By Paul J Betschart, DPM, FACFAS
Anyone who is suffering from heel pain and is looking for the best way to treat it at home.
People looking for an instant cure, pill poppers and those unable or unwilling to follow simple instructions.
Self-management strategies for eliminating heel pain.
By far, the most common cause of heel pain is a condition called plantar fasciitis. This condition is an injury to a ligament on the bottom of the foot called the plantar fascia. This ligament runs the length of the foot from the heel bone to the base of the toes. This ligament is one of the most important stabilizing structures of the arch of the foot. The most common part of the plantar fascia to be injured is under the heel where it attaches to the heel bone. The body responds to this injury with inflammation, which is perceived as pain.
Lack of support of the arch in shoes is a common cause of injury to the plantar fascia.
Other causes include direct trauma, such as stepping on a hard object, overuse, like building up running mileage too fast, and inflammatory conditions, such as rheumatoid arthritis.
Less common causes of heel pain include fractures of the heel bone, bone tumors, bone cysts, foreign bodies, skin tumors and soft tissue or bone infections. These infrequent causes of heel pain would need diagnosis and treatment by a medical professional.
This article will focus on managing the most common cause of heel pain, plantar fasciitis.
I use 3 steps for treating heel pain:
Pain in an area after an injury is the body’s signal to us to rest that body part. Rest is the first part of the recovery phase. Rest doesn’t always mean no weight on the foot or bed rest. Relative rest is often good enough. What we mean by relative rest is reducing the level of activity to below the level of activity that causes the pain to increase. An example would be, if running causes pain to increase, then stop running and switch to walking, which would provide the relative rest needed. Sometimes, a reduction in mileage or intensity is all that would be needed. Sometimes, offloading of the painful area may be necessary. Offloading means taking the weight off the foot or leg with a walking boot or complete non-weight bearing with crutches or a knee scooter.
The body often responds to injury with inflammation or swelling. Reducing inflammation is important in this phase. Using a cold pack is a great way to reduce inflammation: 20 minutes on, 20 minutes off around the clock for the first 48 hours is ideal, but often not possible. Just try to use the on-off cold pack routine as much of the day as possible. An easy way to apply cold at work is to freeze a plastic water bottle and rest the foot on it, gently rolling the arch on the bottle. Gel packs, crushed ice or frozen peas are other alternatives for applying cold. Over-the-counter anti-inflammatory medications, such as aspirin, ibuprofen, naproxen, etc., can be taken for 5-7 days to reduce inflammation (or as you are allowed). Cannabidiol products are an alternative way to reduce inflammation and pain naturally. Topical pain creams can help with symptom control, but these do not have anti-inflammatory properties. This means that they cannot get to the real cause of the swelling. Arnica is a homeopathic topical remedy that can be effective for pain relief.
Protection of the injured area is very important in this phase. Heel cups made from silicone or rubber can be used to protect the heel area for walking. Avoid flat shoes or sandals as these increase the heel strike force. Elevating the heel slightly also takes tension off the plantar fascia and forces your weight to the outside of the foot, which provides stability.
Using these recovery methods for 1-2 weeks should allow symptoms to reduce enough to begin the rehabilitation phase.
The rehabilitation phase is further divided into 3 components: support, stretch, and strength
To allow the plantar fascia to heal properly, tension or strain throughout the tissue must be reduced. This is done by supporting the arch of the foot. Since the plantar fascia runs the length of the bottom of the foot, supporting the center of the arch will relieve strain on the insertion point on the heel bone where the injury usually occurs. Several effective support strategies are available.
Stretching exercises and self-massage help to release tension on the involved soft tissues, improve blood flow and help realign tissue fibers. Stretching also addresses some of the underlying biomechanical imbalances that contributed to the injury. The most important area to stretch for most foot and ankle conditions is the Achilles tendon/calf muscle complex.
