A Common Cause of Heel Pain

This article is only about bruised heels, which are a common cause of heel pain. The article does not talk, for instance, about fasciitis, spurs, heel pad atrophy, Baxter’s nerve, or tibial tendon dysfunction. This is specific to ONE condition only. That said, bruised heels form part of a range of conditions, which are often called syndromes.  Because this condition is an injury and specific to one site, the heel pad, it is not a syndrome. It is often caused by a known injury and the impact of the heel hitting the ground with a repetitive force. 

Why did it happen?

I was on a treadmill (shown), which is one of the most common exercise systems to be found in the fitness centre (gym). I was on a mission to lose weight, keep fit and tone up, and ensure good cardiac stimulation.  Now, into my seventh week of selecting goals, the set speed took me from 5.6 Kph to 9.9 kph every other minute. My heel starts to rise marginally at 7 kph. However, the heel does not fully leave the floor. To achieve little heel contact, one would need to sprint 100 to 220 metres, which, for most of us, could be dangerous on the treadmill. To date, I have run at 15 kph, which is pretty fast for my age and the fact I also have a chronic knee problem. As the heel contacts the ground, the impact forces vary. Heel pain was the result of my session.

Heel with the diagrammatic impression of the fat pad and combined direction of forces (C) 2020 Busypencilcase Reflective communications

The point of contact was the rear section of the heel pad. For the last 5+ weeks, I have either walked or run but have not set the machine to alternate in such short bursts. The ‘profile’ programme set this up. I was beginning to lament selecting this pre-set goal. Furthermore, this was the first time I had set up such a programme. Years ago, I experienced this same pain on the treadmill, but now I could be more objective about the whys. I was older by fifteen years, although my heel pad was still thick and viable. The skin was just a little harder than usual. There were no splits (fissures), which is a common condition often associated with heavy exercise, some shoe types and dry skin. I use creams on the foot to keep the skin (tissue) supple. Four days after the incident, I realised that I was not getting better and set about treatment.

How do you tell that you have a bruised heel pad?

Signs and Symptoms

The heel shows no signs of bruising, nor is it red or obviously swollen. The pain varies depending on the position of the foot. I could squeeze the heel pad, and there was tenderness on the squeeze test but not when pressed underneath. The pain level was around 3-4 (on a scale of 0-10, where 10 is worse) if my heel pad was squeezed hard from the side. Be aware that fasciitis presents differently.

Standing and remaining in one place caused more discomfort than moving around. Painkillers might dull the pain, but they are not the answer. However, it is not harmful to take an anti-inflammatory tablet at the acute stage. The symptoms include periodic pulsating discomfort. The heel does not like to be positioned with weight on the back of the heel, i.e., driving.

I use my cruise control in the car as I use an ‘automatic’. This is helpful for a left foot injury. For a right foot, you would need to use a cushioned heel guard (see below). If there had been a bruise around the heel then I would have considered bone or ligament damage. The level of pain can be described as 2-4, so more of a discomfort than real pain. Reaching level 4 would arise after increased activity, such as a walk. Then, after rest, this discomfort would ease. Early morning standing on the foot is different from fasciitis and does not appear as sharp or biting. 

Mechanics

Heel contact and loading response.(From Perry J: Normal and pathologic gait, in Atlas of Orthotics, ed 2. St Louis, Mosby-Year Book, 1985, p 77.

To understand the mechanics of the injury, we must appreciate that when contacting the ground, the skin and fat respond differently. The direction of contact is sideways rather than directly under the heel. This is why shoes are usually worn on the outer edge and not the inner side. Several types of directional force are involved. One is called a lateral or sideways force, and the other is a vertical contact force. The foot has that peculiar feature in that it twists or rotates as well. Add lateral, vertical, and rotationally twisting forces together, and you will have a group of forces that have collectively increased. The response to these forces acts differently within the deeper fat pad (illustrated above) and the skin.

The skin is more resistant and responds by thickening or forming a callus. This is normal. The fat pad, however, compresses, flattening then expanding. Because the skin is thickest on the foot the protection is excellent through its five layers of cells. Vertical forces alone are catered for well by the foot. However, the lateral forces do more damage. Such damage consists of tearing the connections between fat cells. These just happen to be rich in blood, and the pad is inflammation and can swell. The more damage, the more swelling will arise following injury.

Why should one direction over another matter?

