By: DR. BROOKE GIFFORD
Heel pain is one of the number one foot problems that podiatrists treat. Plantar fasciitis is the most frequent cause of heel pain. The plantar fascia is like a ligament that starts on the heel bone and extends all the way through your arch to the ball of your foot. The interface where the fascia meets the heel bone gets inflamed and thus the sense of sharp or stabbing pain in the bottom/center of the heel. Most times heel pain is related to a change in activity such as training for a race, change in shoes or weight gain. Certain foot types are more inclined to developing plantar fasciitis so for some people the heel pain develops seemingly out of nowhere. The mechanical cause of pulling at the fascia origin leads to inflammation which then causes pain. Although a bone spur can develop where the fascia is pulling on the heel bone, the spur itself is generally not the source of pain and therefore the treatment of fasciitis is not simply removing the spur.
The pain is usually pinpoint on the heel, often more towards the inside of the heel. Patients often complain of pain when stepping out of bed in the morning or when standing up after being seated for a while. This is because when you are sleeping or at rest, the Achilles tendon is slack and the fascia is also relaxed. However, when you step down, both the Achilles tendon and the fascia become taut so when you stand up and put weight on the foot, the fascia pulls on the heel bone which feels very sharp. The pain often starts off being mildly bothersome but can progress to the point of having pain with every step and even causing a limp. It is best to treat heel pain as early as possible otherwise it becomes progressively more painful and difficult to treat.
The mechanical cause of pain should be addressed first and foremost. That can be done with orthotics which are inserts that go into a shoe that support the arch and thus take tension off the fascia (which reduces pull on the heel bone). Supportive shoes are also very helpful. An optimal shoe does not fold in the middle of the shoe (only at the ball of the foot) and has laces. There are some shoes now that have a built-in orthotic and those are optimal for heel pain. Shoes to avoid include flimsy flip-flops or any shoe that folds in half. Patients come to the office all too often wearing shoes w/ a memory foam sole because when they first try them on, their foot feels better. However, those shoes are NOT helping your cause! And in fact, they are making the problem worse. Do not underestimate the importance of a good shoe when it comes to heel pain, it really is the most important thing about treatment! Also, do not walk around your house or yard barefoot as that will greatly exacerbate the pain.
Supportive shoes and orthotics will reduce tension on the fascia, but the inflammatory component still needs to be addressed since that is what is causing the pain. Ice is an easy and effective anti-inflammatory. Fill a 20 oz bottle with water and then freeze it. Once frozen, roll the heel and arch back and forth for about 20 minutes for dual-action ice and massage. Oral or topical anti-inflammatories can also be helpful. Oral anti-inflammatories work best when taken consistently every day for about 1-2 weeks. A steroid injection into the heel is the best "quick fix". It works by directly blocking inflammation at the source, however, the steroid can also break down neighboring healthy tissue. For that reason, we do not give more than 3 steroid injections into the same area within the same year. Even though steroid injections can be very helpful, you still need to be diligent with good shoes, orthotics, stretching, and icing.
The Achilles tendon has fibers that wrap around the back of the heel and form part of the fascia. For this reason, it is important to adequately stretch the Achilles tendon daily. A helpful stretch is to sit on the floor with your legs extended in front of you. Always make sure your knee is locked when doing an Achilles stretch. Use a belt, theraband or rolled up towel to lasso the ball of your foot and pull your foot towards you. Hold for 20-30 seconds and then while that leg is relaxing, stretch the other. Repeat 3 times. Stretches need to be performed at least twice daily for several weeks. Massage is also important. Sit in a chair and place your foot on a small/firm ball. Roll your foot in circles over the ball starting at the heel and rolling up towards the ball of the foot. The fascia has 3 bands so it's best to roll up the inside toward the big toe joint, down the middle and back up the outside aspect of the bottom of the arch. The intention is to stretch out the fascia so rolling directly on the heel where you're having pain is not necessary! A night splint is a device that holds your 90 degrees to your leg to place a constant passive stretch on the Achilles. It is meant to be worn while sleeping so that when you step out of bed in the morning you have no pain, however, if not tolerated for sleeping, it is still helpful to wear in the evening for an hour or two (can be done while watching TV or reading).
Other treatment options include taping the foot, physical therapy, or a fracture boot. Avoid high impact activities such as walking (for exercise), jogging, or hiking and try cycling or swimming instead. Carrying extra weight can also cause heel pain so it is important to eat healthily and perform low impact exercises. PRP, platelet-rich plasma, is taken from your own blood and then once prepared is injected into the heel where the fascia meets the bone. This helps repair the tissue and is an excellent option for chronic fasciitis and/or partial fascia tears. We also use an MLS class IV laser in the office which stops the inflammation and reduces pain. That treatment is usually 2-3 times per week for up to 10 treatments. Surgery is a last resort and usually not warranted since most people do get better with conservative treatment.
There are other sources of heel pain beyond plantar fasciitis so it is best to see a podiatrist for proper diagnosis and thus proper treatment. Heel pain is so common that people almost think it's normal and something they have to live with but it's definitely treatable and we can help you!