Heel Pain: Plantar Fasciitis and Heel Spurs
Heel Pain can be one of the most debilitating issues that brings people to my clinic. For some, this is the first time they have ever felt this kind of pain. For others, It has been off and on for years! Who could have ever thought your feet could bring you to your knees like this?!
According to findings from the American Podiatric Medical Association approximately 40% of all adults surveyed had suffered from heel pain at some point! Many of those were chronic meaning symptoms lasted for 6 months or longer. The majority of those surveryed stated they believed they had or were formally diagnosed with plantar fasciitis.
Plantar Fasciitis
If 40% of people get heel pain, most of those will be plantar fasciitis. Plantar fasciitis is by far the most common ailment of the heel and one of the most common conditions of the foot in general. Plantar fascia heel pain is very indiscriminate in who it will affect:
High arches? You get plantar fasciitis!
Flat arches? You get plantar fasciitis!
Active lifestyle/work? You too!
Sedentary lifestyle/work? Yes, you too!
Basically, if you have a foot there is a good chance you or someone you know will have plantar fasciitis at some point.
What is the plantar fascia?
The plantar fascia is a thick band of tissue along the bottom of the foot connecting the ball of your foot to you heel. It is the main ‘static’ support and shock absorber of the arch. 'Static' refers to the fact that the plantar fascia does not actively move or flex on its own like muscles can. When your feet are kicked up with your shoes off, that resting position of your arch is where the plantar fascia is happiest!
So, what does the plantar fascia look like you ask?
Imagine a triangular slice of pizza on the bottom of your foot. The crust goes along the ball of your foot and the tip inserts in to the heel (hungry yet?). This represents the position, shape, and main insertions of the plantar fascia!
Plantar fascia, if it was made of pizza!
What caused my plantar fascia to start hurting?!
The most common underlying cause is a tight Achilles tendon. Normally, our ankles want to flex towards your leg 10-20 degrees past foot flat (when the foot makes a 90 degree angle with the leg) when we walk. When the Achilles tendon is tight it acts as a tether on your heel bone making normal ankle motion nearly impossible. Due to the lack of ankle motion you put a lot of extra force on your forefoot and use the front of your foot like a lever to try and get the ankle to move more. The increased pressure on the front of your foot collapses your arch and stretches the plantar fascia.
Foot and arch while standing still
Foot and Arch as starting to walk forward.
Can appreciate the decrease in arch height as forefoot is drove in to the ground to allow ankle flexion while walking
As the plantar fascia gets stretched it pulls extremely hard on the front of the heel bone where it is the least spread out and most concentrated. The fascia pulls so hard it will tear itself and pull small pieces of bone from the heel! Your body will react to these microtears and microfractures by sending lots of swelling and inflammation to your heel (inflammation is the -itis of plantar fasciitis). It is this swelling that causes the vast majority of the pain you feel.
Xray of a heel with the plantar fascia illustrated. Blue: representing the plantar fascia. Red: showing tears in the fascia and the spur formed by the pull of the plantar fascia. Also interesting is seeing how high the spur on the bottom of the foot sits above the ground
When you rest your body is able to pool more and more of the swelling in your heel. You go to get back up or start your day and your heel is so swollen it’s like stepping on an over inflated water balloon that wants to explode inside your foot! The swelling pushes on all of the tender muscles and nerves in the area which causes the severe pain. You walk a little bit and slowly work the swelling back to a less painful level- letting you get off your tip toes and walk normal again. Then you rest and start the vicious cycle all over again.
But what about heel spurs? I was told that was the problem!
Remember from above, the plantar fascia will pull hard enough on the heel to cause small pieces of bone to be ripped forward with the fascia. These small pieces will be pulled off and will heal back down to the main heel bone many times during the progression of symptoms. Slowly, these small fractures build up and form a visible spur on the bottom of the foot, because of this the spur is actually inside the plantar fascia. Heel spurs get a bad reputation because they are able to be seen easily. The doctor will come in to the room with the xray, point at the spur, and say “there’s your problem!” However, this isn’t quite the truth. In almost all cases, sparing a few very rare conditions, the spur is just a symptom of the constant pull on the bone by the fascia.
