Pain under your heel can be debilitating, and is commonly due to something called plantar fasciitis. The plantar fascia, a fibrous band of tissue on the bottom of the foot, is an important structure under the foot that can become inflamed, tight and/or injured. Classic plantar fasciitis hurts more in the morning when you step out of bed, gets better as you walk around and is often relieved by anti-inflammatory medication. Another type gets worse with activities, and has affected some big name athletes in recent years.
Injuring this area is similar to any kind of tendonitis, although it is technically not a tendon. It can be from repetitive use or from a quick pull while simultaneously contracting. Risk factors include age (40-60 years old), repetitive stress exercises (running, ballet/dancing, aerobics), over-training, tight calf muscles, faulty foot mechanics (flat feet, high arches), being overweight, and standing on your feet for long periods.
As with any injury, prevention is always best. If you have tight soft tissue under the foot or in the calf, try a preventive stretching protocol. Sleeping with a boot which stretches the fascia while you sleep can prevent contractures that occur during the night when your foot is in the plantar flexed position (ankle pointing down). The plantar fascia can get tight in this position while you sleep, and then hurts when you stretch it while taking your first steps in the morning. Proper shoe wear is always important and runners should routinely change worn shoes.
Treatment should always start with a good stretching program. Thirty second stretches five times a day has been shown to be quite effective. There are devices than can help stretch the plantar fascia, from commercial devices to golf balls to a frozen bottle of water. Properly taking NSAID’s (non-steroidal anti-inflammatory medication) can help the classic form as it reduces inflammation, but check with your doctor before starting any medication to make sure it is safe for you to take.
If stretching and medication are not helping, there are other things that can be done to treat this. A physical therapist can use devices and techniques to reduce the inflammation, stretch the fascia and strengthen the posterior tibialis tendon (a tendon on the inner side of your ankle and foot) which helps support the arch and can be beneficial. Some have advocated shock wave therapy, but this is controversial and can still take several weeks to improve. Orthotics, or shoe inserts, can also help, depending on the design. Traditionally these reduce pain by taking pressure off the heel, but can take 6-12 weeks to improve enough to return to sports.
Cortisone injections can seem like a quick fix, but carry the risk of fat pad atrophy (losing the cushioning under the heel) which can result in too much stress on the heel bone and stress fractures. Major surgery may then be required! Steroid injections can also cause the fascia to rupture. Since the plantar fascia assists in maintaining the arch through something called the “windlass” mechanism, this may result in a flatter foot which can alter the mechanics of the leg, causing more problems. Other injections include PRP (platelet rich plasma), bone marrow aspirate, and stem-cells, but also are controversial, expensive and often not covered by insurance companies.
Traditional surgery releases the fascia and is not recommended before 6 months of non-operative treatment, but again changes the mechanics of the foot, and should be a last resort.
For more information on plantar fasciitis, visit OrthoInfo.org.