Burning Heel Pain: Causes, Diagnosis, and Treatments
By Dr. Dina Elsalamony MD, MScPH
If you are suffering from a burning sensation in the heel and you are wondering, why do my heels burn? This article is here to answer this question for you, explain all the possible causes for this condition and the route for diagnosis and recovery.
It may surprise you, but most burning heel pain is not caused by plantar fasciitis. Plantar fasciitis is the most common cause for heel and foot pain in general, the pain for plantar fasciitis is usually characterized as a stabbing or dull aching pain that occurs mostly in the morning when you take your first few steps or sometimes after a long period of weight-bearing activity.
However, if the pain is described more as burning pain in the heel or bottom of the feet with occasional tingling, prickling, numbness, or hot sensation that is usually worse at night, then the most common reason behind this would involve some form of nerve damage or pathology of the nerve supplying your foot, usually referred to as neuropathy.
If your symptoms are more similar to the latter, then the causes for the burning sensation could be one of the numerous medical conditions that could lead to this kind of nerve impairment, these conditions could vary from mild to severe and the treatment of your burning heel pain will depend on the treatment of the underlying condition. In some situations, even wearing very tight shoes could be the reason behind impacting the nerve, and in this case, the remedy could be quite simple.
What are the possible causes of a burning feeling in the heel?
The following are a number of conditions that could lead to a burning feeling in the heel:
This is considered to be the most common complication of diabetes mellitus, and it affects around 50% of patients with type 1 and type 2 diabetes mellitus. (1)
Over a long period of time, uncontrolled high blood glucose levels, also called blood sugar, and high levels of unhealthy fats, such as triglycerides, in the blood can damage your nerves leading to diabetic neuropathy.
Diabetic neuropathy could affect all the nerves in the body, however, the most common type of neuropathy is the one related to the nerves in the legs and feet and causes the burning sensation, it is also known as peripheral neuropathy, meaning it affects the peripheral nerves fibers that exist further away from the root of the nerve originating from either the spinal cord or the brain. Peripheral neuropathy could also affect the arms and hands, although less common than the legs and feet, it could also manifest in both sides or only in one.
Risk factors: There are a number of risk factors that could be associated with developing diabetic peripheral neuropathy such as poor control of blood sugar, high blood pressure, obesity, tall height, elevated lipids, smoking, heavy alcohol intake, genetic factors, and exposure to other potentially neurotoxic agents such as ethanol. (2,3,4)
Symptoms: In addition to the burning feeling in the heel or the bottom of the foot, there are other symptoms that could be an indication of peripheral neuropathy, hence should not be ignored. These symptoms include:
- Sharp, shooting pain
- A feeling of heaviness or weakness in the feet, leg or arm.
- Numbness or tingling sensation of feet or hand.
- A strange feeling as if you are wearing a tight sock when you are not.
- Hypersensitivity to touch or tenderness.
- Loss of balance, especially when eyes are closed.
- Painless injuries, due to loss of sensation in the feet.
In the case of type 1 diabetes mellitus, the symptoms of peripheral neuropathy start appearing after many years of prolonged chronic uncontrolled blood glucose level, while in type 2 diabetes mellitus symptoms may present after only few years of uncontrolled blood sugar. In some cases, patients are not even aware that they have diabetes mellitus until they present with peripheral neuropathy symptoms, where they get their initial long-due diabetes diagnosis at the same time. Hence, it is critical to see your physician as soon as possible as early diagnosis and treatment are vital when it comes to preventing permeant nerve damage.
Physical trauma or injury:
When it comes to single nerve damage on one foot, trauma or injury is the most common cause for this, for example, injury from a car accident, playing sports, falls, medical procedures or surgeries that led to compressing, stretching, or injuring the nerve supplying this area. Sometimes even milder forms of trauma could cause nerve damage such as extended pressure on a nerve caused by a cast or really tight shoes, forceful and repetitive movements that put pressure on the tendons or ligaments and cause it to swell, which in return narrows the pathway where the nerve passes causing damage. Additionally, dislocated bones can cause damaging pressure to the adjacent nerves.
