Heel Pain Osteopathy and Prescriptive Exercise by Osteopaths

Heel Pain

Heel pain usually builds up gradually and gets worse over time. The pain is often severe and occurs when you place weight on your heel.

In most cases, only one heel is affected, although estimates suggest that around a third of people have pain in both heels.

The pain is usually worse first thing in the morning, or when you first take a step after a period of inactivity. Walking usually improves the pain, but it often gets worse again after walking or standing for a long time.

Some people may limp or develop an abnormal walking style as they try to avoid placing weight on the affected heel.

Common causes of heel pain

Plantar Fasciitis

Plantar Fasciitis occurs when the plantar fascia ligament of the foot spanning the arch of the foot to induce the excessively inward rolling with either over-flexion or stretching. The ligament becomes irritated and inflamed and small tears may develop in the tissue (Agyekum and Ma,  2015).

Heel spur

Heel Spur also contributes to heel pain. When stress is put on the plantar fascia ligament, it does not cause only plantar fasciitis, but cause a heel spur to where the plantar fascia attaches to the heel bone. A heel spur is an abnormal growth of bone at the area where the plantar fascia attaches to the heel bone. It is caused by long-term stress on the plantar fascia and muscles of the foot, especially in fat and overweight people, active runners or joggers. Heel spurs may not be the cause of heel pain even when it shows on an X-ray. They may develop as a reaction to plantar fasciitis (Agyekum and Ma,  2015).

Sever’s Disease

Sever’s Disease, also known as calcaneal apophysitis, is an inflammation of the growth plate in the heel of growing children, typically adolescents. The condition refer to the pain in the heel and is caused by recurrent stress to the heel and thus is particularly common in active children. It usually resolves once the bone has completed growth or activities reduce. Sever’s disease is directly related to overuse of the bone and tendons in the heel. This can come from playing sports or anything that involves a lot of heel movement. Too much weight bearing on the heel can also cause it, as can excessive traction since the bones and tendons are still developing (Agyekum and Ma,  2015).

Haglund’s deformity (heel bump)

Heel bumps or exostoses occur just lateral to the Achilles tendon and cause particular worry to teenagers in whom they interfere with shoes wear. The soft tissue near the Achilles tendon becomes irritated when the bony enlargement rubs against shoes. This often leads to painful bursitis, which is an inflammation of the bursa that produces the redness and swelling associated with Haglund’s deformity (Agyekum and Ma,  2015).

Achilles Tendinopathy

The Achilles tendon constitutes the distal insertion of the gastrocnemius and soleus muscles into the calcaneus. It is the inflammatory process within the tendinous insertion of the Achilles. This condition also refers to Achilles tendonitis, tenosynovitis, peritendinitis, paratenonitis (acute disease), tendinosis (chronic disease), and achillodynia. The acute phase of Achilles tendinopathy is secondary to acute overexertion, blunt trauma, or chronic overuse and muscle (Agyekum and Ma,  2015).

Heel neuritis

Compression of a small nerve (a branch of the lateral plantar nerve) can cause pain, numbness or tingling in the heel area. In many cases, this nerve compression is related to a sprain, fracture or varicose (swollen) vein near the heel. (Agyekum and Ma,  2015).

Heel Bursitis

Heel bursitis It is an inflammation of the heel bursa. It causes includes; landing awkwardly or hard on the heels and pressure from footwear. Heel bursitis pain is typically felt either deep inside the heel or behind the heel. Occasionally the Achilles tendon may swell. As the day goes by, the pain usually gets worse (Agyekum and Ma,  2015).

When to see your GP

See your GP or a podiatrist (foot problems specialist) if you’ve had persistent heel pain for a number of weeks and it hasn’t cleared up.

It is advised that a patient should make an appointment to see a health care professional if he or she has significant heel pain that does not improve within a few days or if the patient is unsure of the cause of the symptoms, or does not know the specific treatment recommendations for the condition. A doctor should be consulted if a patient experience: severe pain accompanied by swelling near the heel, numbness or tingling sensation in the heel, as well as pain and fever; pain in the heel as well as fever; being unable to work normally; being unable to bend the foot downwards; being unable to stand with the backs of the feet raised (you cannot rise onto your toes) (Agyekum and Ma,  2015).

They should be able to diagnose the cause of your heel pain by asking about your symptoms and medical history and examining your heel and foot.

