Heel pain is the most common complaint a podiatrist hears.  In fact, I don’t have to be at work to hear it.  My friends joke because at any given time a stranger can walk up to me waving their foot around asking me about the pain in their heel.  This article is a guide to the most common causes of heel pain.  I like to base the descriptions on location of the pain because not all heel pain is plantar fasciitis.

The bottom of the heel:

Plantar fasciitis:
The most common diagnosis given to heel pain.  The problem is inflammation of the small muscles in the foot where they attach to the heel.  This is caused by an unstable foot and is most often described as deep sharp pain when you get out of bed in the morning or after sitting for a prolonged period of time.  It can extend into the arch and will get worse if left untreated.

Heel spur:
A growth of bone on the bottom of the heel along the attachment of the small muscles in the foot.  This is the same problem as plantar fasciitis.  The best way to think of this is your muscles are pulling away from the bone because your foot is unstable.  The spur forms when the bone tries to hold onto the muscles to keep them from pulling away.  The spur does not cause the pain, it is the plantar fasciitis that is causing your pain.

Systemic arthritis:
Yes, that’s right your heel spur might not be related to plantar fasciitis at all.  Systemic arthritis such as Systemic Lupus, Reiter’s Syndrome, or Psoriatic arthritis cause inflammation along the attachment points of tendons.  This is called enthesopathy.  The heel is a common spot for this to occur, but the spur is different.  With enthesopathy the spur is not crisp at the margins.  We call this “whispering”.  If you have pain in other joints or your low back, your heel pain might not be plantar fasciitis.

Nerve entrapment:
Heel pain that is described as electrical or shooting is more likely to be from nerves.  There are nerves in the heel that can become entrapped or pinched as they cross muscles and fascia.  This pain can mimic plantar fasciitis, but when I press along the side of your heel  and run my finger over the nerve you will have the pain.  The low back is a common area to have pinched nerves that send pain to the heel.  If you tell me you also have pain in your low back I will test your spine to see if the heel pain occurs with stress.

The back of the heel:

Achilles tendonitis:
The Achilles tendon runs from the muscles in your calf to the back of the heel.  This is one of the strongest tendons in the body.  Inflammation of the tendon occurs either around the tendon or within the tendon.  With inflammation around the tendon there is sharp and stabbing pains with activity, but this might be improved in heels.  Inflammation within the tendon is worse, but hurts less.  You will notice swelling of the tendon.  If left untreated the tendon will weaken.  Everyone has heard of a friend of family member who was playing sport and suddenly without warning ruptured (broke) their Achilles tendon.

Pump Bump or Haglund’s deformity:
The heel bone can form a lump on the back side usually the outside edge of the Achilles tendon area.  This area is a pressure point in shoes, especially women’s shoes, therefore was given the name of pump bump.  Avoiding shoes that apply pressure to that area is the easiest treatment of all, but many people need to wear dress shoes for work.  Prominent bone can only be removed by surgery.

Bursitis:
The Achilles tendon attaches to the back of your heel bone, but not at the top edge.  As the tendon passes the top edge working its way to the attachment in the center of the bone there is a fluid filled sack called a bursa.  This allows the tendon to slide over the top edge of the bone as you walk.  This fluid filled sack can become irritated causing pain and swelling.  Relieving the inflammation and stretching your Achilles tendon usually make this problem go away completely.

Heel pain is very common and as you can see there are many reasons your heel can hurt.  Think about where the pain is and when it hurts.  You might not be suffering from plantar fasciitis.

Seeing a new patient is like an athlete getting ready to go onto the field or an actor waiting in the wings preparing to go onstage.  I have to get psyched, this is your first impression of me.  I pick up the paperwork you filled out and see that the reason you came to see me was “foot pain”.  Imagine my reaction.  I start sweating, my heart is beating in my throat, I might pass out.  Foot pain is just about everything and anything.  I need to find out where exactly in your foot the pain is located, what it feels like, and when it hurts.  This is why I write this article.  Help me help you.  Below is a list of common causes of “foot pain”.  There is a brief definition of the problem, where it is located, and in general what the pain feels like.

