heel pain
Heel pain which includes plantar fasciitis and heel spurs are one of the most common complaints seen in the foot. Plantar fasciitis is an inflammation of the large ligament on the bottom of the foot. Although most cases of plantar fasciitis occur near the heel, often described as sharp heel pain, this condition can be evident anywhere from the heel all the way to the ball of the foot.
In order to feel the plantar fascial ligament, with one hand bend the big toe upwards, run your finger from your other hand along the bottom of the foot, you will feel a large cord like structure that runs from the ball of your foot to your heel. The purpose of this structure is to act like a bowstring in order to support the structure of your arch.
plantar fasciitis represented by yellow band
The yellow band represents the plantar fascial ligament. Notice how it attaches from the heel bone all the way to the ball of the foot. Factors such as foot structure, (either a foot that flattens out too much or a very high arched foot that does not absorb shock very well) excessive body weight, occupations that require a lot of standing and walking especially on concrete floors and physical activity such as participating in athletic activities can all lead to excessive stretching and inflammation resulting in plantar fasciitis type of heel pain. Additionally many doctors now feel there is a correlation between a very tight heel cord (equinus-the inability to bend the foot upwards on the ankle) and plantar fascial pain. This is borne out to me by the fact that many women will state that their heel pain feels better when they are in high heel shoes. By wearing high heels they are relaxing the achilles tendon which in turn reduces the tension on the plantar fascial ligament.
Most people relate a similar story in that they find they have the most pain on initial ambulation such as getting out of bed in the morning or getting up from a chair after being seated for a long period of time. As they begin to walk around the pain will usually subside, in varying degrees, in different people. However, many people will report that as they begin to do a lot of walking the heel will start to hurt even more. This increase in pain, the more the person walks, is not necessarily due to plantar fasciitis or a heel spur. Because of the constant pounding the heel is taking, other problems may arise. One is an inflamed bursitis which will hurt the more the person walks. The other is a heel neuroma or pinched nerve. The nerve known as Baxter’s nerve is a small nerve that comes off one of the larger nerves in the area. The problem is that this small nerve becomes caught up in the inflammation occurring in the heel and will cause the pain to increase as a person walks. When people complain of the pain moving around in the heel this is usually due to the bursitis or heel neuroma.
In my experience, I have found that plantar fasciitis rarely occurs alone. As just stated when the heel pain worsens as a person ambulates then one also has to consider heel bursitis or heel neuroma.
When there is excessive inflammation particularly at the insertion of the ligament into the heel bone, calcification can occur and you end up with what is routinely known as a heel spur which is the classic bone spur in the foot, (although there are other types of bone spurs that occur in other parts of the foot). One could argue that this is simply an exacerbation of the plantar fasciitis.
Below is a picture of a true heel spur; a calcification of the plantar fascial ligament.
heel spur
Another problem that can add to the heel pain is lack of fat in the heel. The fat is supposed to act as a cushion, but some people either do not have enough fat, or as we age we lose some of the fat, and now the heel bone becomes bruised because there is not enough fat to protect it. This type of heel pain may also be the result of stepping on something hard on the heel bone (calcaneus) and causing the bruise to the bone. It is essential that a well-trained foot specialist be consulted to rule out the cause of your heel pain. (These are the most common but not an all inclusive list of causes of heel pain).
On very rare occasions heel pain may be due to a stress fracture in the heel bone.
Making the right diagnosis and eliminating the factors aggravating the heel pain are essential in alleviating the problem. If a person happens to be very much overweight or wears very flimsy shoes, or goes barefoot a lot, the chances of success in alleviating the problem are greatly diminished unless those issues are addressed.
There are a number of ways to treat plantar fasciitis and heel spurs. Because of this, no one treatment will work for everyone. Treatment options include short term oral anti-inflammatory medication. Keep in mind that oral anti-inflammatory medication should be viewed as a short term therapy and not a long term solution. Long term administration of oral anti-inflammatory medication may lead to stomach and kidney disorders. Cortisone injections can be helpful, usually done in a series of three over a three-week period, especially if you suspect an associated bursitis. Physical therapy can be helpful including heat therapy and deep tissue massage. If I feel that there is also a neuroma, or pinched nerve involved in the mix, I will usually begin a series of denatured alcohol injections.