Heel spurs can occur on the bottom and the back of the heel, and like the picture above are routinely seen together. Spurs on the bottom of the foot are virtually never a major concern long term. Once you start treatment for the underlying issues, as mentioned below, the pain will go away but the spur will be there as a permanent reminder of what you went through. Spurs on the back of the heel can sometimes cause issues, the difference is in the surrounding anatomy. The bottom of the foot has a very thick fat pad and lots of muscles, tendons, and ligaments that separate and pad the spur from the outside world. The back of the heel on the other hand has very little overlying cushion besides the Achilles tendon itself, but the back of the heel is another post all together.
Conservative Treatment
Conservative plantar fasciitis treatment as hinted at above, revolves heavily around stretching the Achilles tendon. The rest of the therapy takes a much lower priority and that is treating the inflammation and supporting the arch/plantar fascia. Conservative therapy will completely resolve your symptoms over 95% of the time
Stretching
Stretching for Plantar Fasciitis is a marathon, not a sprint. The Achilles tendon is the longest and one of the strongest tendons in the entire body. It routinely moves 3-5x your body weight and is the main reason you can run, jump, and climb stairs or other objects. Anything that causes your foot to point down, called plantarflexion, shortens your Achilles tendon and makes it tighter. As humans, we do a lot of things to put our foot in that position so it takes a very focused effort to encourage our Achilles to stretch the other direction
There are a lot of ways to actively stretch your Achilles, I want to highlight my 2 favorites below.
Sitting/laying calf stretch
Very straight forward, get a towel/belt/dog leash/something without much give and loop it around the ball of your foot. While keeping your knee straight, pull the foot back until you feel a deep stretch, hold 20-30 seconds. Repeat 5-10 times. The reason you don’t want something stretchy: There may be someone I know, who doing this stretch with a stretch band hit themselves in the face. Since the Achilles tendon is tight, those stretch bands may end up by your ears before they finally get tight enough to give you a stretch. Then something happens, it slips off of your foot and smacks you in the face. Also, it was me.
I really like this stretch right before you go to sleep and right before you get out of bed. It REALLY helps with the first step pain! However, its simple, effective, and easy enough to do at any time!
looped around the ball of the foot, pull back until you get a good stretch
unintentional consequence of using the leash, you may greatly confuse you dog
Stair Stretch
Much as it sounds, this stretch for plantar fasciitis requires a step and preferably one with hand rails for balance. I prefer to do this stretch with shoes on, for comfort.
Do one side at a time. Put the ball of your foot, just in front of your arch, on the very front of the stair so your heel and arch are hanging off the stair. While keeping your knee straight, slowly let gravity pull your heel as low as it will go. It is very important that you din’t jump or push your heel down harder as your Achilles is vulnerable in this position. Once your heel is as far down as it wants to go, hold for 20-30 seconds. Repeat 5-10 times. As you come back up, stop when level with the stair, don't go up on your tip toes.
Much more comfortable if wearing shoes.
Don’t bounce or force past where gravity takes your heel
General rules for these or any Achilles stretches:
Keep your knee straight. The Achilles has 2 main muscles in it : the Soleus and the Gastrocnemius. The Gastroc is the main culprit that over tightens and it crosses the knee joint, so if your knee isn’t straight that muscle is slacked and doesn’t get stretched as well
Don't force the stretch deeper than you can tolerate. Pain is a good thing, it keeps us from injuring our bodies! Get a deep stretch, but don’t writhe in pain
Stretch routinely throughout the day! If you can only dedicate 10 minutes to stretching, I'd rather you stretch 10 times for 1 minute than 1 time for 10 minutes
Additional Stretching Aid: Night Splint
Similar to what I use in office. You can not walk in these, they will break. So get comfy
The final area of home stretching I routinely utilize in office is the night splint. Night splints allow us to stretch the Achilles in a much different way than above. In the above stretches, we are trying to get as deep a stretch as we can and then hold it for a short period of time 20-30 seconds. The night splint does the almost the inverse, It gets a very light stretch that you can tolerate for 30-60minutes at a time!
Minor misnomer as you can actually wear the night splint at any time of the day. You can wear it much longer than 30-60 minutes at a time, that is just my general recommendation. Some people do sleep in them, I find that having my foot stuck at 90 degrees while trying to sleep is a special form of torture.
Arch Supports
More in depth guide for this to come but briefly, arch supports don’t serve a major purpose in my practice when you are having acute pain. They can help but I generally reserve them for after you’re feeling better to help with keeping it from coming back.