Bunion:

A lump behind your big toe caused by the big toe going one way, towards the 2nd toe, and the bone that supports the big toe, metatarsal, going the opposite way.  The lump is the metatarsal.  Pain can be divided in two:  on the lump is usually sharp pain with pressure from shoes, redness, and sometimes swelling, while the other pain is deep in the joint described as aching or throbbing that gets worse when you walk.

Bunionette or Tailor’s Bunion:

Similar to a bunion, but at the little toe.  This is where the 5th toe moves toward the 4th and the bone supporting the toe, 5th metatarsal, moves the opposite way making a lump on the outside of your foot.  Pain can be described just like it can for a bunion.

Corns: 

Hard skin on any side of a toe that usually causes sharp pain to pressure or shoes.  You might notice that the toe has changed position or shape.

Calluses:

Hard skin on any surface of the foot other than the toe, usually causing sharp pain while walking.  Why is a corn on the toe and callus on the foot?  I have no idea.

Exostosis:

This is an abnormal growth of bone.  Places where you might be able to see this are on a toe, top of the 1st metatarsal, or on the top of your arch.  These cause sharp pain when pressure is applied, but are caused by arthritis in the nearby joint.  Arthritis pain is deep aching, throbbing and yes it does get worse with the weather.

Hammertoe:

A toe that is buckled, curled, or bent any way other than straight.  Pain from the toe is usually related to a corn, but the joints can cause deep aching pain when walking.

Hallux limitus or hallux rigidus:

The hallux is the big toe and these conditions describe the joint at the base of the big toe.  The motion in this joint can be limited or completely gone, rigid.  These are forms of arthritis commonly described as deep aching, throbbing, or even sharp.  Anything that makes the toe move aggravates the pain such as walking especially in heels or up hill.

Metatarsalgia:

This is a general term for inflammation of a metatarsal.  It has fallen out of favor recently since it is not very descriptive.  Now-a-days this would be inflammation of the joint in the ball of your foot called capsulitis.  This is deep aching or throbbing pain when the joint moves, such as when walking, but usually better in supportive shoes and worse in heels or on stairs.

Metatarsal stress fracture:

A stress fracture is true inflammation of the bone that weakens the structure of the bone and can become a real break.  This is deep aching and throbbing with swelling of the foot in the area of the break.  Usually you have increased your activity or changed shoes before this started.

Neuroma:

A pinched nerve in the ball of the foot.  This causes sharp shooting pains that might travel out the end of your toes, most commonly the 3rd and 4th toes.  Some people can describe a clicking feeling in the ball of their foot when they walk.

Peripheral neuropathy:

The sensations of burning, tingling, or insects crawling on your skin worse when you have no other distractions like when you lay in bed.  These usually follow nerve patterns and can travel up and down the foot or leg.  This can get worse leaving you with loss of feeling.  You would think that loss of feeling has no way to be described, but since you had feeling then lost it patients are able to describe this lack of sensation.

Plantar fasciitis:

Arch pain in the muscles that is often described as cramping, aching, pulling, or even sharp when you walk.  This pain is usually worse with the first steps in the morning or after a period of sitting.  The plantar fascia is a big strong ligament running from the heel to the toes, but it is actually the muscles that sit just beneath the fascia that are inflamed.  The heel is usually involved in the pain as well.

Sesamoiditis:

The sesamoids are like knee caps for your big toe.  They sit in the ball of your foot behind the big toe and help the tendons hold your big toe on the ground.  These can be injured directly or by forceful upward motion of the big toe.  Aching in the ball of the foot at the base of the big toe with or without swelling is usually described by patients.

Tendonitis:

The muscles in your leg travel to your foot by tendons.  Any of these tendons can become irritated, injured, or inflamed.  The pain is usually along the line of the tendon and is commonly described as sharp, stabbing, aching, or throbbing depending on your activity.

Ulcer:

An ulcer is a break in the skin.  Obviously this would hurt, but most patients with ulcerations on their feet are lacking the ability to feel pain.  This can be hidden under callus or develop from a blister next to a callus.

