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Chasing Heel Pain by Michael Adesso

As the warm weather returns, many people will begin walking, running or doing stop-and-go sports activities outdoors. This change in activity may come with an unfortunate consequence – heel pain.

The most common cause of heel pain is known as plantar fascitis. I will try to define what this condition is, possible causes, and treatment strategies.

First, the anatomy of the plantar fascia; it is a thick, inelastic band of tissue that originates from the inside (medial) portion of the heel and fans out to each of the toes. It provides support for the medial arch of the foot.

When your heel strikes the ground, the foot and the bone above it (the tibia) begin to rotate internally (a movement called pronation). The foot begins to flatten onto the ground, placing tension on the inelastic plantar fascia. Though this is a normal occurrence, sometimes these forces can cause micro injury to the plantar fascia, resulting in inflammation and heel pain.

Imaging studies have shown that the fascia can actually thicken to two to three times its normal size. As the tight fascia pulls on the heel, it can sometimes cause calcium to be deposited, which can be seen on an x-ray. This is commonly referred to as a heel spur.

In most cases however, this is not the cause of the pain. Rather, it is the chronic inflammation of the injured fascia that is the culprit. Typically heel pain will be worse in the morning hours, due to the shortened position of the calf muscle and fascia that take place in sleeping positions. Pain may also be noted at the beginning of exercise, or if someone begins to walk after sitting for a while.

Explaining the cause of heel pain is the easy part; treating it can prove to be frustrating.

Treatment begins by identifying factors that may be contributing to a patient’s heel pain. Possible causes may include:

- Tight calf muscles (which place an abnormal force on the fascia)

- Changes in exercise patterns (surface change intensity, frequency, type of exercise)

- Foot mechanics (flat feet, high arches)

- Change in footwear

- Excessive pronation (too much rolling in of the foot while walking and running)

I usually find that it is a combination of these factors, and that is why it is difficult to treat. Conservative treatment of plantar fascitis may include the following:

- Stretching of tight muscles (this may include muscles higher up from the calf)

- Icing

- Wearing a night splint (a device worn while you sleep that places a gentle stretch on the calf and heel)

- Activity modification

- Orthotics

- Physical therapy

In my experience, there seems to be no magic formula that works for every patient. Research shows that it may take six to twelve weeks or more for symptoms to completely resolve.

Steroid injection, aimed at decreasing inflammation, is another treatment your doctor may consider.

A small percentage of people may need surgery. Dr. David Davidson, a podiatrist with University Sports Medicine and Podiatry Affiliates PC, says this surgery is performed with an endoscope – a small instrument that lets the surgeon visualize the fascia.

Using an incision less than half an inch, a small portion of the fascia can be cut from the bone, eliminating tension in the fascia. This is normally an outpatient procedure.

Most people return to wearing their regular shoes in one to three days, and may return to work in about a week, Davidson said.

It may take up to six weeks or more to return to high level activities. Of course, everyone heals differently. Age, severity of the condition, weight, and occupation may also influence your outcome. As with any surgery, your doctor will outline the risks and complications.

Here are some tips to keep in mind if you are starting an exercise program:

- Start slowly. Warm up using dynamic stretching prior to your activity and do slow steady stretching after exercise and on your off days.

- Make sure you have footwear that fits well, is in good shape and is the proper type of shoe for the sport in which you are engaging.

- Do not make big changes in your training. If you are changing to outdoor surfaces, cut back on your intensity and mileage. Give your body a chance to adapt to the different forced it will encounter.

Though plantar fascitis is the most common cause of heel pain, other injuries (i.e., stress fracture) may be present. Please consult your doctor before beginning any treatment regimen.

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Michael Adesso, PT, ATC Director of Physical Therapy University Sports Medicine Amherst Location

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