I’m sitting on a plane as I write this flipping through the airline magazines.  I notice a few things that drive me nuts.  There are suggested exercises to do while seated.  Ankle rotation, foot flex, and heel lift.  You’re not serious are you?  Have you done these?  Who is this supposed to help?  So I flip past it and come across a section of foot products where there are 2 flimsy night splints, orthotic sandals, inserts to make you taller, and a stretchy thing.  OK I’m in a bad mood because I just paid to bring my luggage on the trip, but come on!  We’re talking plantar fasciitis.  This is severe pain in the heel of your foot.  Why do people buy this stuff?  Then I remember the single question I ask of all my residents when discussing heel pain, “why?”.

Why does your heel hurt, but mine does not?  Why are your first steps out of bed so painful?  Why did my aunt say that wearing cowboy boots is one of the best heel pain treatments?  Why is your right foot heel pain seem so much worse than your left foot?

Enough already, the flight attendant just spilled water on me.  Let’s get technical.

Why do we call it plantar fasciitis?

The plantar fascia is a broad ligament that runs from your heel to the ball of your foot.  If you pull your toes back (up) you can feel your plantar fascia in the arch of your foot.  Because there is this severe pain in the heel of your foot and into the arch it seemed reasonable to the first doctors who described this condition to call it inflammation of the plantar fascia.  They never asked “why?” or “what else could it be?”.  Here’s the technical part.  Inflammation at its’ most basic level is increased blood flow to an area that has been injured.  That’s why you can sometimes feel throbbing like your heart beat in your foot.  The plantar fascia is a ligament.  That means it is a thick, tough band that doesn’t have any space for wimpy, soft, little arteries.  How can you have increased blood flow to something that has no arteries?  Ha, ha you can’t.

We now know that the problem in your heel is the muscles not the plantar fascia.  The small muscles in your foot also run from your heel to your toes.  Bend you toes back and feel the fascia again.  The muscles are right under that, so how can you tell which one hurts by pushing on the heel or arch?  You can’t!  MRI has shown that plantar fasciitis type heel pain is really inflammation in the muscles where they attach to your heel.  Have you heard of a heel spur?  Well the spur actually develops from the muscles pulling away from the heel bone.  The plantar fascia attaches to the heel bone in a different area not at the spot where a heel spur is seen.  A classic heel pain treatment is injecting steroids.  The shot goes in the area where the muscles attach to the bone, not the plantar fascia.

Why are my first steps out of bed so painful?

That feeling of a hot poker sticking into your heel when you get out of bed is a classic complaint if you’re suffering from plantar fasciitis.  In order to explain this severe pain in the heel of your foot, I need you to keep in mind that the problem lies in the muscles.  Ligaments resist stretch up to a point then they break, like spraining your ankle.  Muscles can stretch.  It takes a very special set of circumstances all occurring at the same time to break a muscle.  When muscles work they are happy.  Lots of fresh blood circulates through bringing oxygen and washing out the used stuff.  If you stretch a happy muscle too far or too fast what happens?  That muscle is not so happy anymore and lets you know it my fighting back, in other words, cramping.  So you’re walking along, doing your own thing.  The muscles in your legs and feet are working so they’re happy.  Eventually you go to sleep and the muscles get what seems like a well deserved rest.  Of course from the muscles point of view it is not working anymore so tightens up a little to try to keep active.  You wake up and step on your foot, stretch the muscles all of a sudden, and they fight back.  Zing, zang, zoom you’re seeing stars and thinking you have a harpoon stuck in your heel.  Gradually the muscles relax with a few more steps and you feel better.  If I place your foot in a night splint that holds your foot muscles stretched slightly while you sleep the muscles stay happy because they are taught so working a little and when you get out of bed there is no harpoon because there is no sudden stretch.  This is no flimsy piece of fabric night splint like in the airline magazines.  I have a night splint in my office that goes along the top of your foot and ankle so it’s more comfortable than other rigid splints and not slippery if you have to get up to go to the bathroom in the middle of the night.

Why do people tell me to wear cowboy boots for my heel pain?