Depending on the cause of heel pain, my favorite treatment is the use of orthotics. Orthotics should be the focal point of heel pain therapy. They are effective in treating all the causes of heel pain that have been discussed. An orthotic works in a number of ways:
1. It rests the plantar fascial ligament when you walk so that the ligament is not being constantly stretched out; it is the over-stretching of the ligament that causes it to become painful.
2. It cushions the heel bone. As I have mentioned the constant “banging” of the heel on the ground only causes the heel to hurt more.
3. It redistributes body weight more evenly so that some of the body weight is taken away from the heel during the gait cycle.
4. It takes a foot that is flattening out too much and thus over-stretching the plantar fascial ligament, and better aligns the foot by raising the arch and reducing the tension on the plantar fascial ligament.
5. In a person with a high arched foot, the orthotic allows for better shock absorption so that the heel does not absorb so much shock while walking.
6. It addresses the underlying cause of the problem. Even if some of the other therapies mentioned in this article relieve the heel pain, without wearing an orthotic, there is a very good chance for recurrence.
Do not be fooled by all the hype you read in magazines and see on the internet. There is no one orthotic that will work for everyone. The type of orthotic a person will require for their heel pain is determined by more than the pain itself. Factors such as weight, shoe type, activity, age and occupation will all factor in.
During the night the plantar fascial ligament will tighten up from lack of use. The first steps that people take in the morning can be very painful as their bodyweight stretches out the ligament. The use of a night splint can be helpful in certain individuals to keep the ligament from tightening up and thus making those initial steps in the morning far less painful. There are many different types of night splints on the market. From my experience many patients complain of the more bulky type night splints, simply because it makes it very difficult to get a good nights sleep. A better choice are the low profile night splints which are now out on the market.
When conservative therapies fail to alleviate the problem, more aggressive treatments are called upon. I have found, and the literature will bear me out that 90-95% of heel pain sufferers will respond to the conservative treatments I have discussed. The time frame for relief from conservative therapies can vary from anywhere from a few days to a few months. If you and your doctor have tried a few different therapies and you are three months down the road and still having pain then other options need to be considered.
At this point an MRI would be indicated to rule out a small stress fracture of the heel that I previously mentioned as well as a possible tear in the plantar fascial ligament as well as other soft tissue issues that may be causing the heel pain.
A relatively new treatment option is known as Extracorporeal Shock Wave Therapy. The science behind this is the same theory used to break up kidney stones. It is high power ultrasound directed at the site of pain. There is strict FDA regulations as to its indications; basically when all other options other than surgery have failed. In my experience I have seen some very dramatic results but I also must report that some patients have been no better off after the procedure. It should also be noted that the procedure is covered by some but not all insurance companies and that it can be costly if you have to pay for it out of your own pocket. There is a growing body of research showing that plantar fasciitis may actually not be an inflammation of the plantar fascial ligament but actually is a degenerative condition of the plantar fascial ligament. Research shows that after injury to tendon or ligament there is a brief period of inflammation of approximately two weeks, then the tissue begins to degenerate. So, there is pain, but since there is no inflammation, the brain does not recognize the problem. Extracorporeal Shock Wave Therapy works by recreating the inflammation in the heel and thus allowing the brain to recognize the problem (again) and then begin to heal the area. This is the reason why anti-inflammatory medication is never prescribed after the procedure.
I have included a video for you on the shock wave therapy procedure.
Lastly, when all else fails, surgical intervention should be entertained. Today’s foot specialist is trained in doing both conventional large incision procedures and minimal incision procedures. Keep in mind, that surgery for a heel spur or plantar fasciitis can have a very long recovery period. The simple truth of the matter is that after surgery, every time you step on that heel you are basically aggravating the surgical site and for that reason the healing process can take a long time.
