Heel pain can be due to several different conditions. Pain in the back of the heel is often due to achilles tendinitis. Pain in the heels of kids is usually due to calcaneal apophysitis (or an inflamed growth plate in the foot). Pain in the heel can even be due to nerve entrapment in the ankle or cysts/tumors in the heel bone. MOST commonly, however, it is due to a condition called plantar fasciitis. If you haven’t had heel pain or plantar fasciitis in the past, the chances are you know someone who has. Statistically speaking, plantar fasciitis is the reason for at least 1 million doctor visits per year - and I'd say that it an underestimate. Heel pain from plantar fasciitis is attributed to several different underlying issues. Therefore, avoiding or preventing heel pain is successful by heading off these issues. Speaking from personal experience, this author will tell you that you want to avoid having heel pain.
What makes it so bad?
Having heel pain means your foot hurts with every step you take and sometimes even when you aren’t taking any steps at all. When treating active heel pain from plantar fasciitis, the main contributing factors are mechanical abnormalities and inflammation. Under the umbrella of mechanical abnormalities, successful treatment of heel pain must include addressing inflexibility or inhibited of motion as well as providing appropriate support for the foot. The inflammation which presents as pain in the heel is a result of overuse, inflexibility and lack of support. So while it needs to be addressed in active plantar fasciitis, prevention of this inflammation stems from ensuring the mechanical issues are addressed.
The first morning you step out of bed and feel that dreaded pain in the bottom of you heel, it stops you in your tracks – literally. You immediately lift your heel off the ground, take a deep breath and then slowly step back down thinking “that can’t be – I didn’t DO anything.” As you slowly put your heel down, the pain is still there, you muster up some courage, grip the edge of your bed or the wall and start to force yourself forward, step by step, to get ready for the day. You get to the bathroom, it isn’t quite as bad, but you are still wondering how in the world your heel can hurt so bad when you felt NOTHING yesterday. You get your teeth brushed, shower and get dressed and in some cases you even forget that you had that pain. Grab breakfast and a coffee, head out the door and get in your car.
Maybe when you get to work you step out of the car and things just keep feeling “normal.” In many other cases, you step out of the car and it starts all over again. This pain after sleeping, resting or sitting is called post-static dyskinesia. This is a fancy way of saying you have difficulty walking after being at rest. In the case of plantar fasciitis it is because of the pain and stiffness. The stiffness that is present with plantar fasciitis is to both the arch of the foot itself as well as the calf and achilles tendon. If you suffer long enough and alter your walking pattern and activities long enough, you may also develop tightness in your posterior tibial tendon – this is the tendon that is in charge of holding up your arch structure. In plantar fasciitis, it gets more than it bargained for and becomes fatigued. It is used excessively as you turn your foot to the outside trying to avoid stepping on that painful spot on your foot.
So what can we do?
This brings us to the first step of avoiding plantar fasciitis heel pain. Stretching is essential in helping your foot to function normally. By keeping loose through the achilles and calf, your foot doesn’t have to twist abnormally across the arch to bear weight. When your tight and your foot twists in this way, it puts strain on the plantar fascia-especially at the part of the heel where the plantar fascia attaches on the big toe joint side. Simple daily stretching to the calves once or twice daily – or especially before and after exercise – helps to keep strain off of the tissues in our legs and feet. A more elastic tendon is less brittle and less likely to tear.
The plantar fascia can be stretched with some static stretches, but another very effective technique is roll stretching. This can be done with a small ball, as you roll your arch across it, it massages and loosens the arch up. A similar effect can be had if you roll your foot over a frozen water bottle. The added benefit with this is that you will also be icing the area. This type of exercise is more often performed in cases where plantar fasciitis is already present.
Static stretching can be performed while standing or seated. If seated, having an exercise band allows you to use your upper body to gently pull the foot back until stretch is felt in the leg. For this type of stretching, it is a good rule to hold for the stretch for 30 seconds, switch to the other leg for 30 and then back to the first leg. Three to five sets per leg is recommended.
Now onto discussing support for the feet. For someone who is trying to avoid plantar fasciitis, the most important thing to remember is to wear shoes that are appropriate for a given activity. Dressier shoes, ballet flats, wedges and high heels when worn chronically, lead to excessive pressure in some areas of the foot and they do not provide arch support. If you wear this type of shoe on a daily basis during thousands on thousands of steps, this will catch up to you. Your feet will start to change and mold to the shoe in some ways. Having a shoe with a heel on it allows your achilles tendon to function in a shorter contracted position and over time it will physically shorten. This then changes your gait pattern and puts stress on the ball of the foot and also the plantar fascia. If you have a dressier shoe and you wear it to a particular event or out to dinner, when you won’t be walking excessively, it is less likely you will end up with pain in your foot or heel. Similarly, wearing a flat flip flop for walking around all day is not going to provide appropriate support. You may do this summer after summer but at some point your feet won’t be able to keep up with this excess stress and pain will start. A good walking shoe or gym shoe is typically the best shoe to wear for activity. If you are into hiking, a supportive boot may be needed for extra ankle support.
For better support a fabricated arch insert (if you’ve had a foot issue in the past that you would like to avoid in the future) works well with good shoes. The gold standard for support is custom orthotics. Unlike over-the-counter arch inserts, these are made to foot your individual foot structure and account for imbalances within the foot that may be placing excessive pressure or strain on one part of the foot more than another. This essentially balances your foot structure so that from side-to-side and front-to-back you aren’t overusing any one tendon more than another. If you haven’t ever experienced foot or heel pain and are looking to just have some extra support, starting with and OTC arch support may not be a bad idea. Be aware though that there are two main types of prefabricated inserts. There are some inserts out there that are aimed at adding cushion to the inside of the shoe for your foot. Those which have more rigid plastic material through the arch are going to be more supportive. I recommend trying to find both characteristics in any insert you plan to try. In addition, be mindful that these prefabricated inserts are designed to fit the bell curve. This means that if you have a particularly high or low arched foot, the support is less likely to fit your foot structure and may actually increase pain. For shoes that may not fit an insert and for support while you are in sandals or barefoot, arch straps that wrap around the foot can be helpful as well.
Our Helpful Heel Pain Kits
Our office is well equipped to treat patients with heel pain, but of course we would be happy if our patients could avoid it in the first place. We have a heel pain kit at the office which has some great tools to help you start some foot healthy habits that may keep you out of our office and painfree! The kit includes cards that provide pictures and instructions on proper stretching, including frequency. There is an exercise band in the kit which helps for that stretching you want to do at home and also has a FootRubz ball which is just the perfect size for rolling and massaging the arch of the foot. The bumpy texture on the ball really helps get into the tissue that may be tight (even if you don’t have pain) to help your foot function better. The kit also includes an ice pack that may come in handy – whether for your foot or another part of the body. Finally, it includes Vive Straps. These are nice arch straps for the foot that provide support and have 3 different sized silicone inserts so you can get a more customized fit in addition to the compression and support offered. We typically have our patients use these In the short term for some extra support while we get to stretching, but some patients find them useful thereafter in certain shoes or circumstances.
Nobody wants to have pain. Pain in your feet is one that won’t let you forget about it. It is great that some simple habits can help to keep you pain free. They may make the difference between enjoying your daily walk, playing with your kids or even enjoying a vacation to see things you’ve always wanted to see. Don’t let heel pain get in the way of living your life to it’s fullest. And if you are reading this and you are already having pain, call today! The sooner you address your foot concern – whatever it may be – the sooner you can feel better and do all the things you love.