Heel pain can occur in two major locations: the back of the heel and the bottom of the heel.

Pain at the back of the heel has three major causes.

Achilles tendonitis is the most common. It is usually the result of injury or overuse. An example is the weekend warrior who decides to go out and run 4 or 5 miles going up hills... or a person who goes on a long walk in flat shoes, shoes with little or no heel. In both cases, stress is placed on the Achilles tendon- the large thick cord located in the back of the heel.

This tendon- the largest in the body- connects the gastrocnemius (calf) muscle to the back of the heel.

The likelihood of Achilles tendonitis developing is increased if a person has flat feet. Older patients taking corticosteroid medications and people treated wtih quinolone antibiotics like ciprofloxacin (Cipro) also are at increased risk of Achilles tendonitis and even Achilles tendon rupture.

Haglunds syndrome presents with a bony bump located at the back of the heel. A bursa (small sack of fluid) located near the bump may contribute to the swelling. The Achilles tendon insertion near the bony swelling may become inflamed. Because of the location, this syndrome is often referred to as "pump bumps" and the cause often attributed to womens' shoes.

Inflammation of the Achilles tendon at its insertion into the heel can be seen with certain types of arthritis, specifically the spondyloarthropathy group which consists of Reiter's disease, psoriatic arthritis, and ankylosing spondylitis. Other signs of disease such as low back pain and stiffness, rash, and joint swelling may provide clues to diagnosis.

Pain in the bottom of the heel is usually due to plantar fasciitis.

Pain in the plantar fascia presents with sharp stabbing pain in the bottom of the heel. Plantar fasciitis is a common problem that is due to repetitive trauma to the soft tissue in the heel.

Typically a patient will feel fine so long as they are lying down or sitting. But if they get up to walk, the pain feels like an ice pick is being jammed into the bottom of the heel.

This pain gets better over several minutes but occurs again after inactivity followed by weight-bearing.

Causes of plantar fasciitis include:

• An abrupt increase in activity

• Worn footwear,

• Footwear with no arch support (eg., flip-flops)

• Obesity

• Recent rapid weight gain such as with pregnancy

• Overuse as in excessive running and over-training

• Systemic inflammatory arthritis (particularly ankylosing spondylitis and other spondyloarthropathies such as Reiter's disease and psoriatic arthritis).

Treatment involves first establishing the diagnosis. Most of the time, the diagnosis can be suspected by the history and physical examination.

Imaging tests such as diagnostic ultrasound and magnetic resonance imaging can confirm the diagnosis, if necessary. X-rays may reveal the presence of a heel spur. A heel spur, by itself, is not the cause of pain in the bottom of the heel and heel pain should not be attributed to "a heel spur".

Once the diagnosis has been made, treatment options include:

• Identifying likely causative factors such as excessive weight, inappropriate footwear, and errors in training.

• Non-steroidal anti-inflammatory drugs (NSAIDs) sometimes provide symptomatic relief.

• Therapeutic taping gives short-term symptom relief.

• Exercises to stretch the heel cord and plantar fascia.

• Orthotic devices can help in the short-term reduction of pain. These can be off-the-shelf or custom made. For people with Achilles tendonitis, having the patient wear a lift in the shoe to elevate the heel will help reduce symptoms.

• Glucocorticoid (steroid) injection may also work for plantar fasciitis and should be used if the patient has not responded to conservative measures. The use of diagnostic ultrasound to guide the injection is recommended.

Caution should be observed with the Achilles tendon as far as steroid injection. The tendon can be weakened if steroids are directly injected. This then can lead to Achilles rupture.

The bursitis that occasionally accompanies Achilles tendonitis (retrocalcaneal bursitis) will respond to steroid injection.

If a patient is taking a quinolone antibiotic (such as ciprofloxacin), it should be discontinued and the patient should be monitored for tendonitis and tendon rupture.

Night time braces are sometimes used for plantar fasciitis.

Often the best treatment for heel pain, whether it is located in the back or on the bottom, is rest.

A surgical solution should be considered for those patients with intractable pain which remains despite conservative treatment.