Heel Spurs, Plantar Fasciitis, and Heel Pain
heelspurs.com is an extensive source of information about plantar fasciitis, heel spurs, and heel pain. The links above are to different areas of the web site.
The most common cause of heel pain is plantar fasciitis. Many patients with plantar fasciitis have a heel spur on the front and bottom of their heel, but heel spurs do not cause pain. The common name is "heel spur" because it's easier to pronounce than "plantar fasciitis" and doctors are able to point to the spur on an x-ray. Causes of heel pain include inadequate flexibility in the calf muscles, lack of arch support, being overweight, suddenly increasing activity, and spending too much time on the feet. Arch support was rated the best treatment in our first survey of 1,800 visitors to heelspurs.com. The Plantar Fasciitis Orthotic is getting the best customer reviews and it is the most popular product. It is new for 2011. Returning customers may be seeking the
Pinnacle Orthotic. The primary difference is that the PF Orthotic should be used only for current cases of plantar fasciitis or heel spurs and the Pinnacle is best for general use once the condition has subsided. Survery respondents also benefited from: rest, ice, tape, and night splints.
See the products page for a list of other products.
Introduction to The Plantar Fasciitis Booklet
Plantar fasciitis (pronounced PLAN-tar fashee-EYE-tiss) is an inflammation of the plantar fascia. "Plantar" means the bottom of the foot,
"fascia" is a type of connective tissue, and
"itis" means "inflammation". Heel spurs are soft, bendable deposits of calcium that are the result of tension and inflammation in the plantar fascia attachment to the heel. Heel spurs do not cause pain. They are only evidence (not proof) that a patient may have plantar fasciitis. The plantar fascia encapsulates muscles in the sole of the foot. It supports the arch of the foot by acting as a bowstring to connect the ball of the foot to the heel. When walking and at the moment the heel of the trailing leg begins to lift off the ground, the plantar fascia endures tension that is approximately two times body weight. This moment of maximum tension is increased and "sharpened" (it increases suddenly) if there is lack of flexibility in the calf muscles. A percentage increase in body weight causes the same percentage increase in tension in the fascia. Due to the repetitive nature of walking, plantar fasciitis may be a repetitive stress disorder (RSD) similar to tennis elbow. Both conditions benefit greatly from rest, ice, and stretching. Surgery is a last resort and may result in more harm than good in up to 50% of the patients.
We get a lot of calls from parents who have very active children who are between 8 and 13 years of age who have heel pain. The children probably just have "Severs disease" which means the combination of activity and a growing heel bone is causing pain. Rest and time are required. Ice may ease the pain. Very few people under the age of 25 get plantar fasciitis.
Here are the treatments that I think are the most important:
The classic sign of plantar fasciitis (which is often called a "heel spur" because it's easier to pronounce) is heel pain with the first few steps in the morning (84% of our visitors). If this symptom is not present then the diagnosis of plantar fasciitis has to be checked more carefully. The pain is usually in the front and bottom of the heel, but the definition of "plantar fasciitis" indicates it can be over any portion of the bottom of the foot where the fascia is located. Patients often report that the pain "moves around." The pain can be mild or debilitating. It can last a few months, become permanent, or come and go every few months or years for the rest of a patient's life with no obvious explanation. Every year, about 1% of the population seeks medical help for this condition (one company claims it's 2.5%). The heel may hurt when it strikes the ground, but plantar fasciitis is not caused by the heel striking the ground. Some patients begin walking on the front of their foot because of heel pain. This may help if they have something other than plantar fasciitis, but if they have plantar fasciitis, walking on the forefoot causes more tension in the plantar fascia (which pulls more on the heel) and it can make their condition worse. Unfortunately, it can take 12 to 36 hours after harmful activity before the pain increases, so it is not usually obvious what activity is causing an increase in pain. For example, a runner may not know if it was a recent change in shoes or changing to a terrain with hills that is causing an increase pain. But since a lack of flexibility in the calf muscles and/or excess weight are the causes of most cases, it is not usually a particular activity that can be blamed.