These are the most common causes of “foot pain”.  I hope this will help when you need to explain the pain.  My heart can only handle so many complaints of “foot pain” in a day.

Paul trained for his first marathon.  He was smart about it going first to his doctor for a physical then having his feet and shoes checked in my office.  His training program included strength training, flexibility, and running.  Paul said the race was hard on his body, but he was happy to have finished.  About 3 weeks later I saw Paul again.  This time he was a wreck.  He was in pain from his low back to his toes.  Paul hadn’t been sleeping well and was just not as happy as he expected to be after completing his first marathon.

I asked about his recovery from the race.  I heard about the celebration that night soaking in a hot tub with friends drinking and eating whatever was there.  His wife had scheduled him for a massage the day after the race.  Paul said it hurt more than it felt good and had no lasting effect.  Stretching was impossible because of the pain and stiffness.  The tight muscles made it nearly impossible to run the few times he had tried.  When I asked if he was following any schedule or program he reminded me of his pre-race training program, but had nothing to follow for recovery.  Do you know what Paul did wrong?

What you do immediately after the race is as important as what you did to get there.  You know that running 26 miles is serious business, that’s why you were so careful in your training program.  After the race you will be exhausted mentally and physically.  Your recovery plan has to be set before you race so you won’t have to think about it.  Your muscles have worked hard for 26 miles and all nutrients in your body have been used.  When your body works hard for a long time you get inflammation.  Treat your body right and this will go away quickly so you’ll be running again in no time.  Ignore the inflammation and you’ll suffer.  I’m sure you’ve heard stories about people who ran a marathon and were never able to run again.  If you ask them about their post-race recovery I bet you’ll get a blank stare.

As soon as you finish the race:

You’re exhausted and legs feel weak, but this is the time you need to keep walking.  Don’t stop and get a chair massage, don’t chat at the booths.  Get your packet, medal, snack pack, and drink water as you walk around.  Make a mental note of what hurts.  I don’t mean big areas like your entire leg.  I mean specific areas like your calf muscle, front of your thigh, back of the thigh, front of your leg, arch, heel, toe.  Pay attention to any pains so that you can address these after a thorough cool down.

Your kidneys have been fighting to balance your hydration and electrolytes.  All the waist products coming from all that muscle action of running 26 miles is filtered by your kidneys.  They have worked overtime and need to recover.  Anti-inflammatory medications stress your kidney more.  This is not the time to take anti-inflammatory medications like Ibuprofen or Naproxen.  Refuel by drinking water, electrolyte drinks are OK, but water has to continue even if you’re drinking electrolytes.  Eat like you did while you were training.  Protein helps repair muscles and carbohydrates help with fuel. 

I don’t know how to describe it, but there’s an excited feeling in your legs, some people tell me a throbbing, others say it’s like their legs are just revved up.  Don’t stretch until that feeling in your legs goes away.  You can ice the sore spots and gently stretch.  When you get home take a cool bath.  Use a foam roller or gently massage sore muscles.  If possible schedule a massage in the evening, at least 4 hours after the race.

Things to avoid:

1. Sitting for more than 10-20 minutes
2. Soaking in warm water or hot tub
3. Sauna
4. Anti-inflammatory medications

The first week:

Inflammation can last 24-72 hours.  You will have to pay close attention to your body. If you treat the inflammation right you’ll be running again after a few days.  Ignore the inflammation and it can become a repeating cycle that is difficult to break even with my treatment.  Have more massages, practice yoga, swim or bike.  Don’t be aggressive, your goal is to stay loose.

If you have no aches and pains by day 3 you can begin gentle-paced, low mileage runs.  Do not exceed the mileage you did the week before the marathon.  Begin every three days with light resistance training on off days.  Any aches and pains need to be addressed.  Don’t wait to see me for any pains that remain.  The sooner these are addressed the easier they are to treat.