Achilles Tendon/Calf/Soleus: This tendon attaches to the back of the heel bone and its fibers extend to the bottom of the foot and blend with the plantar fascia fibers. Stretching this tendon will reduce tension on the plantar fascia. The easiest stretch to perform is the wall push-up or sprinter’s stretch. Stand a few feet from a wall with feet together and toes pointed at the wall, place both hands on the wall and lean forward, bending at the ankle, keeping your body as straight as possible. When a comfortable stretch is felt in the tendon or calf muscle, hold the stretch for 10 seconds then relax for several seconds and repeat the 10-second stretch 10 times. As mobility improves, stretches can be held for up to 30 seconds to improve flexibility. Keep the knee fully extended in the initial set. With a slight bend in the knees, repeat the 10-second stretches for another 10 repetitions. This will stretch another part of the calf muscle, the soleus. Some people find it easier to stretch one leg at a time in a lunge position. An alternative to this stretch is the towel stretch. Wrap a towel or exercise band under the ball of the foot and while standing upright, pull the foot up toward the leg. Repeat the 10-second holds as above.
Plantar fascia: Stretch/Self-Massage: To stretch the plantar fascia, sit on the edge of the bed or chair with the foot on the floor. Lift the heel and roll up on the toes. You will feel the stretch in the bottom of the foot. Do the 10-second hold 10-repetition set as above. An important note: The plantar fascia, which functions as a ligament to hold the foot stable, is not designed to stretch, so don’t force it. Be careful with this stretch if you have arthritic toe joints. This stretch can be performed first thing in the morning when getting out of bed to help with the first step pain that is common with plantar fasciitis.
Self-massage of the plantar fascia should be performed for 10-15 minutes daily. A firm ball or foam roller works best. Alternatives are plastic water bottles or aluminum cans. Place the center of the arch on the ball. Roll the foot back to front using as much pressure as is comfortable. Avoid rolling directly over the heel where the plantar fascia attaches. Another area to massage is the calf muscle fascia. This area is in the back of the leg just below the thick portion of the calf muscle. While seated on the floor or couch, rest the leg on the ball or roller and roll from the calf muscle to where the Achilles tendon starts.
Warming up soft tissues prior to stretching and massage can increase their effectiveness. Epsom salt warm water solution soaks work well. Mix 1 cup of Epsom salt per gallon of warm water. Make sure the water is not too hot by using a thermometer. Soak for 10-15 minutes. Foot soaking devices are available that agitate the water and keep it warm. A deep basin works fine.
Alternative heating modalities include gel packs, electric heating pads and infrared devices.
Strength. Once the pain has subsided and mobility has improved, the final phase of rehabilitation can begin. The small muscles of the foot help to stabilize it during walking. They are difficult to isolate to exercise, but worth the effort. Towel curls are an easy first exercise. Place the foot on a towel and try to scrunch up the towel with the toes. Do this for 5-10 minutes. When you get good at the towel curl, you can try picking up a pencil with the toes or even marbles. One of the most effective exercises for the arch stabilizing muscles is a yoga technique called Short Foot. It can be difficult to master, but the resulting improvement in stability and balance is unmatched by other exercises. A search of YouTube will bring up a number of videos to instruct the technique. As with most yoga techniques, there are many interpretations on the form and focus. My colleague Emily Splichal, DPM, has several videos on her website – barefootstrong.com – that explain and demonstrate it well.
Once symptoms have been resolved, the main objective is to keep the problem from coming back. The first step is to try to identify any causative factors that may have brought about the injury, such as training errors, inappropriate footwear, direct trauma, etc. and take steps to avoid that issue in the future. If a cause cannot be identified, the injury is likely the result of a biomechanical imbalance of the foot or leg. This is where seeking the advice of a foot and ankle specialist will likely be needed. A specialist certified by the American Board of Foot and Ankle Surgery or the American Board of Foot and Ankle Medicine is a good place to start.
A stretching program should be maintained after symptoms have stopped. Focus on stretching the Achilles tendon daily and after sporting activities. This tendon tends to get tight easily, especially in athletes and those who wear high heels. Regular stretching can help prevent this and many other foot injuries.
Continued support of the foot with a firm supportive insole should be maintained for at least 6 months. If a biomechanical cause is suspected, support should be maintained for the future. If symptoms return despite the use of a good OTC arch support, a custom foot orthotic may be needed. Again, this is where consultation with a foot and ankle specialist would be appropriate.
Paul J. Betschart, DPM, FACFAS, is a podiatrist in private practice in Danbury, Connecticut. A Fellow of the American College of Foot and Ankle Surgeons, his goal is to help his patients achieve optimal health from the ground up.