5 min read
The first steps out of bed are the ones people remember. A sharp, focused pain under the heel that eases after a few minutes of walking, returns after sitting through a meeting or a long drive, and is waiting again the next morning. It is one of the most common reasons adults see a foot specialist, and most people have already found a name for it before they call. It is also a pattern that more than one problem can produce, and that is the part worth knowing.
What the plantar fascia actually is
The plantar fascia is a broad, fibrous band running along the bottom of the foot, from the heel bone forward to the base of the toes. It is not a muscle. It works more like a tie rod across the arch, holding tension as the foot takes load and releasing it as the foot leaves the ground.
When that band is irritated where it anchors to the heel, the result is the pattern above. Overnight the foot rests in a relaxed position and the tissue shortens slightly. The first steps of the day stretch it again, which is why the first step hurts and the tenth does not.
Why it starts
Plantar fasciitis is usually a loading problem rather than an injury with a moment attached to it. Most people cannot name the day it began. Several things come up repeatedly when the history is taken:
- A change in time spent on the feet, particularly a sudden one. A new job, a new shift, a return to running, a summer of standing.
- Tightness through the calf and Achilles, which changes how the ankle moves and shifts load forward onto the arch.
- A change in weight, which changes the tension the band carries with every step.
- Foot shape. A flat foot and a high arch each load the fascia differently from a neutral one.
- Footwear that has quietly worn out, or unsupportive shoes worn for long days.
The heel spur question
Heel spurs come up constantly, usually after an x-ray taken somewhere else, and they cause more worry than they deserve.
A heel spur is a small bony projection on the underside of the heel bone. They are common findings. They are frequently present in people with no heel pain whatsoever, and frequently absent in people with a great deal of it. A spur on an x-ray is therefore not an explanation for the pain by itself, and neither its presence nor its absence settles what is going on.
When heel pain is not plantar fasciitis
This is the reason a heel that keeps hurting is worth having identified rather than managed indefinitely on an assumption. Several other things produce pain in the same region, and they are not the same problem:
- A stress fracture of the heel bone. The pain tends to build with continued time on the feet rather than easing after the first steps, and the heel is often sore when squeezed from both sides.
- Nerve irritation. A nerve branch passing near the heel can be compressed, which tends to produce burning or tingling and does not follow the morning pattern.
- Insertional Achilles problems. Pain at the back of the heel rather than underneath it, sometimes with a thickened, tender area.
- Thinning of the heel fat pad, more common with age, which produces a deep, bruised ache in the center of the heel.
- Inflammatory conditions. Heel pain arriving alongside morning stiffness elsewhere, or with other joints involved, is a different conversation and is worth raising at the visit.
The cost of waiting it out
These possibilities are managed differently from one another, so time spent treating the wrong one is time that does not count for much. That is the first cost of waiting.
The second is easier to miss. A heel that hurts changes how a person walks. A gait built around avoiding one sore spot quietly loads the other foot, the knee, and the hip in ways they are not arranged for, and it is common for the second complaint to arrive well before the first one has resolved.
What an evaluation involves
Assessing heel pain is largely a history and a physical examination, and the history does a great deal of the work. When the pain is worst, what it feels like, what changed in the weeks before it started, and how it behaves across the day all point in different directions.
The examination establishes where exactly the tenderness sits, since a centimeter or two separates several of the possibilities above. Ankle and calf flexibility are assessed, the arch is looked at under load, and the way the foot meets the ground is observed. Imaging is not automatic. It is used when the history or the examination raises a specific question it can answer, such as a suspected stress fracture.
Heel pain that has run on for weeks, or that keeps returning after settling down, is worth having identified rather than assumed. Our Chillicothe office evaluates heel and arch pain and can determine which of these is actually in play.
This article is general information about a common foot and ankle condition. It is not medical advice and it is not a diagnosis of your own symptoms. If something is wrong with your foot, have it examined.
Care at Bends Foot and Ankle is provided by Eric Storts, DPM, FACFAS, board certified podiatric foot and ankle surgeon.