The 2nd week and forward:

If you’ve made it this far without needing me you’re doing well.  Gradually increase run frequency and distance back to your training levels as tolerated.  You might find that you are more easily fatigued, but that is normal for the first month.  Anything more than that and you should seek medical attention.  Don’t forget to have your running shoes checked.  During this return to training period you will need to have new shoes.  At Desert Foot Surgeons we offer video gait analysis to see what the naked eye cannot.  Come have your gait analyzed in or out of shoes.

Congratulations, you did it!!

screw and absorbable pin

So your toe is bent to the point where your shoes rub on the top of your to causing pain.  The skin is always red and sore.  The bending has gotten worse over the past year and at times you have pain in the ball of your foot.  What if I told you I could fix the bend in your toe so that the pain goes away?  Take it one step further, I can fix the bend in your toe so that the pain goes away, but there will be a pin sticking out the end of your toe for 4-6 weeks.  For a lot of people that’s a deal breaker.  They want the toe fixed, are willing to deal with the pain and recovery of hammertoe surgery, but don’t want to see that pin sticking out the end of their toe.

This is a big problem and as your surgeon I have to address your concerns.  I recognized this early in my training and began using absorbable pins that did not stick out of the toe while I was a resident.  Smaller screws became available that could be used in toes and more recently special little devices made of space-age material were introduced just for toe surgery.

I’ve already talked about the difference in hammertoe surgery between the 2nd and 3rd toes as compared to the 4th and 5th.  Here I’m talking about the 2nd and 3rd toes only.  When I fix the bend in your toe I need to make a stiff, straight toe.  I remove the crooked joint and force the bone to heal together straight.  That’s why I need to use a pin, screw, or special little device to get the bones to heal together, or in other words fuse.  The only question to ask for this part of your surgery is how strong is your bone?  That changes my options.  Stronger bone means I can use just about anything, but weaker bone limits my options.

Why do some people still have hammertoe surgery with the pin sticking out of the end of the their toe?  The most common reason is weak bone.  Some things that have been around a long time are still used today because they work in almost every case.  Even if your bone is weak a pin can be used to hold it straight until healed.  The other reason is the joint at the base of our toe where your foot begins.  Many people have toes so badly bent that the joint in the ball of their foot is also bent.  More recent advances have shown that breaking the bone in the ball of your foot to straighten this joint is better than the older method of cutting tendons and ligaments.  When we used to cut the tendons and ligaments in this area the best way to hold the toe straight was using a long wire.  Now we use screws to hold the bone in the ball of your foot without having to use a pin across that joint.

smart toe

New techniques and new technology are sometimes slow to catch on.  Hammertoe surgery without the pin sticking out of your toe is not new.  As I said in the beginning, I started doing this when I was in residency.  I’ve been training residents for about ten years and even the very first resident I taught learned how to fix a hammertoe without a pin sticking out the end of the toe.  When I discuss toe surgery with you I will talk about the options and what I think is best for you.  I want to hear your opinion and make sure I’m addressing your goals.  It is very important that we are on the same page when it comes to fixing your toe.

Hammertoe toe surgery might be in your future.  If you are scared about having a pin sticking out the end of your toe come and talk to me.  More often than not I can straighten your toe without having to leave a pin sticking out the end.

Grab a pair of sneakers and go.  That’s all it takes to run, right?  Maybe that’s why more people than ever are running marathons.  Running a marathon is an admirable goal, but the philosophy of just grabbing a pair of shoes and running may be why I’m seeing more running injuries than ever before.  Training for marathons has turned into big business.  You can join a club, buy a magazine, or purchase a plan online.  My problem with these training schedules is a lack of individual attention.  Remember my saying, “feet are like snowflakes, no two are the same”.  Some people have feet that can run 26 miles, but does that mean your feet can?  Well there’s two mind sets:  1. you’ll never know until you try, or 2. I’ll follow a training program.  But what’s missing?  Neither approach is designed with you in mind, so when you get hurt you end up needing me.

Recently three people came to see me for the most common running injuries.  Even though these people had different pain, were different ages, lived in different cities, and had different lifestyles, they all had similar stories about training for a marathon.  All three had not run for exercise consistently in more than 5 years.  A friend had convinced each one to train for the marathon.  Not one of the 3 had a training program made specifically for them, but all were using a group training schedule from either a magazine, the internet, or joining a training group.

