Down at the Heels

By: Christine Haran
Last Reviewed on: October 14, 2004
Most of us take our heels for granted, until they start hurting. It is hard to believe that heels can cause so much havoc, but it turns out that pain felt under the heel bone?which works in collaboration with 33 joints and a network of more than 100 tendons, muscles and ligaments?can bring the most stoic person to their knees. Heel pain is one of the most common types of foot pain, and podiatrists say they are seeing more people complaining of it. The increase in heel pain rates is due, in part, to the aging population and rising rates of obesity. But one of the major causes of heel pain is associated with positive trend: More Americans are starting exercise programs. The problem is that they often lack shoes with good arch support and don't incorporate stretching into their regimen.

Below, Dr. Ronald Jensen, a member of the Board of Trustees of the American Podiatric Medical Association (APMA) and a podiatrist in private practice in Modesto, California, explains what causes heel pain, and how to treat it.

How common is heel pain?
The APMA feels that there is an epidemic of heel pain afflicting this country. Questions related to heel pain make up over 70 percent of the inquiries to consumer hotlines cosponsored by the APMA and the USA Today over the last ten years. Heel pain is probably one of the most common diagnoses that we treat.

What is the most common cause of heel pain?
The most common cause of heel pain is a condition called plantar fasciitis, which is inflammation of the plantar fascial ligament. The plantar fascial ligament is a tight band of tissue that originates from the bottom of the heel bone and spreads in a web like fashion to the pads of the toes. If this ligament becomes "overworked" it can become inflamed and painful. The reason it's most common to feel the pain underneath the heel is you have all the tension being placed on that ligament concentrated in a very narrow area underneath the heel bone itself. The pain can be experienced anywhere along the length of that ligament: right underneath the heel, in the central portion of the arch, or less commonly out towards the ball of the foot.


What else contributes to heel pain?
Shoes that do not give adequate support to the foot are among the most common causes of heel pain. Some of the new athletic shoes that are being designed have large cutouts through the arch area, which causes the shoe to flex at the midfoot instead of the ball of the foot, which is much more natural. As a result, the plantar fascial ligament is overstretched.

We are also seeing street shoes that are more affordable but have less arch support built into them. The shoe companies are saving money on the construction of these shoes at the expense of the consumer. The lack of support from the shoes results in an increased stress on the plantar fascial ligament, resulting in inflammation of the ligament.

Exercise can be a risk factor if the patient is not training properly or is using equipment improperly. We're seeing people leading a much more active lifestyle to improve their overall health, but if they're not stretching or wearing appropriate shoes, they can have heel pain. Being overweight contributes to heel pain, because anything that makes the foot work harder during activity is a risk factor.

Another large source of plantar fasciitis is a natural flattening of the arch. It has been my experience that this condition can strike women as early as their 20s and affects men in their 40s. As the arch begins to flatten, the ligament is under greater tension and becomes painful. This flattening of the arch is usually accompanied by an outward rolling of the heel, which results in a motion called eversion, or the rolling of the foot inward (inversion). These movements cause the arch to flatten and this results in an increased stretch on the plantar fascial ligament, which causes the pain.

What is a heel spur?
A heel spur is a calcium build-up that can occur either on the back of the heel, where the Achilles tendon attaches, or on the bottom of the heel that is closer to the ground where the plantar fascial ligament originates from the heel bone. As the ligament becomes pulled, the bone can become irritated and the calcium begins to build up. It's important to remember the pain is usually associated with the pulling on the ligament as opposed to the heel spur.


What does heel pain usually feel like?
There is a great deal of variability in how each patient feels the pain. The discomfort can be anything from a dull ache under the heel commonly referred to as a stone bruise on up to a sharp, shooting pain where the patient is unable to walk on the foot at all. The pain can be most severe upon first getting out of bed in the morning or after sitting for a period of time, or it can be mild in the morning and become progressively more severe with activity during the day.

Who does heel pain affect?
Heel pain/plantar fasciitis can occur in children through the elderly. Plantar fasciitis commonly hits in middle age as the foot matures and the arch flattens. We see it in a lot in people who are starting new exercise programs, particularly walking programs. They're not doing appropriate stretching or obtaining appropriate shoes.
We also see heel pain in younger people who are more aggressive with their exercise. People who spend long periods of time on their feet, such as hair stylists, waitresses and sales people, are also at risk for heel pain at some point in their life.

What can people do at home to ease their heel pain?
People with heel pain should inspect their shoes to make sure that they are stiff through the middle portion of the shoe, also known as the shank, to insure that the shoe isn't contributing to the problem. The shoe should have a reasonably firm heel, so you don't get excessive rolling of the foot as you walk.

Patients can also buy an over-the-counter arch support inner sole. You can get arch supports either through your local sporting goods store or through your pharmacy.

In addition to arch supports, people should try reducing their activity level, applications of ice, stretching exercises and anti-inflammatory medications that are available over-the-counter.


What kind of stretches do you recommend?
Most important is a stretch for the Achilles tendon. Many of us have jobs where we're working sitting down, and even some of the athletes who are very physically active sit down after they've exercised. As a result, the Achilles tendon becomes tight. This causes people to walk in such a manner that leads to increased stretch on the fascial ligament. If you can stretch out the Achilles tendon, many times you relieve your heel symptoms.

My personal favorite is a stretch where the patient places the ball of the foot on the edge of a step with the heel hanging over the edge of the step. With a straight leg, they simply allow the heel to lower and that causes the stretch on the Achilles tendon. It's important not to force the stretch, just let it happen very passively and easily.

Are there particular kinds of exercise that are harder on the heel than others?
One of the types of exercise that has been a real problem is the treadmill. As people begin to elevate the treadmill in order to increase their heart rates, it increases the stretch on the plantar fascial ligament. It's not natural to walk uphill all of the time. So if they are going to elevate the treadmill for periods of time, they should also lower it back down for a while.