A Treatise on Heel Pain

One of these spurs is painful, the other isn't

Today I'd like to talk just a little bit about heel pain, specifically the most common cause of heel pain: plantar fasciitis. I can't count how many times I've had a patient come in complaining of a "heel spur." Without wanting to discount the presence of a spur, generally speaking, heel spurs don't typically cause pain. There are some exceptions, most of which involve the Achilles tendon developing small chunks of calcified material that builds up in the tendon or on the bone at its attachment point.

When a patient comes to me with heel pain, I first have to determine whether their pain sounds like it is coming from the plantar fascia--the most commonly irritated soft tissue structure of the foot--or from some other structure. Usually the history of a patient with plantar fasciitis will tell me that the first few steps in the morning are the most painful. They also experience pain after standing up when they've been sitting for a while. The pain is most commonly on the inside of the heel, where the fascia is tightest. Next most common is directly beneath the heel. Every now and then you'll find a patient with pain on the outside of the heel or underneath the middle of the foot.

I will often get X-rays for heel pain because you want to make sure this pain isn't from some rare condition that mimics plantar fasciitis. This is a two-edged sword, however, because I often see a spur on the X-rays where the fascia attaches to the heel. Usually I tell my patients a thorough overview of the X-rays, but the only thing most patients remember afterwards is that enormous-looking spur they saw on the heel.

There are a lot of factors that cause plantar fasciitis, but the most common ones are weight, tightness in the calf muscles, overuse, and some sort of inherited foot structure (both high arches and flat feet can cause plantar fasciitis but for different reasons).

This shoe fails the "Squish Test"

Typically treatment for plantar fasciitis involves a calf muscle stretching routine, ice massage (exactly what it sounds like: massage your foot with a block of ice), anti-inflammatory treatment, and some sort of arch support. I usually recommend a good running shoe for support. Most of your standard running brands are good. The main thing I like to test is what I like to call the "Squish Test."

Basically, the test determines how supportive the arch and middle of the shoe will be for the arch. If the shoe bends in the middle when you squeeze it together, it fails. If it bends up at the ball of the foot, it passes.    I do this test whenever I try on a shoe. I even make sure my dress shoes pass the test.

This shoe passes

Ultimately, only a trained physician can diagnose the cause of your heel pain with a high degree of confidence, but at least I've armed you with a little more knowledge, so if you find that you do need help with heel pain, you're not surprised that your doctor will ask you to stretch. If your heel pain symptoms don't have any of the characteristics I've mentioned, or haven't benefited from any of the first-line treatments I've described, it may be time to get a closer look from a specialist.