This was a big topic not too long ago when Eli Manning, the quarterback for the New York Giants, was following the advice of his old coach by wearing his cowboy boots for heel pain.  Why the cowboy boots?  Because wearing a slight heel and I’m not talking high heels here, but wearing a 1 1/2 to 2 inch heel relaxes your ankle.  This will decrease the pull of your Achilles tendon just enough to decrease the stretch on the muscles in your arch.

Wearing heels or cowboy boots all the time causes other problems so this is not a long term treatment or prevention.  Remember what I always say, “ you can’t begin to heal until the inflammation is gone”.  Sometimes a patient who has a decent pair of cowboy boots or low heels will ask and I will tell them that wearing these shoes or boots is a good idea for a week or two, but stretching is the real treatment.

Ok, the plane is about to land so let’s wrap this up.  This has been a little more technical than other pieces on this website.  It’s ok to read it over a time or two.  When you think you have it then I want you to ask yourself one more question:

Why can one heel hurt and not the other?

I’ll answer that and other questions in another technical article about the nuts & bolts of how the foot works.

The back of your heel is a small area, but there are a few different problems that can cause pain here.  This isn’t plantar fasciitis we’re talking about.  The area where your Achilles tendon attaches to your heel is what I want to discuss.  You can imagine that since this involves your Achilles tendon the more you walk or run the worse it gets.  Shoes that push on the back of the heel can cause horrible pain.  Achilles heel pain is all in this one small area on the back of your heel so it can be easy to confuse what is causing your pain.  If I play tic-tac-toe on the back of your heel I can tell exactly is causing your Achilles pain.

Just this week a resident surgeon diagnosed one of my patients with a “pump” bump.  This is a lump of bone on the back outside “shoulder” of the heel that was thought to be caused by high heeled women’s shoes.  Unfortunately in this case the patient was a man.  How was I going to diagnose the cause of his heel pain without embarrassing my resident or the patient?  We played tic-tac-toe.  I drew a grid around his Achilles tendon attachment to the heel.  Next, I pushed on each square and marked an “X” if he felt pain.  When finished I stepped back and looked at the pattern of X’s.  All of a sudden the true cause of this patient’s heel pain was staring me in the face.

The center square is where the Achilles tendon attaches to your heel bone.  If my X-pattern involves the center row or even sometimes the bottom your problem is with the Achilles tendon insertion.  An X-pattern in the upper squares are a sign of Haglund’s deformity.  This is a lump of bone extending across the top portion of the heel.  The Achilles tendon sits right over this area and is separated from the bone by a fluid filled sack called a bursa.  The tendon, bursa, or both can be involved in this pain pattern.  If my X’s are more along the outside of the heel (right side of the picture) this would be the “pump” bump my resident had suggested.

You can see from the picture that my patient has a problem in the central square.  This is pain at the Achilles tendon attachment to bone.  Fortunately anti-inflammatory medicine, ice, stretching, a lift under his heel, night splints, and physical therapy will usually make this better.  Some times a heel spur can form in this tendon attachment and needs to be removed, other times an arthritic condition such as Rheumatoid arthritis or systemic lupus can inflame the tendon attachments to bone.  This is called enthesopathy and requires medical care with arthritis medications besides the ice, night splints, and physical therapy we just talked about.

The other areas of heel pain in this part of the foot are lumps and bumps.  If the pain is across the top squares, a Haglund’s deformity, or along the outside squares, a pump bump, I will recommend starting with the relief of inflammation like I always do and add a change in shoes that won’t push on this painful area of the heel.  If your pain does not go away with stretching, night splints, ice, anti-inflammatory medicine, changing shoes, and physical therapy that pretty leaves us with only one option, surgery.

Even though there are 3 causes of heel pain in this area surgery always involves the Achilles tendon because either the tendon is the cause or it lies just over the problem area.  For this reason no matter which diagnosis you have the recovery from Achilles heel surgery is the same.  Your game plan for recovery will include 2 months completely off that foot using crutches or a knee walker.  I will begin your physical therapy at 2 weeks.  Your first steps will be in a cast boot with the help of a physical therapist around the 8 week mark.  From there I’ll teach you how to gradually return to shoes.  Your total time out of shoes will be about 3 months.

I don’t think my resident will ever forget how to diagnose Achilles heel pain after this.  Using a simple child’s game to make a complex diagnosis is just one of the things I love about my job.

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.