Visit my site for more information on this subject and other foot and leg conditions. www.foot-pain-explained.com
February 3rd, 2009 at 12:51 am
(from http://www.foot-pain-explained.com)
I have been experiencing burning and stabbing pain in my right heel which had initially surfaced 10 years ago and has gotten progressively worse over time. There have been periods when it mitigated slightly due to greatly decreased activity, but then re-emerges worse than ever when normal activity is resumed. While my foot does hurt right out of bed in the morning, I do not believe I have “first step” pain. The pain decidely worsens as the day progresses. It is always worst immediately after I have been off my feet for any period of time and then I stand up again. I have been treated with taping, anti-inflammatory meds, stretching exercises (which greatly exacerbates the pain) and icing, passive night splinting, multiple rounds of cortico-steroid injections (which relieved the pain temporarily, but then it returned with a vengence after several weeks time), and finally physical therapy (which entailed iontophoresis and ultrasound with deep tissue massage). I have been “diagnosed” with plantar fasciitis and, more recently, tendonitis of the abductor hallucis. (Although the pain in my heel is most intense where the abductor hallucis attaches, it also exists in the middle of the heel and the outside.) Within the last year, I developed similar pain but with less intensity in my left foot. Physical therapy (ultrasound with deep tissue massage and stretching) and rest resolved that pain within six treatments, but so far nothing has touched the pain in my right foot. I have most recently been diagnosed with Baxter’s Nerve Entrapment and my new podiatrist recommends surgical release. (My x-rays are normal and I am scheduled for an MRI. I do not experience tingling or numbness and do not react to Phalen’s maneuver.) I have read in other articles that there is a possibility of developing further nerve entrapment from the medial incision and that surgery should really only be considered when one can no longer walk. I would really appreciate any thoughts/recommendations that you could offer. I am completely exhausted, confused, and demoralized at this point. The only thing I am certain about is that this is no way to live.
Karen
Hi Karen,
Well you certainly have run the gamut of treatments. As soon as you mentioned burning and stabbing pain, I knew you had more than plantar fasciitis. That is why your pain is not at its worse first thing in the morning.
Since you have been diagnosed with a heel neuroma, Baxter’s nerve, instead of surgery you might want to first consider cryosurgery where the nerve is frozen in an effort to reduce the sensitivity. Additionally you may also want to try denatured alcohol injections of the nerve, which I do and have had a great deal of success.
Yes, you do run the risk of further nerve entrapment when the nerve is excised due to scarring of the incision.
I am glad you are having an MRI done because many times the tendonitis of the abductor hallucis muscle is actually a rupture which will require surgical repair.
Marc Mitnick DPM
February 5th, 2009 at 6:35 am
(from http:// http://www.foot-pain-explained.com)
I have very sore feet in the morning and after excercise. I have gone to Physiotheraphy clinic and they suggested Orthodics. I am waiting to order them. I had to go to my family doctor to get a referal for the insurance company to cover the orthodics, and the doctor told me not to waste my money and to get a cortizone shot. I am not to sure which one to go to or what to do. Do you have any advises?? I know that Cortizone does not cure the problem it just soothes it and needs to be repeated, but do the orthodics cure the problem and will I have to give up wearing the shoes that I love?? I appreciate any advise you can give me on this. Thank You for your time.
Shawna
Prince Edward Island, Canada
Hi Shawna,
Most cases of plantar fasciitis that I see are due to life style situations. The pain is in response to the abnormal tension of the plantar fascial ligament either as a result of excess weight, standing on your feet for long periods of time or from some athletic endeavor. This is compared to situational plantar fasciitis which may be the result of wearing a lousy pair of shoes or stumbling, or some other one of a kind activity.
Your family doctor’s advice about a cortisone injection would make sense if you had situational plantar fasciitis (a cortisone shot and eliminating the situation that caused the plantar fasciitis could remedy the problem).
If your problem is due to a life style situation than orthotics are the only thing that makes any real sense over the long term. You need to control the plantar fascial ligament on a daily basis so that it does not continually over stretch. By not allowing the ligament to over stretch, the pain will eventually subside plus you stand a good chance of it not returning (unlike a cortisone shot).
Since you exercise I am assuming you do it on a regular basis and this would be one example of a life style situation plantar fasciitis.
I hope this information helps.
Marc Mitnick DPM
February 10th, 2009 at 11:23 pm
(from http://www.foot-pain-explained.com)
50 year old Home builder by trade over last couple weeks pain getting progressiveley worse centered in heels radiating into arch,back of heel and up ankles.
Have tried different boots and inserts but to no relief. On my feet all day long carrying heavy weights, using ladders, on concrete and uneven ground pain so bad at times have twisted ankles causing them to pop. What do you think this might be and is there corrections i can take?
Edward,
Riceville, TN
Hi Edward,
People in your line of work are notorious for having foot problems, as you state, the daily grind you put your feet through makes it highly probable that at some point in time you will have pain in your feet.
The heel pain is more than likely due to plantar fasciitis or perhaps a heel spur.