- Stretching the calf muscles several times a day, especially in the morning and after prolonged sitting. Everyone seems to think the Foot Stretch is best (see reviews). We also have Night Splints
- Ice after activity.
- Tape when applied as shown (especially for severe cases)
- Stretching the plantar fascia in the morning.
- Arch Support (especially if you have flat feet). We recommend the PowerSteps.
- Losing weight if possible, especially in overweight women because our survey of 5,000 visitors shows overweight women are 6 times more likely than overweight men to get plantar fasciitis. This is probably because fat deposits lower on the body in women than in men. This lowers the center of gravity which will cause excess tension in the plantar fasciitis if there is not also greater flexibility in the calf muscles.
Despite the claims of various product manufacturers, there is no cure-all. Different treatments help different people. Patients need to be active in their treatment. Experimenting with several different treatments is often necessary before finding those that help. As in exercising and working out, actively finding a way to enjoy the daily routine that is beneficial to your feet is crucial for continued improvement. Applying ice, stretching, and taping are not inherently enjoyable, and it is not always obvious that they are helping. The pain usually increases gradually over weeks or months before help is sought, and improvement is usually just as slow. Patients often have to be patient. Setbacks are the norm in dealing with plantar fasciitis, and simply preventing the daily minor injuries is just as important as preventing the less frequent big injuries. A portion of a patient's lifestyle (excessive running or standing, over-eating, inactivity, or inflexible shoes) has often caused the pain, and it is that portion of their lifestyle that has to change. Desk jobs are unnatural and a very recent development, so they are probably a major cause by way of atrophy (desk jobs prevent the feet and legs from being naturally flexible and strong). Frequent stretching before walking should be emphasized for those with desk jobs.
Plantar fasciitis is related to "heel spur syndrome", but they are not the same. The heel spurs to which this web site refers are on the front and bottom of the heel, not the back of the heel. But many of the ideas presented here may be helpful for dealing with other types of heel spurs and heel pain. Heel spurs are not spike-shaped, but flat and shelf-like. They appear like spikes because x-rays are taken from the side looking down along the edge of the shelf. Pain probably rarely if ever results from heel spurs poking into tissue. Many people have heel spurs and they do not have any pain. A heel spur and/or the plantar fascia may trap or irritate nerves in the heel area (if only by inflammation) and this may be the primary cause of pain in some cases. It is often difficult and usually unnecessary to distinguish between plantar fasciitis and heel spur syndrome, if there is a difference. Causes and treatments for the two conditions are the same. Many doctors use the terms "heel spurs" and "plantar fasciitis" interchangeably. The phrase "heel spur" is used more often than "plantar fasciitis" because a heel spur can be seen on an x-ray, the idea of a "spur" poking into tissue provides a believable and understandable cause of pain even if it's a false description, and because it is easier to pronounce and spell than "plantar fasciitis".
Causes: The condition is usually caused by a change or increase in activities, no arch support, lack of flexibility in the calf muscles, being overweight, a sudden injury, using shoes with little cushion on hard surfaces, using shoes that do not easily bend under the ball of the foot, or spending too much time on the feet. The cause is usually unknown and mysterious to the patient. It has often been said that those with flat feet or high arches are more likely to get plantar fasciitis (heel spurs), but I do not know if that is the case. 30% of our visitors indicated they have high arches and 20% indicated they have flat feet, but this may not be different from the rest of the population. Arthritis, heel bone damage ("stress fracture"), loss of natural tissue for cushioning under the heel ("fat pad atrophy"), tarsal tunnel syndrome (the foot's version of carpal tunnel syndrome), and other conditions can cause similar foot and heel pain. Many of the ideas presented here can be helpful in dealing with these other conditions. Excess body weight is a major cause of heel pain. Our visitors are 27 times more likely to be overweight from either fat or muscle (BMI>25) than underweight (BMI<20). Our visitors are twice as likely to be obese (BMI>30) as the average American. But our visitors often do not know they are overweight because they are comparing themselves to other Americans who are the heaviest people in the world. Here's a chart to check your weight.