These types of physical traumas or injuries could end up causing an uncommon chronic issue known as Complex regional pain syndrome (CRPS), which is a form of chronic pain that is out of proportion to the initial injury. (5)
Symptoms may include:
- Ongoing burning or throbbing pain.
- Swelling of the area and sensitivity to touch or cold.
- Changes in skin temperature between cold and hot or sweaty.
- Weakness, spasms or tremors, or muscle tightening.
- Changes in the skin color or texture in the affected area. CRPS occasionally spread from one side of the body to the opposite side. It is very important to seek medical help if you develop any of the first 3 symptoms as by the time muscle and skin changes happen it is usually irreversible. (6) Treatment is often more effective when started as early as possible, and in some non-severe cases, the condition could improve on its own.
People who have a long history of consuming large volumes of alcohol have a great risk of developing peripheral neuropathy, in fact, studies have shown that the prevalence of developing peripheral neuropathy in chronic alcohol abusers is 46.3%. (7)
The beginning of displaying symptoms of alcoholic neuropathy is usually slow and extended over a long period of time, although in some exceptions it could be more acute and progress rapidly. (8)
The most common presenting complaint is often a hot burning feeling in the heel and toes.
Symptoms may also include:
- Decreased sensation to vibration.
- Unpleasant, abnormal sense of touch
- Skin temperature abnormalities.
- Weakness of ankle or toes.
- Issues with gait, loss of position sense, or frequent falling.
In severe cases of alcoholic neuropathy, symptoms could progress to develop in the upper legs, the forearms and hands. While in rare cases, it could also affect the laryngeal nerve, causing horsiness and weakness of voice.
These are diseases where your own immune system could mistakenly attack its own tissues, it could cause neuropathy either by impacting the tissues surrounding the nerve leading to its compression or entrapment or by directly attacking the nerve.
Rheumatoid arthritis, lupus, and Sjögren’s syndrome are examples of systemic autoimmune diseases that affect the whole body, including nerves, leading to neuropathy.
On the other hand, autoimmune diseases that only directly target nerves without impacting other tissues, are usually triggered by infections that could have happened recently. This includes Guillain-Barré syndrome, multifocal motor neuropathy, and chronic inflammatory demyelinating polyneuropathy. These conditions could develop slowly or quickly, they could cause chronic pain and feet burning sensation while also fluctuating in severity over time.
Some infections attack the nerve tissues causing neuropathy. For example, within few weeks of developing Lyme disease, which is transmitted by tick bites, a number of symptoms related to neuropathy may start developing, also viruses like herpes simplex, cytomegalovirus, and West Nile virus tend to target sensory nerve fibers causing attacks of burning, shooting or sharp pain. The human immunodeficiency virus (HIV), which causes AIDS, can attack both the central and peripheral nervous systems leading to peripheral neuropathy and experiencing neuropathic pain.
This is a relatively rare disorder characterized by redness, burning pain, and warmth of extremities, particularly the soles of feet and toes. (9) In the absence of other underlying vascular, neurologic, or hematologic issues, the cause for this disorder is usually unknown. The burning pain can worsen when exercising, walking, or when exposed to heat. The severity of this condition could vary from one person to another and it could involve parts other than extremities such as ears, face, and genitalia. The pain is usually relieved by cooling.
Charcot-Marie-Tooth disease (CMT):
This is known to be the most common inherited neuromuscular disorder and it affects both the motor and sensory nerves in the body. People usually have a significant family history of CMT, and the onset of the symptoms usually takes place during the first 2 decades in life. (10) The progress of the symptoms is slow, typically starting with the lower limb and exacerbates after to include the upper extremities too.
Symptoms may include:
- Burning sensation
- Muscle weakness
- Difficulty walking and frequent tripping
- Muscle cramping
Blood and vascular problems that affect the amount of oxygen carried to the nerve to supply it can lead to damage of the nerve fibers. Narrow arteries from atherosclerosis (fatty particle depositing on the inside of the walls of the blood vessels), or high blood pressure can lead to peripheral neuropathy. Additionally, vasculitis can cause thickening and scarring to the blood vessel wall impacting the blood flow and causing patchy nerve damage and burning heel pain.