The fact that you get radiating pain is highly suggestive of an associated bursitis or perhaps a heel neuroma.
The feet have to be x-rayed to rule out stress fracture of the heel. You do not mention how big you are but generally any kind of arch support that you purchased in a store will not adequately support you particularly if you are carrying heavy weights and climbing ladders.
Since you need your feet in order to make a living I would suggest you see a podiatrist as soon as possible, because I find the longer heel pain persists, the harder it is to clear up.
Good Luck
Marc Mitnick DPM
February 16th, 2009 at 10:18 pm
(from http://www.foot-pain-explained.com)
I am a 37 yr old female with rheumatoid arthritis and flat feet. I wear orthotics. I have had an ongoing problem with pain that start in the bottom of my foot and travels up through the arch. Like I stepped on a nail or something. It is happening frequently now, about once or twice a month. When it occurs, I have tingling sensations and coldness in my foot, and weight bearing is almost impossible. I looked through this site and it seems it could be a number of things.
Lynn
Massachusetts
Hi Lynn,
Because it could be a number of things your best bet would be to see a local podiatrist. Without having the luxury of examining you, but based on the symptoms you describe, it sounds like you may have a nerve entrapment in the area of the heel which is very common. This would account for the tingling sensation and possibly the feeling of cold.
The good news is that presently it is only occurring infrequently, but by the same token you do not want to wait until it gets worse as it will probably be harder to treat, so I personally think the smart thing to do would be to have a podiatrist examine you.
Marc Mitnick DPM
February 22nd, 2009 at 10:15 pm
(from http://www.foot-pain-explained.com)
I have pain when first getting up in the AM, I have had plantar fascitis, this feels different this time, It is so much worse, It is now in my left foot, right foot is resolved. I have pain in my heel, and the side of my foot, and also in the ankle area. I hurt all the time, sitting, standing, walking especially hurts.
Hi Deb,
Like most medical conditions there can be varying degrees of pain, in other words not all heel pain presents in the same way. If you visit my page on heel pain you will see that heel pain can be more than just plantar fasciitis.
Obviously, if you are in as much pain as you state you should seek medical attention. Although I have no hard statistics, I find the longer people wait to have heel pain treated, the longer it takes to resolve the issue.
Good luck.
Marc Mitnick DPM
February 27th, 2009 at 12:02 am
(from http://www.foot-pain-explained.com)
i had foot surgery twice on both feet, 1st was to release the planter, then a year or so later they removed the heel spurs. it has been a year and the pain is worst the doctor tells me it is nothing more that can be done. please help
Melissa, Camden, SC
Hi Melissa,
Nothing could be further from the truth. Did you have an MRI to rule out other pathology in the heel such as a stress fracture?
Assuming you do not have a fracture and you had true heel spur pain, then I would question the results you got from your surgery.
In any event there are other things that can be tried. Have you gone for physical therapy?
If not, I would suggest that. Additionally, there are other treatments out there such as shockwave therapy, and prolotherapy that attempt to create new inflammation in the area so the brain can pick up the sensation and then heal the area. (read my section on ESWT for a complete explantation).
Prolotherapy is an injection that essentially does the same thing as shockwave therapy.
There is also cryosurgery and radiotherapy injection that obliterates the surrounding nerves in an effort to reduce the pain.
Most doctors do not perform these procedures so you will have to ask around.
Marc Mitnick DPM
March 10th, 2009 at 11:47 pm
(from http://www.foot-pain-explained.com)
started wearing orthotics and my ankles swelled, normal? I just comnpleted 3 months in a cam walker boot for a calcaneal stress fx-also have plantar fasciitis Maureen, Martinsville, VA
Hi Maureen,
Sometimes a foot and ankle can swell when you first get a new pair of orthotics, but generally will subside in a few days. I think the bigger issue here is that you are just coming out of a cam walker and you are putting more stress on the foot and ankle and that is why it is swelling. It too should subside as you get used to walking normal again; if it does not, you need to make your doctor aware of the problem.