The most successful treatments reported by our visitors are the following:
- heelspurs.com (this web site) was ranked by visitors as the most beneficial "treatment", indicating visitors believe information is a key to getting better. Visitors are frequently very thankful for heelspurs.com because it shows them they are not alone or crazy as is often implied by friends, family, co-workers, and doctors.
- Rest was ranked the number two "treatment". The most important part of my recovery was to finally learn the motto "when in doubt, don't do it". I'm a little afraid to emphasize this too much because reduced activity can lead to atrophy which may be the cause of some cases. It takes 12 to 36 hours for many soft-tissue injuries to reach their maximum soreness, so it's often difficult to know when you're overdoing it or which particular activity (like squatting or climbing stairs) caused the pain to increase again. Swimming is one of the few safe alternative exercises.
- Ice is a miracle cure for soft-tissue injuries. Ice is not only great for professional football players with knee or shoulder injuries, but also for desk-jockeys who can't seem to get rid of their heel pain. It was ranked the third best treatment by our visitors. Applying ice after activity or injury is crucial. It may be beneficial to apply it up to 5 times a day. The best method of applying ice seems to be freezing a can of beans and applying it for 5 minutes. It can be reused, it doesn't melt and get things wet, and the metal transfers cold better than a plastic water bottle. It's best to keep the injury cool as much as possible for up to 48 hours after the injury, but cooling it for only 5 minutes after the activity provides possibly 50% of the benefit. I would apply ice every evening immediately after daily activities. Keeping a recent injury cool reduces internal "micro-bleeding" that can lead to micro-scars (and spur formation) and keeps inflammation down. Applying ice for longer periods of time may cause vasodilation (blood vessels increase in diameter in order to keep the tissue warm) that may speed healing by improving blood flow, but it may also be harmful by increasing inflammation if an injury occured within the last 2 days. Some sources say apply ice for 15 minutes, but that is too long unless there is something like like plastic or cloth that is partially insulating the ice from the skin. The tissue should be made cold, but not frozen. If the skin turns blue, it has been applied for too long. Some effort should be made to enjoy the ritual of applying ice so that you're not discouraged from doing it.
- Stretching the calf muscles without reinjuring the fascia before getting out of bed in the morning and a few times per day is well-known to be a cure for many patients. It's difficult to explain why stretching the calf muscle helps the heel, but to state it briefly, if the calf muscles allow the foot to bend back easily then there will be less tension in the bottom of the foot when walking or running. If the foot cannot bend back as far as needed, then it translates into excessive tension in the plantar fascia and Achilles tendon. Several visitors have emailed to say that religiously stretching after extended periods of sitting down at work and before walking was the cure. You can obtain products for stretching like the Foot Stretch and night splints, but leaning against a wall or using a step correctly may be just as beneficial (see the section on stretching). I use a 12x12x1 board leaning on a brick as an inclined plane. Not stretching before walking may cause a re-injury that can take a week to overcome, so consistently stretching before walking is crucial in many cases. But stretching too much can hurt the heel and Achilles tendon. The usual advice is to never stretch a cold muscle, but I believe this rule needs to be mostly ignored and taken as a warning against over-stretching when dealing with plantar fasciitis. A recent article claims stretching the plantar fascia itself is important.
- Tape can be used to give the fascia rest without reducing activity. Athletic tape can be bought at all pharmacies. We have a page of instructions and pictures for printing out in our document on taping. Tape was the cure for my severe case which began as a result of suddenly increasing in weight and playing volleyball. Losing weight, ice, and stretching would have been enough in my case, but I didn't know how important ice and stretching is, so the inflammation and pain became chronic and tape was necessary.
- Arch support is often recommended by doctors and journal articles, and it ranked #1 in our first survey, but in our 2nd survey it did not rank as high as the above treatments. My favorite arch supports are the Powerstep Insoles and Pinnacle Insoles which have more arch support than the ones I've seen in stores. If you're looking for an insert with the thickest and best cushion without arch support, we also sell the Super Cushion Insoles