This is a condition that is caused by compressing the tibial nerve or any of its branches while they are passing by the ankle to the foot. (11)
Several factors may contribute to the development of tarsal tunnel neuropathy.
These causes could be categorized into:
- Intrinsic/local causes such as space-occupying masses including lipomas, nerve tumors, varicose veins, tendon sheath ganglia, and any bony prominences.
- Extrinsic causes such as severe ankle sprains, dislocation of hindfoot or ankle, and external trauma (stretch injury, crush injury).
- Nerve tension that could be caused by deformities. For example, foot valgus deformity can lead to neuropathy due to increasing the tensile load on the tibial nerve.
Symptoms of tarsal tunnel syndrome may include:
- Sensory symptoms: burning sensation, numbness, sharp pain or loss of sensation.
- Loss of muscle.
- Gait abnormality such as limping or overpronation as a result of experiencing pain while walking.
Tarsal tunnel syndrome can be sometimes confused with plantar fasciitis as the symptoms could be vague and quite similar in some people. However, the symptoms of tarsal tunnel syndrome while generally decrease with rest, they typically do not completely or rapidly disappear after rest.
Some medications can cause peripheral neuropathy, particularly in the case of long-term use. Often the conditions associated with medication-induced neuropathy include both feet where the person would experience a number of sensory or/motor symptoms including burning heel pain, hence, it is very important to inform your physician of any medications that you are currently taking or used to take for a long period of time. These medications may include paclitaxel, thalidomide, pyridoxine, cisplatin, amitriptyline, chloroquine, disulfiram, cimetidine, phenytoin, lithium, metronidazole, colchicine, and nitrous oxide.
Cancers or tumors:
Some cancers or even benign tumors can lead to neuropathy in a variety of ways, either by infiltrating the nerve, pressing against the nerve causing nerve damage or by causing the immune system of the person to respond in a way that could lead to neuropathy.
Chemotherapy drugs that are used in the treatment of various cancers can cause damage to multiple nerves around the body, however not all chemotherapy can cause neuropathy nor do all people get it from the same medication. The prevalence associated with chemotherapy could vary from 30% to 68%. (12) Radiation treatment can also lead to neuropathy, sometimes shortly after treatment, and in some cases, it could develop years after treatment.
The thyroid gland is a small butterfly-shaped gland that is located in the front of the neck. Hypothyroidism is a common disorder that occurs due to the deficiency of the thyroid hormones, these hormones are responsible for helping your body use and regulate energy consumption around the body. Therefore, when there are not enough thyroid hormones being secreted, your body’s organs’ natural functions tend to slow down. Prolonged hypothyroidism can impact the nerve fibers causing damage to the walls and sheath of the nerve leading to neuropathy and burning feeling in the feet. Hypothyroidism is more common in women than men, especially small body size at birth and low body mass index during childhood. (13)
Risk factors and causes:
- Low iodine intake: Worldwide, particularly in developing countries, iodine deficiency is by far the most common cause for developing hypothyroidism.
- Autoimmune: In the US and other developed countries where iodine intake is sufficient, autoimmune thyroid disease (Hashimoto thyroiditis) is the most common cause. Studies have shown that first-degree relatives of people who suffer from Hashimoto thyroiditis, could have up to nine times greater risk of developing it. (14)
- Pregnancy: Known as postpartum thyroiditis, up to 10% of women may develop postpartum thyroiditis in the period after giving birth, usually symptoms start appearing 2-12 months after. The prevalence could be up to 25% in women with type 1 diabetes mellitus.
- People with history of radiation therapy on the head or neck.
- Older people, often above 60 years old, with older women having a higher risk than men.
- Having type 1 diabetes mellitus or other autoimmune diseases.
- Medications: Various medications can affect the level of secretion of thyroid hormones such as some psychiatric medications, cardiovascular medication, and chemotherapy.
Symptoms may include:
- Weight gain
- Dry skin
- Decreased appetite
- Cold intolerance
- Lethargy, loss of energy, and fatigue
- Hair loss
- Neuropathy with numbness, tingling, burning, and prickling sensation
- Moodiness and mental impairment
- Joint pain, muscle pain, and weakness.