Scientists have found that some tissues, like fat, deal with the stress of forces better in one direction than in another direction. This means the fat is stronger at vertical compression than at lateral impact. The time factor, or length of contact, makes a difference. The repetitious nature of stress can increase the damage to the material substance of the heel, the fat pad. The pad is made up of a matrix. A fibrous patch network surrounds fat. The Tuli Heel pad (shown below) mimics this, which is why this particular design is better than a piece of foam. Many off-the-shelf foam pads help a bit but do not help a lot.

The dangers of short intervals

Short periods of exercise seemed to create more heel pad stress at one-minute intervals. I wanted to test this theory by lengthening the intervals and developing a different strategy. I also needed to stabilise my left foot, so I added a prescription orthotic to my running shoe.

If a foot overpronates, which means it leans in, the excess movement can add to the strain and even cause plantar fasciitis. The period when the foot is less stable is when the heel strikes the floor, and the weight moves onto the front of the foot (forefoot and toes). This takes but part of a second to occur, but it is sufficient to make the fat pad tear internally. These tears are small or micro-tears, but they cause inflammation and increase fluid release. Repair starts rapidly, but because the heel is used frequently, any resolution takes time. My last event took 2 weeks to settle, so I expect a similar recovery period.

Fast forward to WEEK 4

At three weeks, the heel pain had eased. I had a week off but went walking using my Tuli heel cup. This meant I could keep going as long as the discomfort was contained. Back at the gym now, I decided to go for the treadmill at the start of week 4 but would make sure that my heel was mainly set in the running mode—7-10 kph.

I used my prescription 3/4 length orthotics, which fell behind the ball of the foot (outline illustrated). I did 21 minutes, started with a gentle 5 Kph, and then built it to 9 Kph. The difference was that using longer periods between the shocks of the heel hitting was less effective. I had learned my lesson from the short intervals. This meant my tissues could recover. I, therefore, discovered the secret was about the time allowed for tissue recovery. One minute between impact speeds meant it was poor.

Three minutes at the slow speed to warm up, then 10 minutes at the faster speed. I dropped it to 3.5kph for some rest. I checked the heart rate and waited for it to come down to around 115 beats per minute. The machine enables all of the information to be viewed. I then set the gradient to its maximum pitch of 15%. The speed went back up to 5 kph for another 5 minutes and then dropped for a short rest at 3.5 kph and then onto 10 kph for the remainder of the time. I was even able to do my fast burst of 13-15kph and ill effect. 

Self-help strategy

Tuli Heel cup available for around £8-10 (pair)

We want to avoid drugs. Using anti-inflammatories for a few days, e.g., ibuprofen, won’t hurt. I made a soft heel pad out of foam and ordered a unique heel cup called a Tuli heel (shown). I dug out my custom orthotics because I had not used them for a while. I had also noted some tendon discomfort, and now this ensured I would take all precautions to reduce the shock. The orthoses (orthotics) would stop overpronation and control my foot when walking. Despite using a foam pad, heel cup, and orthoses, I found a three-day rest from the gym helpful. However, this did not resolve the heel immediately. I cut back on walking and noted burning discomfort for around 10 days.

So, lessons learned? 

1. We can treat the heel provided that we identify the cause of the problem early on. We have to stop the primary activity, but ideally, we should keep mobile.
2. Total rest is not ideal for heel pain unless, of course, there are medical complications like fractures or infection. Rest actually means reducing activity.
3. Skincare and using some heel pad containment systems are important. The Tuli Heel Pad worked well initially. A flat foam heel pad may cushion the heel, but the benefit is limited.
4. Bruising takes THREE WEEKS to settle, and it may be less with the withdrawal of overactivity. I continued to trek and walk during my recovery, which may have slowed matters. However, I was mostly experiencing low pain grades of 2-3. 
5. The use of a good heel cup and contoured orthotic worked.
6. Adjust your programme, whatever. If you are at a gym, look at those profiles or pre-programmed features. Although intended to help you keep fit, they can add an unsuspected injury to your life.
7. My intervention, skincare, containment, change of activity, and altered programme worked. I am delighted to say that today, at the end of week 4, after first experiencing pain, I am back to full running on the treadmill.

Thanks for reading – ‘Heel Pain due to a bruised heel’ by David R. Tollafield 

You can now read Foot Health Myths Facts & Fables by David R. Tollafield, published on Amazon Books.

Modified January 2025

Published by Busypencilcase Communications & Publications. Est. 2015 for ConsultingFootPai