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You might not know the term “plantar fasciitis” very well, but you may know the feeling of dread many people have every morning at the thought of putting their feet on the floor. (Perhaps you’re one of them!)
The heel pain of plantar fasciitis often presents itself as a sharp discomfort just behind the arch of the foot. In addition to feeling this pain first thing upon moving around in the morning, it can also crop up during the day after a long period of inactivity and after a period of prolonged activity (it’s hard to run away from).
Additional symptoms can include:
- Pain when pressing against the bottom of the heel.
- Pain when flexing your foot upward.
- Tingling or burning sensations, in some cases.
Most cases of plantar fasciitis involve heel pain in one foot, but a significant number can develop heel pain in both feet.
Plantar fasciitis is a very common cause of heel pain. The good news is that it’s also often a highly treatable one, too!
If you suffer from this condition and need treatment, call our Indianapolis office at (317) 545-0505 or contact us online to request an appointment.
What Causes Plantar Fasciitis
The plantar fascia is a thick band of tissue that runs along the bottom of the foot. It helps form the arch and flexes as you move, storing and releasing energy.
While strong, it’s not invincible. Excess strain on the tissue can cause very tiny tears to develop, which then leads to pain and aggravation. This strain can be caused by 4 common factors including:
- Biomechanics – the overall way your foot works.
- Activity – How many steps your take, especially in in excess.
- Gravity – Recent weight gain puts extra stress on your feet, often resulting in heel pain.
- Shoes – while not the primary cause of heel pain, they can be the straw that breaks the camel’s back.
Usually, a combination of 2 or more of the above will create Plantar Fasciitis.
A Pain in the Bottom of the Heel
I hear this 95% of the time with Plantar Fascia patients. This location is very common because that is where the Plantar Fascia attaches to the heel bone (calcaneus). The other 5% of Plantar Fasciitis patients have less specific symptoms. The cup the entire bottom of the heel to describe the location.
This structure is a very robust piece of connective tissue. It is very close to the strength of the Achilles tendon – the largest tendon in the body.
Why is this important? A tendon attaches muscle to bone. A ligament attaches bone to bones at a joint. A fascia is made of the same type of connective tissue except it connects and supports bones over a larger area than a joint. The plantar fascia runs the entire length of the foot from the toes to the heel. This directly supports about 14 bones and 12 joints. It is a great workhorse for the foot. It also acts as a floor for muscle attachment and stabilizes the arch. The foot greatly depends on the Plantar Fascia for function and support.
When the plantar fascia is stretched, the first area to get damaged is the attachment at the bottom of the medial heel. This is the weakest part of the band. The forefoot part of the Plantar Fascia is very wide. It spreads out over 5 metatarsals near the toes. As the damage escalates it may spread to more of the Plantar Fascia. In some chronic cases, it may extend beyond the arch area.
So why is there more pain in the mornings or after sitting for a while? Because of the flexibility of the plantar fascia.
Why do I have Heel Pain in the Morning? Or After Resting?
This is the second most common thing patients tell me. This may sound strange that there is more pain when you start walking than after a day of activity. The damage IS happening during standing, walking, or running. But when soft tissue is warm it is more flexible. This is true if it is a muscle, tendon, or ligament/fascia. After it cools down, the tissue is tight and not really happy about getting stretched. Sitting for 20 minutes or after a night of sleeping will make a huge difference in the level of pain. Perhaps this is where the expression “Cool your heels” came from.
If you have ever had a pulled muscle or tendonitis you may remember how painful it is to start moving. There is some improved comfort after the area is warmed up with activity. The fancy name for this is “Post Kinetic Dyskinesia” – which means pain after rest.
If there is no pain after rest (in the morning) then the heel pain may not be Plantar Fasciitis. Or the plantar fascia is just starting to get damaged and it is in the very early stage. The symptoms can be intermittent in the early stages and show up only a few days a week. It goes away with rest (we will talk about this later). Symptoms will show up after an increase of activity. Tenderness soon after Hiking, a heavy block of training for a race, and a weekend with the grandkids are things to watch out for.
You really have to appreciate how well the foot is designed. It will protect you for decades before symptoms show up. If the heel pain has been present for 1 month, 1 year, or 5 years the symptoms have been brewing for much longer. Fire is a great comparison to inflammation. If the fire is small it is quickly addressed. The longer the fire is ignored the bigger it gets and the more difficult it is to put out.