- Menstrual disturbance and infertility
- Horsiness of the voice or feeling fullness in the throat
- Blurred vision
Symptoms and signs of hypothyroidism could manifest very slowly both physically and mentally, symptoms could be quite subtle and difficult to recognize, in some cases people could even be asymptomatic for a very long time.
When the kidneys are not functioning properly, the toxins that should be excreted in the urine will build up in the blood, these toxins will damage the nerves causing peripheral neuropathy, also known in this case as uremic neuropathy. The severity of the nerve damage is strongly correlated with the level of kidney disease. In the United States, the prevalence of uremic neuropathy could vary from 10% up to 83% of all patients with renal failure. (15)
Neuropathy from renal failure is often more common in males than females, with a male-to-female ratio of 60:49. (16)
The symptoms of uremic neuropathy are usually slow in onset, with oversensitivity, burning, prickling, numbness, and tingling sensation in the feet and lower legs being the most common and earliest symptoms followed by weakness and atrophy in the muscles.
In addition to neuropathy, other symptoms of kidney disease may include:
- Decreased urine output.
- Shortness of breath
- Blood in the urine
- Weight loss and poor appetite
- Itchy skin
- Muscle cramps
- Water retention leading to swollen feet, ankles, and hands.
- Erectile dysfunction in men.
- Increased urgency to pee, especially at night
Exposure to toxins:
Exposure to toxins could be one of the causes of neuropathy that leads to burning heel pain, however, this is much less common than the rest of the peripheral neuropathy reasons mentioned on this list. People could have had exposure to industrial agents either from their workplace or their environment and where they live. The symptoms may present shortly after exposure or it can take years for them to manifest, hence, it is difficult sometimes to attribute the neuropathy to specific toxin exposure and may require a lot of research to confirm the exact cause.
Toxins that affect the nervous system causing neuropathy may include but not limited to Lead, Mercury, Arsenic, Ethylene oxide, n-hexane, Thallium, Dimethyl aminopropionitrile (DMAP), Carbon disulfide, and Styrene. (17,18)
Symptoms of toxic neuropathy may include:
- Burning, tingling, or numbness of feet.
- Diarrhea or constipation
- Decrease or increase in sweat level.
- Rapid change in blood pressure
- Sexual dysfunction
- Facial flushes
- Blurry vision
- Urinary retention or incontinence
- Gait changes and foot drop in severe cases
Burning sensation in the heel could also be caused by peripheral neuropathy that occurred as a result of developed nutritional deficiencies. The deficiencies could happen either due to lack of appropriate intake or as a result of absorption issues.
The most common deficiencies causing peripheral neuropathy are:
- Cyanocobalamin (vitamin B12); which is found in fish, meats, especially liver and kidney, and in eggs, milk, and cheese.
- Pyridoxine (vitamin B6): which is widely available in animal and plant tissues, such as muscle meats, liver, whole-grain cereals, and vegetables.
- Niacin (vitamin B3): which is found in yeast, chicken, beef, pork, mushrooms, avocados, and nuts.
- Thiamine (vitamin B1): which is found in most vegetables, the outer layer of seeds, nuts, and wheat germ.
- Vitamin E, which is found in Nuts, seeds, salmon, avocados, kiwi, and wheat germ.
The neuropathy can occur either due to isolated deficiency, meaning usually deficiency only in vitamin B, or as a complex deficiency as a result of various metabolic disorders (often due to malabsorption).
- Malnutrition due to following a highly restrictive diet, either greatly decreasing the number of calories and nutrients, or following a strict vegan diet that eliminates all animal products without taking the appropriate supplements to compensate for the lack of vitamin B12 in plants.
- Alcohol consumption: In addition to alcohol consumption has a direct toxic effect of ethanol on the nerves leading to peripheral neuropathy, ethanol can also interfere with the absorption of some vitamins particularly Thiamine (vit B1), in addition to vitamin B3, folate, and protein.