Further tests will only usually be needed if you have additional symptoms that suggest the cause of your heel pain isn’t inflammation, such as:

  • numbness or a tingling sensation in your foot, which could be a sign of nerve damage in your feet and legs (peripheral neuropathy)
  • your foot feels hot and you have a high temperature (fever) of 38°C (100.4°F) or above, which could be a sign of a bone infection
  • your heel is stiff and swollen, which could be a sign of arthritis

Possible further tests that may be recommended include blood tests, X-rays, a magnetic resonance imaging (MRI) scan or an ultrasound scan.

Who gets heel pain?

Heel pain is a common foot condition. An estimated one in 10 people will have at least one episode of heel pain at some point in their life.

People who run or jog regularly, and older adults who are 40-60 years of age, are the two main groups affected by heel pain.

Treating heel pain

There are a number of treatments that can help relieve heel pain and speed up your recovery. These include:

  • resting your heel – avoiding walking long distances and standing for long periods
  • regular stretching – stretching your calf muscles and plantar fascia
  • pain relief – using an ice pack on the affected heel and taking painkillers, such as non-steroidal anti-inflammatory drugs (NSAIDs)
  • wearing well fitted shoes that support and cushion your feetrunning shoes are particularly useful
  • using supportive devices – such as orthoses (rigid supports that are put inside the shoe) or strapping

Foot Orthoses /Orthotics

Osteopaths generally prescribe insoles or custom orthotics to treat a mechanical issue of the lower limb and / or lower back. In the event that heel pain is due to a health issue, you are likely be referred to a GP or Podiatrist.

A summer alternative to wearing shoe insoles and orthotics, should be contoured sandals. Contoured provides a similar beneficial effect to that of a contoured shoe insert and a superior effect to that of a flat flip-flop over a 3 month period. The contoured shoe can be a prefabricated shoe foot orthoses that have been shown to be of benefit over 3 months (Vicenzino et al. 2015).

Osteopathic Treatment


Massage therapy to posterior calf muscles and neural mobilization combined with stretching exercises had superior short-term FS outcomes compared to ultrasound treatment with stretching exercises (Saban et al. 2014).

Neuromuscular Inibition

Neuromuscular inhibition techniques can be applied to reduce sensitivity of the soft tissues of the lower limb that that causes heel pain.

This can then by combined with a self-stretching protocol prescribed by an osteopath.

In particular it has been shown that adding Trigger Point manual therapies to a self-stretching protocol, it gives superior results to the sole application of self stretching in the treatment of individuals with plantar heel pain at short-term. The stretching protocol should include the calf musculature and plantar fascia for the treatment of plantar heel pain. Though it is unclearly of the long term effects of this treatment (Renan-Ordine et al. 2011).

Effect of Stretching on Plantar Heel Pain

The main pain-relieving benefits of stretching appear to occur within the first two weeks to four months. There is no conclusive evidence regarding the most effective number of repetitions or frequency of stretching, or whether self or therapist applied stretches are most effective. Inclusion of stretches directly to the plantar fascia may provide better short-term pain relief than stretching the Achilles tendon alone (Sweeting et al. 2011).

Evidence Base

Recent evidence suggests that manual therapy is effective in the long term in the treatment of plantar heel pain using joint, soft tissue and neural mobilization techniques (Mischke et al. 2017).

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Reference List

Agyekum EK, Ma K (2015). Heel pain: A systematic review. Chin J Traumatol. 18(3):164-9.

Mischke JJ, Jayaseelan DJ, Sault JD, Emerson Kavchak AJ (2017). The symptomatic and functional effects of manual physical therapy on plantar heel pain: a systematic review. J Man Manip Ther. Feb;25(1):3-10.

Renan-Ordine R, Alburquerque-Sendín F, de Souza DP, Cleland JA, Fernández-de-Las-Peñas C.(2011). Effectiveness of myofascial trigger point manual therapy combined with a self-stretching protocol for the management of plantar heel pain: a randomized controlled trial. J Orthop Sports Phys Ther. Feb; 41(2):43-50.

Saban B, Deutscher D , Ziv T (2014).  Deep massage to posterior calf muscles in combination with neural mobilization exercises as a treatment for heel pain: a pilot randomized clinical trial. Man Ther. Apr;19(2):102-8.

Sweeting D, Parish B, Hooper L and Chester R (2011). REVIEW The effectiveness of manual stretching in the treatment of plantar heel pain: a systematic review. Journal of Foot and Ankle Research 4:19

Vicenzino B, McPoil TG, Stephenson A, Paul SK (2015). Orthosis-Shaped Sandals Are as Efficacious as In-Shoe Orthoses and Better than Flat Sandals for Plantar Heel Pain: A Randomized Control Trial. PLoS One.  Dec 15;10(12):e0142789.

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