Creekside Physio Blog

Foot: Heel Pain

Posted on: November 14th, 2017 No Comments

The Achilles TendonHeel pain comes in many varieties and causes with each requiring different treatments. The pain can be felt under the heel on the inside, outside or right in the middle of the heel or it can be felt at the back of the heel. Less commonly pain is felt along the inside or outside of the heel bone (calcaneus). Among the better-known pathologies are Achilles tendonitis and plantar fasciitis but there are quite a few more and over the next few weeks I will try to make all of them understandable and give you options for treatment.

There are a number of tissues positioned behind the heel and any of these are potential sites of pain. They include:

  1. The big Achilles tendon that attaches the calf muscle to the heel
  2. Two bursas
  3. The upper part of a fat pad
  4. A large fat pad under the Achilles tendon
  5. The heel bone and it’s lining

All of these tissues are capable of causing pain but some of the pathologies are more severe than others and need to be identifies by the physician or therapist.

Achilles Tendon

This is the very large and thick tissue that is easily felt behind the ankle. Two major muscles connect with it and their job is to raise the heel from the ground when running or walking.

A number of conditions can affect the tendon, it can be inflamed, degenerative, scared, torn either completely or partially, and it can be pulled off the heel bone. Treatment is usually given at urgent or emergency care.


Tendinopathy - Achilles TendonTendinopathy simply means that the tendon has a pathology but the term doesn’t say whether the pathology is one of inflammation or degeneration; an inflamed tendon is called a tendinitis and a degenerative or scared tendon is called tendinosis. Not usually thought of as a tendinopathy a rupture nonetheless is.


A complete or even a substantial partial rupture of the tendon is a catastrophe for the patient. The pain is sudden and severe and causes the person to limp by walking on his toes, it is initially impossible for the patient to put the foot flat on the ground to step over it although with a complete rupture this may be possible after a few days as there is nothing to stress. Generally, there is no problem diagnosing this condition when the rupture is large. Occasionally ruptures are painless because there is existing pathology; reduced blood flow, connective tissue disorders and just too much cumulative stress.

Risk factors4

Factors that may increase your risk of Achilles tendon rupture include:

  • Age. The peak age for Achilles tendon rupture is 30 to 40.
  • Sex. Achilles tendon rupture is up to five times more likely to occur in men than in women.
  • Recreational sports. Achilles tendon injuries occur more often during sports that involve running, jumping, and sudden starts and stops — such as soccer, basketball and tennis.
  • Steroid injections. Doctors sometimes inject steroids into an ankle joint to reduce pain and inflammation. However, this medication can weaken nearby tendons and has been associated with Achilles tendon ruptures.
  • Certain antibiotics. Fluoroquinolone antibiotics, such as ciprofloxacin (Cipro) or levofloxacin (Levaquin), increase the risk of Achilles tendon rupture.
  • Obesity. Excess weight puts more strain on the tendon.

In addition, a single injection into the tendon of any substance but particularly steroids run a high risk of causing a rupture and repeated episodes of Achilles pain (tendinosis or tendinitis)


The tendon can be treated surgical or non-surgically both tend to have good outcomes but full recovery with either can take a year or longer. Non-surgical treatment consists of rest initially and then physiotherapy. Surgery is an open repair followed by physiotherapy rehabilitation.


Tendinitis - Achilles TendonThe Achilles tendon like others can be inflamed or have degenerative areas within it that can be
painful. Tendonitis is inflammation and like other acute inflammatory conditions is felt to be severely painful, sometimes swollen and doesn’t like to be stressed. The tendon can be most severely stressed by stretching and less so by the muscle contracting so normal walking is pretty much impossible as every time you step over the planted foot the tendon is stretched. While walking on your toes also stresses the tendon it is more possible because it is less painful and so you walking with a limp and on your toes. The tendon is exquisitely tender to the touch and may even be hot and it often feels swollen compared to the other side. When it is severe crutches or a cane are useful at relieving some of the stress of weight bearing.

Causes include:

  • severe over-use
  • badly fitting running shoes rubbing against the tendon and the friction causes inflammation
  • direct blows
  • diseases such as gout and arthritis.

Sometimes the cause cannot be determined even with exhaustive testing by your therapist and physician and in these cases the cause must be searched for within the patient; foot and hip biomechanical dysfunctions, low back problems and leg length discrepancies may all cause or contribute to the issue but more severe causes must be ruled out first.

Treatment consists of:

  • rest; – reduced activity and crutches
  • ice – to reduce the chemical reactions occurring during inflammation
  • loading the tendon – this is done carefully and must not cause pain; its purpose is to help optimal healing along the lines of habitual force
  • ultrasound to improve blood flow into the area
  • deep friction massage
  • shock wave therapy


Tendinosis - Achilles TendonTendinosis is non-inflammatory degeneration of the tendon fibrosis and scarring. It may the results of previous injury and non-optimal healing or it can be caused by intrinsic factors such as poor foot, hip or back biomechanics, poor blood flow to the tendon, repeated or cumulative stressing that does not cause tendinitis and certain medications.

The best physiotherapy single treatment according to best available evidence is Shockwave therapy but no treatment should be given in isolation and the tendon needs to be loaded to improve the healing that Shockwave has kicked off and gradual increase in function.

Of equal importance, though it finding the cause and while sometimes the cause is obvious more often it is not even though it seems to be. For example, a runner complains of it in one foot and running is blamed but the question must always be why that foot. So again the therapist must look for causes within the patient.

The treatment of these causes may be manipulative therapy to restore optimal biomechanics, an orthotic when properly applied and followed up can be a great help and appropriate exercises.

In short ruptures of the tendon are a major problem and take a long time to recover while tenditis’ are often easy to treat but may indicate a more serious underlying problem and tendinoses are relatively easy to treat, especially with shockwave but can be complicated when it comes to dealing with the underlying causes.

Other problems that may be misdiagnosed as an Achilles tendinopathy are:

  • A cutaneous or retrocalcaneal bursitis
  • Superior part of the heel pad inflammation or oedema
  • Kager’s fat pad syndrome
  • Fracture of the heel bone

So for back of the heel pain see your doctor or physiotherapist for the best treatment.


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