- Gastric bypass surgery has been shown to cause nutritional deficiencies and consequent neurologic problems. (19,20)
- Pernicious anemia, which makes it hard for your body to absorb vitamin B12 and is usually more common in people from northern European descent.
- Atrophic gastritis, in which your stomach lining has thinned which affects the secretion of intrinsic factor.
- Conditions that affect your small intestine, such as Celiac disease, Chron’s disease, bacterial growth, a parasite or surgery that affects the part of the small intestine where the vitamin is absorbed.
Symptoms may include:
- Neuropathy symptoms such as burning, numbness or tingling sensation in the feet, muscle weakness, and problems walking
- Weakness, tiredness, or light-headedness
- A swollen, inflamed, or a smooth tongue
- Difficulty thinking and reasoning (cognitive difficulties).
- Mental problems like depression, memory loss, behavioral changes
- Heart palpitations and shortness of breath
- Constipation, diarrhea
- Loss of appetite
- Pale skin
These are conditions that may cause a burning sensation in the heel/feet without involving nerve damage:
Athlete’s foot: Is a fungal infection known as tinea pedis that is contagious and often seen in athletes.
- Tropical hot, humid environment.
- Certain activities communal bathing or swimming. (21)
- Prolonged wearing of shoes that are tight and are not well-aired in hot environments, leading to excessive sweating and softening of the skin.
The symptoms typically involve the bottom of the feet, between the toes, and occasionally the hands.
Symptoms may include:
- Burning, tingling, and itching sensation.
- Painful fissures between the toes
- Peeling, scaly sole
- Change in color or appearance of toe nails.
- Peripheral arterial disease (PAD): This condition occurs due to the narrowing of the arteries supplying the lower extremities, this is often caused by atherosclerosis. It is characterized by pain that could be felt as dull aching, and in some cases also burning or prickling sensation in the feet and lower leg, usually with moving or exercising and stops after resting for few minutes.
Diagnosis for burning heel pain:
If you suffer from burning, tingling or prickling sensation in your heel or the bottom of your feet in general, it is imperative to consult with your physician, as early diagnosis and treatment of any underlying condition is the key to stopping this pain from becoming chronic and preventing permanent damage.
Your doctor will ask you about the nature of your symptoms, your medical history, including smoking and alcohol consumption, your occupation, and what medications you’re currently taking or used to take for a prolonged period. Afterward, your physician will conduct a physical examination to determine your basic neurological reflexes, changes in the skin appearance (color, temperature), signs of fungal infection, lack of sensation, structural problems with the feet or legs, and any possible gait issues. Your physician will also check your shoes and the way you walk in them to determine whether you have too-tight or ill-fitted shoes which could be causing the problem.
Imaging may be requested by your doctor if tarsal tunnel syndrome or structural issues are suspected, while blood tests may be ordered to confirm the diagnosis of diabetes, kidney disease, infection, hypothyroidism or vitamin deficiency.
Treatment for burning heel pain:
As mentioned earlier, the treatment of burning heel pain usually relies on the treatment and management of any possible underlying conditions.
If the issue is due to ill-fitted shoes, your physician will advise you to change your shoes and use well-padded and cushioned footwear or orthotics to ensure appropriate foot positioning and support to your feet structure and that the nerve tissues in your feet are not being too compressed or getting damaged by wearing the wrong footwear. You can check out Heel Seats foot orthotics with the unique fascia-bar technology that provides the ultimate support needed for structural tissues of the feet, also absorbing the impact while walking or standing. If your heels or skin are too sensitive, Heel That Pain also offers Gel Heel Seat shoe inserts for sensitive feet so you can benefit from extensive and greatly comfortable feet support.
Other treatments may include:
- Change in diet, lifestyle, and medication to help manage diabetes mellitus.
- Thyroid supplements for treatment of hypothyroidism.
- Vitamin B supplements for treatment of nutritional deficiencies.
- Antifungal medications for the treatment of athlete’s foot.
- Quitting Alcohol for managing alcohol neuropathy.
- Your physician may also prescribe treatment for your pain depending on the severity of it, ranging from regular pain killers to other advanced pain therapy options such as laser therapy, electrical nerve stimulation, magnetic therapy and light therapy.
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