weight-bearing activities. It can arise from various factors, including strain, inflammation, or structural issues in the foot. Symptoms may develop gradually, ranging from mild discomfort to persistent pain that worsens over time, potentially limiting mobility and daily activities if left unaddressed.

Symptoms of Heel Pain

Heel pain presents with several recognisable signs that vary in intensity depending on the underlying cause and individual factors such as age and activity level.

Many patients experience sharp or stabbing pain when taking their first steps after getting out of bed. This discomfort typically improves after walking for a few minutes as the foot tissues warm up and stretch.

Discomfort often returns after periods of rest followed by resumed activity. The pain may intensify after standing or walking for extended periods, particularly on hard surfaces.

Pressing on the underside of the heel or along the arch often elicits pain. This tenderness may be confined to a specific spot or extend across the heel area.

Some patients notice mild swelling or redness around the heel. These visual symptoms are more common in severe cases or those involving an injury.

Heel pain may start as mild discomfort in the morning but gradually intensifies with continued weight-bearing activities.

Causes and Risk Factors

Heel pain develops due to various factors that place excessive stress on the heel bone and surrounding tissues, leading to inflammation and discomfort.

Plantar fasciitis

Inflammation of the plantar fascia is the most common cause of heel pain. Repetitive stress creates small tears in the fascia, resulting in inflammation and discomfort, particularly with the first steps after rest.

Achilles tendinitis

Overuse of the Achilles tendon, which connects the calf muscles to the heel bone, can cause inflammation and pain at the back of the heel. This typically develops gradually due to repetitive strain, particularly in physically active individuals.

Heel spurs

Bony growths on the heel bone often form due to chronic plantar fasciitis. While spurs themselves are usually painless, they can irritate surrounding soft tissue.

Excessive pronation

Abnormal foot movement during walking or running can place additional stress on the heel and arch. Flat feet or low arches often contribute to this biomechanical issue, leading to strain on the plantar fascia.

Inappropriate footwear

Shoes with inadequate arch support, poor cushioning, or an improper fit can contribute to heel pain. High heels and completely flat shoes may both place excess strain on the plantar fascia and Achilles tendon.

Occupation-related factors

Jobs requiring prolonged standing or walking on hard surfaces can increase the risk of developing heel pain.

Age-related changes

The fat pad on the heel naturally thins with age, reducing its shock-absorbing capacity. This can lead to increased pressure on the heel bone and surrounding structures, making pain more likely.

Obesity

Excess body weight places additional stress on the plantar fascia and heel bone. For each pound of weight gained, the feet absorb an extra 3–5 pounds of impact force when walking.

Diagnostic Methods

Clinical examination

A physical assessment evaluates foot structure, alignment, range of motion, and tender points in the heel. Gait analysis helps identify abnormal walking patterns that may contribute to pain.

Medical history review

Symptom onset, pain patterns, previous injuries, activity level, and footwear are assessed to identify potential causes. Key factors include when pain occurs, what worsens or relieves it, and how long symptoms have persisted.

X-rays

Radiographs assess bone structure and can reveal heel spurs, fractures, or arthritis. While they do not show soft tissue inflammation, they help rule out bone-related causes and provide insight into foot alignment.

Ultrasound imaging

This non-invasive test visualises soft tissues, including the plantar fascia and Achilles tendon. It detects thickening, inflammation, or tears and allows for dynamic assessment of tissue movement.

MRI scan

Magnetic resonance imaging provides detailed views of bone and soft tissues when the diagnosis remains unclear. It detects tissue degeneration, bone marrow oedema, stress fractures, and soft tissue damage. MRI is usually reserved for cases that do not respond to initial treatment or when surgery is being considered.

Treatment Options

Heel pain management includes a range of approaches, from self-care to medical interventions, depending on the diagnosis and severity.

Non-Surgical Treatment

Rest and activity modification: Avoiding high-impact activities allows inflamed tissues to heal without requiring complete immobilisation. Low-impact exercises such as swimming or cycling help maintain fitness while reducing strain. In some cases, a walking boot provides additional support during acute pain.
Physical therapy: Stretching and strengthening exercises improve flexibility and reduce strain on the plantar fascia, Achilles tendon, and calf muscles. Programmes may include heel cord stretches, towel curls, and marble pickups. Consistent exercise helps prevent recurrence.
Orthotic devices: Custom or over-the-counter inserts provide arch support and redistribute pressure. Orthotics help correct biomechanical imbalances, while night splints maintain a gentle stretch on the plantar fascia to reduce morning pain.
Medications: Non-steroidal anti-inflammatory drugs (NSAIDs) reduce pain and inflammation but do not correct structural issues. Corticosteroid injections may offer temporary relief in severe cases, though repeated use is limited due to potential side effects.

Surgical Treatment

Plantar fascia release: Partially cutting the plantar fascia reduces tension on the heel bone, helping to relieve pain. The procedure can be done through an open incision or a minimally invasive endoscopic approach. Recovery involves wearing a surgical boot for a few weeks, followed by a gradual return to normal activities.
Heel spur removal: If a heel spur is causing persistent pain, surgical removal eliminates the bony growth and reduces soft tissue irritation. This procedure is usually performed alongside plantar fascia release. Recovery includes limited weight-bearing initially, followed by gradual rehabilitation.
Gastrocnemius recession: Tight calf muscles can increase strain on the plantar fascia, worsening heel pain. This procedure lengthens the gastrocnemius muscle to improve ankle mobility and reduce tension. Recovery involves modified weight-bearing for 4–6 weeks, followed by physical therapy.

Prevention and Management

Wearing supportive, well-fitted shoes with proper cushioning helps reduce heel strain. Maintaining a healthy weight minimises pressure on the foot, while regular stretching of the calf muscles, Achilles tendon, and plantar fascia improves flexibility. Gradually increasing activity levels and avoiding sudden increases in high-impact exercise can prevent overuse injuries. For those prone to heel pain, orthotic insoles or supportive footwear may help. Long-term management includes addressing foot alignment issues and adjusting daily activities to reduce recurrence.

Dr Chong Xue Ling

Senior Consultant Orthopaedic Surgeon

Dr Chong Xue Ling is a Swiss fellowship-trained orthopaedic surgeon specialising in foot and ankle, as well as shoulder and elbow surgery.

She is a member of the European Group for the Study and Research of Minimally Invasive Surgery of the Foot and Ankle. For shoulder and elbow surgery, she completed her fellowship at La Tour Hospital, an accredited Swiss Olympic Medical Centre and learnt innovative techniques in arthroplasty for earlier return to activity as well as the stabilising techniques, developed to have greater strength without extensive fixation.

MBBS (S’pore)
MRCS (Ireland)
MMed Orthopaedic (S’pore)
FRCS Orthopaedic (Edinburgh)

Through active involvement in research, she aims to constantly improve existing treatment in the pursuit of quality care for her patients.

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Heel Pain

Frequently Asked
Questions

How long does heel pain typically last?

Recovery time depends on the cause and treatment consistency. Most cases of plantar fasciitis improve within 6–12 months with conservative care, especially when treated early. Long-standing cases may take longer to resolve.

Can I continue exercising with heel pain?

Low-impact activities such as swimming or cycling help maintain fitness without worsening symptoms. High-impact exercises should be reduced or avoided until pain subsides. Gradually resuming activity helps prevent recurrence.

When should I seek medical evaluation for heel pain?

Seek medical advice if pain persists beyond two weeks, worsens, or prevents weight-bearing. Urgent care is needed for severe swelling, numbness, fever, or if you have diabetes or circulation problems.

Heel Pain

Symptoms of Heel Pain