Biomechanics – Flat Feet
I also hear “I have always had flat feet. Why is my heel bothering me now?” The Plantar fascia is not a frail piece of tissue. It is thick and strong and it takes a lot of force to injure it. The end product is a sum of multiple and repetitive injuries. There is the proverbial straw that will eventually break the camel’s back. When the foot pronates (becomes flat and rolls inward) it pulls on the Plantar fascia.
If you take a 3-foot long rope that is 2” in diameter and tug on it- it won’t budge. If you do this for 1 month, 6 months, or 1 year, it will start to stretch. Small fibers begin to break and tear. That is the same as the micro-trauma the plantar fascia goes through.
You can blame your parents and grandparents for your foot structure. Next time you go to a family reunion look around. If you do not see any flat feet you should ask the adoption question. It is a very strong trait.
What many people don’t understand is the amount of force you put your feet on any given day. An average day is 5-6,000 steps and the recommended amount of activity for a healthy lifestyle is 10,000 steps a day. (Use 1,100 steps for a mile).
A light person (120 lbs.\54 kg) is putting at least 120,000 lbs. or 60 tons on their Plantar Fascia every day for 5,000 steps. If the foot is working as intended it will handle this force without problems. But… if you do not have good mechanics, and few of us do, then you have the invitation to join the Plantar Fasciitis club.
The mechanics of your foot is 75% of the reason you have heel pain.
Combining bad mechanics and a decrease in flexibility is like pouring gasoline on the fire. As we get more active or older, tendons and muscles lose flexibility. No athlete enjoys stretching but it is a big influence if they want to stay injury free and perform well. Nobody wants to get old but collagen (the stuff that makes up soft tissue) losses its flexibility.
Specifically, a tight Achilles complex is the problem. The heel is pulled off the ground earlier than it should during the gait cycle. That means it is under greater force for a much longer time. The Plantar Fascia is a strong structure but not as strong as the Achilles. It is pretty common to get discomfort at the attachment point of the Achilles (the other heel pain).
You can experience relief when you wear a shoe with a higher heel elevation than your daily shoes. The problem is that soon you will eventually need to elevate a little higher …and then higher. Good for short-term relief but not a great long-term plan
You just found out how much force there is with walking. The pounding can be 6-10 x a person’s weight with running, basketball, softball, or pickleball. Remember, that is for EACH step. So any increase in steps or change of activity can be a big contributor to Plantar Fascia stress.
Beginning a fitness program that increases running or walking can be the start of heel pain. Except it can be 3 weeks to 3 months before symptoms show up. You made a New Year’s resolution to be active but you did not plan on heel pain in February or March. Again, the delay in symptoms is because the Plantar Fascia is so strong and thick.
Springtime brings better weather and people become more active. There is an annual rise in heel pain following Spring break. Walking on the beach without shoes increases plantar fascia strain. And when the heel sinks into the sand it amplifies a tight Achilles. This is a great way to start or re-start heel pain.
Just Don’t Do It is four words that are not in our vocabulary. Rest is not a very good long-term solution for Plantar Fasciitis. More about this is in the “How To Treat Plantar Fasciitis” section.
Why Bad Shoes are Bad for Heel Pain
Shoes age like the rest of us. With age comes the loss of stability (at least for shoes). The soles of a running shoe are functional for 400-5oo miles. The EVA material may look good but the compress will lose 40% of its function at 500 miles. The same is true for the most important part of the shoe – the heel counter. This is the part of the shoe that surrounds the heel just above the sole. If this area weakens then the foot will rock back and forth more than it should. So getting a “New Shoe” will not be much help if it does not have all the important parts.
There are some people that cannot bring themselves to toss their old shoes away. My grandmother called these people “string savers”. The old shoes get demoted to cutting, grass, dog clean up, cleaning, creak stomping, camping, or car washing. Guess how many steps it takes to cut the average yard? That is a lot of unprotected steps. Bad shoes will not help bad biomechanics.
Children’s Heel Pain
These are the most common causes of adult Plantar Fasciitis. There is a kid’s version of this called Severs disease you should check out if your child is struggling.