Heel pain After Running: What are the Possible Causes

Why Does Heel Pain Occur After Running?

The heel is the first point of contact with the ground when running. This repetitive impact stresses multiple structures, including bones, tendons, and nerves. When these tissues are overloaded, excessive mileage, poor footwear, or biomechanical issues can lead to heel pain after running. The most common cause is plantar fasciitis. However, not all heel pain is due to plantar fasciitis. So, careful assessment is required to make the right diagnosis. 

Common Causes of Pain in the Heel After Running

Plantar fasciitis

This condition involves irritation of the thick tendon from the heel bone to the toes. Runners typically report pain at the bottom of the heel, which is worse with the first few steps after rest or early in the morning. It may ease during a run but can flare up afterwards. Pain can occur throughout the run, making running difficult in more severe cases. 

Calcaneal stress fracture

Stress fracture of the calcaneus occurs particularly in long-distance runners or those who have rapidly increased their training load. In this case, the pain is deep and constant, often worse with walking or running. Sometimes, patients can limp during or after a run. Unlike plantar fasciitis, pain can be on the side of the heel rather than underneath. Generally, there is no relief once the body warms up.

Insertional Achilles tendinopathy

This tendon pathology is another contributor, especially in runners with uphill training or shoes with poor heel support. This causes pain at the back of the heel, where the Achilles tendon attaches. It may be associated with morning stiffness. Sometimes, a visible lump is seen at the back of the heel. Tight shoes can make the pain worse. 

Baxter’s nerve entrapment

This condition occurs when a small nerve near the heel becomes compressed, causing burning pain or numbness. Generally, pain occurs during running. Unlike plantar fasciitis, there is no morning pain or stiffness, and the area of tenderness is located at the medial arch rather than the heel. 

Other less common causes of heel pain with running include fat pad atrophy, subtalar joint arthritis, bone growths, sural nerve entrapment and referred pain from the lumbar spine. 

How to Assess Someone for Heel Pain

Generally, the assessment begins with a detailed history. I ask when the pain started, what triggers it, and whether it improves with activity or worsens afterwards. Morning pain or stiffness is also an important clue. It is critical to ask about any training changes before the symptoms began. Shoe wear, running surfaces, and recent increases in volume or intensity all offer important clues. I also ask about a past history of stress fractures or issues with bone health, such as Vitamin D deficiency, low bone density, abnormal periods or disordered eating habits. 

Examination involves palpating the heel and surrounding structures to identify tenderness. In plantar fasciitis, the pain is localised to the medial calcaneal tubercle. Achilles insertional tendinopathy presents with tenderness at the posterior heel. In cases of suspected stress fracture, squeezing the heel from both sides may reproduce a deep, aching pain. Finally, for Baxter’s nerve entrapment, tenderness is pinpoint at the start of the medial arch. The range of motion of the ankle and subtalar joint, gait, and foot posture are assessed. Any neurological symptoms, such as tingling or numbness, warrant further exploration for nerve entrapment or lumbar spine referred pain. 

Imaging 

Imaging is not always required immediately, especially in cases where the clinical picture points to something simple like plantar fasciitis. However, imaging becomes critical when symptoms suggest another cause or pain fails to settle with treatment. 

Ultrasound is generally the first choice. It allows for a detailed look at the plantar fascia, Achilles tendon, bursae, and surrounding tendon structures. It can reveal thickening of the fascia, fluid around the tendon, or signs of bursitis or calcification. It can also reveal other clues, such as swelling in the subtalar joint, which may indicate subtalar joint arthritis. 

If a calcaneus stress fracture is suspected, especially in the early stages, I recommend an MRI. This is more sensitive than X-rays and can show bone marrow oedema before a fracture line becomes visible. MRI can also help identify causes, such as plantar fasciitis, Achilles tendonitis, fat pad oedema, or nerve compression.

X-rays may rule out bony abnormalities such as heel spurs, calcifications at the Achilles insertion or bone growths. 

Final Word from Sportdoctorlondon regarding Pain in the Heel After Running

Heel pain after running requires careful clinical assessment to pinpoint the underlying cause. While plantar fasciitis is the most common diagnosis, conditions like stress fractures, Achilles tendinopathy, or nerve entrapment should be considered, especially when symptoms are atypical or persist. If you’re a runner struggling with persistent heel pain after running, it’s worth seeing a Sports Medicine doctor for an assessment to ensure an accurate diagnosis and get you back running as soon as possible. 

Related conditions: 

• Plantar fasciitis 
• Calcaneal stress fracture 
• Baxter’s nerve entrapment 
• Sural nerve entrapment