Oh, my heel hurts! Details on a common injury

Posted on July 2, 2021 by James Slauterbeck, M.D.
James Slauterbeck, M.D.

Back of shoes and ankles with arm holding ankle. data-lightbox='featured'

A common cause of heel pain in runners is plantar fasciitis. It is a painful condition that feels like a bruise after stepping on a stone, but it just does not go away. The first step in the morning is very painful. The pain often gets worse throughout the day. The pain is located deep on the bottom of the heel and moves toward the toes.

The plantar fascia is the flat leathery band of tissue that connects the heel, known as calcaneus, to the ball of the foot. The fascia acts like a tether to help maintain the curve in the arch and to support the bottom of your foot. The fascia can be ruptured from a single high-energy landing from a jump or from stepping on an object but more commonly is an overuse injury.

Other factors can cause heel pain, such as stress or insufficiency fractures seen in osteoporosis. Some nerve compression syndromes can manifest as foot pain but not usually painful on the bottom of the foot.

Plantar fasciitis is likely caused by traction of the plantar fascia between the toes and calcaneus. When one walks, runs or jumps the plantar fascia is stressed. Sometimes in an overuse setting, the stress on the fascia is not repaired appropriately before the next exercise event. Over time, the plantar fascia thickens. The chronic thickening of the fascia may be the source of the pain.

Who is at risk?

Some people are at greater risk for developing heel pain. Runners with a high arch or with a pronated foot are at greater risk for developing plantar fasciitis. Some people when converting to barefoot running may develop plantar fasciitis, especially if they continue to heel strike during the transition period.

The diagnosis of plantar fasciitis is made by an accurate history and identifying tenderness on the bottom of the heel. A bone spur may be seen on an X-ray, but the size or presence of the spur is unlikely to be related to clinical symptoms. An MRI or any other imaging is not necessary to make the diagnosis.

Treatment options

Treatment is usually based upon limiting running, providing better rest periods, engaging in non-impact cross training, such as biking or swimming, taking non-steroidal anti-inflammatory medications like Aleve and placing a soft silicone support in the shoe under the heel. The shoe inserts are commonly found at a drug store. A high arch or foot pronation can be corrected with an orthotic shoe support to help decrease the risk for developing plantar fasciitis.

Physical therapy and exercises that involve stretching the bottom of the foot and calf muscle are beneficial. Stretching before getting out of bed and wearing night splints to stretch the calf and foot helps to decrease pain significantly. Some also advocate for dry needling and cupping.

One must beware of injections in the heel area. Short term relief may occur with a cortisone injection near the heel spur, but the steroid can result in rupture of the plantar fascia or loss of fat in the heel area, which are devastating complications to the runner. The resulting heel pain from the thinned fat pad or from ruptured plantar fascia can be severe. If these complications occur there are few good options to solve the new problem. There is some evidence that platelet-rich plasma injections into the plantar fascia may be of some benefit, but sound scientific studies are needed to support this.

Surgery to remove the bone spur is not necessary and often increases pain and decreases function. Be very careful to avoid surgery even if your pain is significant. If the pain is very bad and lasts a long time, then request an MRI or CT imaging to make sure that you are not suffering from another problem like a stress fracture.

Plantar fasciitis is a self-limiting process that typically goes away within six months to a year. Stretching, splinting and bracing are usually curative. Patience, activity modification and silicone pads therapy are the best forms of treatment today. It will go away. Be patient and avoid surgery at all costs.

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