Heel Pain in Runners

Heel Pain in Runners

– April 2015 –

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heelpaininrunnersHeel pain is a problem that is very familiar to both runners and podiatrists. It can be a frustrating condition to manage as symptoms can often linger or reoccur many months (or even years) after the initial presentation. Understanding the process and how to manage it can lead to better outcomes.

What is heel pain?

Heel pain can be defined as pain on the bottom of the foot (plantar surface) in the region of the heel.  It can be a complicated pathology, involving multiple structures and attachments.

Anatomy of the Heel

In normal function these structures work together to enable us to walk (or run) efficiently. However, pain can present when they are over stressed or damaged, for example:

  • The plantar fascia – the long ligamentous sheath which supports and protects the sole of the foot. Damage to the fascia (Plantar Fasciitis) commonly occurs near the attachment to the heel bone – a site of high stress.
  • The smaller foot muscles – there are a number of smaller muscles lying deeper to the plantar fascia that attach around the heel. Strains, tightness, or poor function of these muscles can contribute to heel pain.
  • The calcaneus (heel bone) – fractures of the heel bone commonly occur after heavy trauma to the site and can be very painful. Smaller microfractures (stress fractures) are much harder to identify and may cause prolonged pain.
  • Heel spurs – the constant pulling of tendons and ligaments on the calcaneus causes changes to its shape. Boney prominences at attachments help to reduce forces. However sometimes this boney growth (a heel spur) causes aggravation and pain around the heel.
  • The ligaments – a ligament is a tough fibrous tissue that connects bone to bone. There are many small ligaments around the heel and ankle that stabilise the foot. Sprains, rupture, or weakness to ligaments can cause significant pain and dysfunction.
  • The nerves – nerves form a complex system that transmits signals and coordinates movements of the body. Disruption or damage to the nerves that run around the heel can cause pain, numbness and dysfunction of the foot.
  • The skin – blisters, cuts, calluses, and corns under the feet may all contribute to heel pain and discomfort. Inflammation of the deeper fatty layers of the skin under the heel can cause pain.

Things are further complicated by the fact that heel pain may in fact be caused by problems away from the heel itself (i.e. referred nerve related back pain or calf muscle tightness).

In conclusion, identifying the exact structures involved is difficult but understanding the anatomy of the foot and what may be the problem will give us the best chance of effectively treating it!

Why does heel pain present in runners?

3 primary factors specifically contribute to heel pain in runners:

Increased forces

The motion of running (with periods of no ground contact) and speed of movement places high forces on the body. Typical vertical forces on first contact with the ground are twice as much compared to walking. Although there is some debate as to how footstrike (rearfoot/midfoot) and different running style affects these forces, there is no doubt that running places increased stress on the structures of the lower limb.

Repetition and fatigue

A typical marathon consists of approximately 30,000-40,000 steps. Add in all the training, most of it on flat hard surfaces, and that’s a lot of repetition. The accumulation of these repetitive forces increases the likelihood of injury.

The demands and mindset of a runner

Long distance runners in particular, are well known for pushing their bodies to the limit. Even amongst recreational runners the goals of training and competing in events mean that prolonged periods of rest or doing alternative activities are not a favourable option. The desire to run can lead to delayed healing of minor niggles or the development of more serious problems.


Heel pain is usually a self-limiting condition. In other words, provided the appropriate actions are taken, the pain will resolve. However, a person’s daily demands can make this process more difficult. For example, just simple standing places significant forces on the bottom of the feet. The concept of total rest as a management for heel pain is usually not rational or desired. Therefore, a more proactive approach needs to be taken.


There are many different therapies that can be used in the management of heel pain. I am going to focus on those which I believe are vital to the long term management of heel pain and prevention of further injuries.


The topic of footwear is a controversial one. Despite a range of styles and trends of running shoes (motion control, stability, minimalist, maximalist) there continues to be no evidence that any particular type of shoe can reduce any particular running injury or improve performance.

However, anyone experiencing heel pain should definitely review their footwear. The condition of the shoes as well as whether they met the required training demands should be considered. There are strong arguments to suggest that using more than one footwear style (in conjunction with different types of training) will reduce the overall likelihood of injury.

Comfort and fit are vital too. Your shoes should allow you to run in a relaxed manner – sometimes just having the right “feel” in your footwear can make a big difference in injury prevention.


Orthotics/insoles are another highly debated therapy. In simple terms, orthotics work with the foot and shoe to adjust the forces being placed on the foot. In the management of heel pain the goal is to reduce the forces on the stressed or damaged structures and divert them somewhere else. For example, by either providing increased support for the arch or raising the heel in relation to the front of the foot.

Depending on the foot structure and function these goals can be achieved with either simple off the shelf devices or more complex custom made orthotics may be required. The key is to understand what might be going “wrong” in the foot and how orthotics can correct it.

Orthotics are designed to change foot function and thus should not be used in isolation. Their use needs to be combined with regular review and the appropriate exercises to enable the lower limb to adapt to the changes.

Soft Tissue Therapies

  • Stretching – Stretching around exercise is another highly debated topic. The amount of stretching runners do around exercise is highly variable, as are the perceived benefits. However there is strong evidence that structured stretching programs can play a key role in the treatment of heel and other foot pain.
  • Massage – Massage is a therapy that is under utilised in the management of heel pain.  Effective massage can promote healing, increase function, and reduce pain around the affected site. It also feels pretty good too.
  • Dry Needling – Dry needling involves inserting fine needles into taught bands of muscle (trigger points). The resultant chemical changes from the action help to relax to muscle. In the management of heel pain, the calf and plantar foot muscles are typically needled. This therapy is increasing in popularity and is supported by some good evidence.
  • Strengthening – strengthening and effective activation of the core muscles can play a big role in the management of foot pain in runners. The large gluteal muscles are a commonly neglected group that play an important role in stabilising the leg during running and reducing the forces on the smaller structures of the foot. Including core training within a running program can play a big part in injury prevention.

Activity Modification

Managing heel pain depends on modifying running activity accordingly. In the short term, rest and alternative activities may be required. Longer term planning should include regular training reviews. The breakup of running intensity, duration, and surface within a training plan may need to be adjusted to best meet the needs of the body.

The Bigger Picture

Other factors to consider are general health, occupation, lifestyle, and in particular diet. Running long distances requires adequate nutrition before, during, and after activity. Poor nutrition can affect recovery and increase the likelihood of injuries.

So that’s it! I hope you found this overview of heel pain in runners informative and useful. I work together with a range of specialists at South Yarra Sports & Spine Medicine to provide a holistic approach to managing problems like this for our clients.

Thanks for reading!

John Charles