The first patient complained of heel pain that was worse with the first steps out of bed then again in the evenings especially after running.  I diagnosed this patient with plantar fasciitis and relieved her pain by teaching her how to stretch and ice, gave her foot orthotics to support her sudden increase in activity, and plantar fascia night splint for the morning pain and stiffness.  Plantar fasciitis is a common overuse injury.  The muscles in your arch stretch beyond their limits when you walk or run.  A sudden increase in activity, change in shoes, or an injury is usually related to the start of pain, but very few people realize this until I point it out.  In this case the patient had a new activity, running.  She also had new shoes that she bought for this training.  Had I seen her before she started training I could have watched her walk on slow motion video and analyzed how her foot might be effected by running.  Stretching could have been started before training began and help individualizing her training program could have been arranged.  Her heel pain and time away from training could have been avoided, but she will be able to run the marathon.

The second patient came to me with the complaint of pain and swelling in the top of his foot.  He was training for a marathon and noticed the pain increasing gradually as his distance increased.  Pain was present all day long, worse in shoes, and swelling increased the more he walked.  Running had stopped because of the pain.  X-rays showed a stress fracture of his 2nd metatarsal.  This is the bone behind your second toe and is commonly the bone involved in stress fractures of the foot.  Stress fractures are broken bones that happen gradually when you have a sudden increase in activity.  The sudden increased pressure on the bone causes inflammation that weakens the bone, but you’re still not aware of it so you keep on training.  When the weak area of the bone breaks you get the big ouch.  Treating the fracture early is easiest.  A removable cast and anti-inflammatory pills relieve the pressure and inflammation allowing the fracture to heal.  Once you heal the real treatment begins.  There is a reason the fractured bone has more pressure than the others and it’s my job to find out.  Detailed exam of your foot structure including video gait analysis will be done so that custom foot orthoses can be made.  This will correct the pressure problems in your foot and prevent further fractures.  Unfortunately in this case the patient came to me once his bone had broken.  His goal of completing a marathon will have to be postponed until later in the year.

The third patient wasn’t far along in her marathon training when she developed pain in her lower legs.  This pain was very bad when running and improved with rest.  She wanted to run the marathon so bad that she trained until until her leg started to swell.  By the time I saw her my major concern was a stress fracture of her tibia, the main bone in the lower leg.  The beginning of her story was more like shin splints, but I had to make sure so a few tests were done to prove this was not a stress fracture and she improved with treatment for shin splints.  Medial tibial stress syndrome is the newer term used in sports medicine for shin splints.  The cause is always related to pronation, see my article “Are You a Pronator”.  Most foot problems can be related to pronation, but medial tibial stress syndrome occurs in the leg.  To make a long story short, it’s the rotation of your lower leg when you run that causes this pain.  Custom foot orthoses are the only way to make this go away and stay away.  I had to modify this patient’s training program and get her help to strengthen her thigh muscles, but she will be running in the marathon.

Running is good for you!  No one will argue that point, but getting started is the hard part.  Buying a running shoe from a specialty store is a good idea, but now a lot of stores are using pressure mapping to tell you how your foot works.  First of all, you cannot tell how the foot works by standing still on a pressure plate.  At Desert Foot Surgeons I use video gait analysis to see exactly how your foot works while you run or walk barefoot and in shoes.  Second the study of foot motion is called biomechanics.  This takes years of study to master and is only provided in podiatry schools.  I have many friends in the running shoe business and have learned a lot about shoes from them.  Likewise I have taught my friends a lot about biomechanics.  I won’t pretend to know more about shoes than these professional salespeople and all of my friends will not pretend to know more about the function of the foot than I do.

Come see me before you start running.  I can help you with more than just shoes and orthotics.  I can get you personalized training or even physical therapy.  If you have shoes already video gait analysis will show if they are working for you.  Preventing injuries is much easier than treating injuries.  Running is good for you, just do it smart!