Marc Mitnick DPM
March 23rd, 2009 at 6:52 pm
I have had severe heel pain since august 08. i am a ups driver. i had to have my knee scoped in march of 07 and april 08 to clean out a 1 inch tear. when i returned to work in late july 08 i started to have a hard time walking in the mornings, and after sitting for short periods of time. by oct 08 the pain was so bad i it hurt to walk all day long. i worked through it until dec 19th. i have been out of work since, but i still have a sharp pain when standing or walking. its on the bottom inside of my heel. you can just push on it and it hurts really bad. i have used a night splint, a walking cast, and i just went 4 weeks with a real cast. i still have the same pain. i just had an mri done, and it didnt show anything wrong. my bones were fine, along with my everything else. the was no signs of plantar fascitis, just a slight swelling around the ankle area. im happy the mri didnt show anything was wrong, but not having an explanation for why im in so much pain is very upsetting. i am to the point of just accepting that ill have to just go back to work in severe pain.
A xray showed a small heel spur, but an mri shows nothing?
March 23rd, 2009 at 9:33 pm
Hi Thad,
Heel pain can be caused by a multitude of different problems. An MRI should have ruled out a stress fracture of the heel bone, a tear of the plantar fascial ligament, a rupture of the abductor hallucis muscle which is one of the small muscles in the foot that originate from where your pain is centered.
So…that pretty much leaves us with either plantar fasciitis that has not responded to treatment (you do not mention if you have had had cortisone injections or oral anti-inflammatory medication).
There is rapidly becoming a new “school of thought” that plantar fasciitis that becomes chronic and does not respond to treatment may be due to the fact that the ligament in question cannot heal itself. This is due to the fact that ligaments and tendons have a very poor blood supply; they generally get their blood from surrounding tissue, so if they are not getting enough blood then they are not getting enough nutrients and they do no heal.
In these cases you have to then consider things like ESWT which is shock wave therapy that re-creates inflammation and allows the body to heal the area. (See my article on this site) Prolotherapy is another treatment that also recreates the inflammatory process to allow for healing.
A second possibility for your prolonged pain, would be a heal neuroma which is a pinched nerve that gets caught up in all the inflammation and can be very painful. Typically this pain is most evident on the bottom towards the inside of the heal (the same spot that you mention). This can be treated in a number of ways including denatured alcohol injections , cryosurgery where the nerve is frozen and radiotherapy where radio waves destroy the nerve.
My best advice to you would be to get another opinion, mention these potential sources of pain that I have just mentioned to the doctor. If he or she looks at you with a blank look in their eyes, then find another doctor who is familiar with all the different sources of heel pain and you should get some relief.
Marc Mitnick DPM
March 24th, 2009 at 7:20 pm
Thanks for the advice and information. I did have a Cortisone injection, and i have taken anti-inflammatory meds over the course of my treatment. My Brother-in-law is a surgern, and he had a radiologist look at the films i was given. The radiologist said everything appeared fine from what he could see. I have been hoping that the radiologist who reads my mri associated with the doctor gets a cd or something better than the mri films show. I know thats grasping at straws, but anything negative would really be a postive. I dont like the idea of being in pain, without an answer for it.
I also had 4 weeks of therapy, which was very hands on. they even tried some type of elec shock with a steriod type medicine.
I know that another UPS driver who had the same type of pain, did get the shock therapy, and has had positive results. My fear was getting a MRI result that was postive, and that slowing down any decision the doctor might have towards being more aggresive so that i can be pain free sooner and also get back to work.
I was at the ball park for 3 hours yesterday, and the pain needle sharp pain right at the bottom of my heel is just constant while standing and with every step.
thanks again.
Thad Brooks
August 27th, 2009 at 12:22 am
hi im a 19 year old that works at longs drugs so im on my feet all day i have these heel pains every day at work ever since i sarted back in november of last year and it has gotten worse its in both feet in my heel and the middle side of my foot and middle of my foot. it feels sore wen i sleep too and it has an itchy tingly feeling of pain that never goes away. i notice i have it worse wen im sleeping on my back with my feet up right so i am always having to sleep on my side since that does cause more pain
its extremely bad at work because of the standing it does feel a little better wen i walk around but it still does hurt
Hi Chanel,
Standing long periods on hard floors tends to make most people’s feet ache. What bothers me about your complaint is the constant tingling feeling that never seems to go away. Some of the conditions you need to research would include heel neuroma, tarsal tunnel syndrome and radiculopathy or nerve irritation coming out of your lower back.
If you wanted to try something simple, you could try an arch support in your shoes, look for one that actually supports the arch. If this does not alleviate your problem then your next best option would be to consult with a podiatrist who could perform a full evaluation in an effort to find the source of your heel pain.
Marc Mitnick DPM