In office, I will make a removable strapping that sits in the arch only. It is tight and has a pad built in, its job is to absorb some of the stress on the plantar fascia and pad to help decrease some arch collapse. You can find similar by googling arch support brace, I don’t have a brand I recommend as we make ours in house but look for highest, best reviews you find.
Orthotics/insoles should have a rigid inner shell which is why they can sometimes cause more pain during acute plantar fasciitis than help. I only usually recommend 3 brands of over the counter inserts and none of them are gel based or branded with Dr. Whatever. If you want to try a brand I would recommend you to look up Redithotics, Powerstep, and/or Superfeet. They are excellent products, have internal shells, and work for over 90% of the people I think need insoles . Custom orthotics are beneficial for some, but are overkill for most, extremely expensive (300-600$), and usually too rigid. Unless your insurance is great for covering them, please try over the counter products like mentioned above first. The links to these products can be found in the helpful links.
The rigid shell is what sets these apart from other OTC brands and why they are so highly recommended and routinely sold by podiatrists. The other stuff listed is just padding and fluff for the most part.
Anti-inflammatories
Quick disclaimer: the medications listed below are purely my opinion and not to be used to dictate your treatment. Your doctor will prescribe or recommend medications based on your individual situation
ICE!
Ice is an amazing natural anti-infamatory! I almost always recommend Ice as a front line treatment for pain and swelling. The only times I do not are in patient’s like certain diabetics or other conditions that cause of loss of sensation in the feet. I don’t want to risk them getting unintentional frost bite.
My recommendation: freeze a water bottle and roll it under your arch and heel for 20 minutes a few times a day. It will help with swelling via the cold itself and by acting like a rolling pin to help push the swelling out of the area for a little while!
Over the counter NSAIDs
Always take NSAIDs (NON steroidal anti inflammatory drugs) with food or milk to protect your stomach. Make sure you are well below the daily recommended maximum dose, and consult your doctor if you have a history of heart, kidney, or stomach issues before using.
These will work well for most people. Ibuprofen and Naproxen work better than Acetaminophen (Tylenol) and Asprin as they work better against inflammation. If you have kidney issues, you may only be allowed to take Acetaminophen/Tylenol in which case, it will still help better than nothing.
Prescription NSAIDs
These will be given by your doctor with the hope of either protecting your stomach or decreasing how often you take the medications.
Your doctor will likely talk to you about these and offer them at your visit. What your doctor offers may differ and is based on what they have the best experience using. The main ones I use are:
Mobic (Meloxicam): Same class of medicine as ibuorofen. For patients with no known stomach, heart, or kidney issues, who tolerate NSAIDs well, who want to try a 1 pill a day option. Insurance covers this well for most people.
Celebrex (Celecoxib): Similar class as Mobic but with less stomach irritation. Usually a 2nd option after mobic fails or people with known stomach issues with ibuprofen or mobic. For patients who want a 1-2 pill a day option and don’t have heart or kidney issues. Insurance coverage is spotty and can be pricey for many.
Duexis: is for people who respond very well to ibuprofen and want to take ibuprofen but have stomach issues. It is ibuprofen coated with famotidine (medication used for people with heart burn and acid reflux) which helps protect the stomach from the ibuprofen. Still not advised in people with heart or kidney issues. Usually not covered by insurances as there isn’t a generic, have to send prescription through a specialty pharmacy to make affordable.
Oral Steroids
Similar to ibuprofen, but like ibuprofen on steroids! 😁
The Oral steroids prescribed are usually either prednisone or methylprednisolone. They act much stronger on the bodies inflammatory response than Non steroidals.
Steroids have a laundry list of potential side effects that worsen the longer you’re on them and the higher your dose so you doctor will usually give as a tapered dose: start off with a high dose, then slowly come back down. Usually will only last 6-10 days.
Not used in most diabetics as it will cause blood sugars to sky rocket while on them or in people with history of significant side effects.
For patient’s with 6/10 pain for more than a week, not responding to OTC NSAIDs I will offer either a round of oral steroids to start or the next topic…..
Steroid Injections
Steroid injections for plantar fasciitis are a blessing and a curse. On the one hand, they will provide the strongest, fastest acting anti-inflammatory relief available. On the other hand, they have to be injected directly in to the foot.
Steroid injections can be fairly painful for 2 reasons (other than it’s a needle):
The skin on the bottom of the foot where it is injected is 2-3x thicker than anywhere else on the body. The needle has to go through a lot to get where the steroid needs to be injected
The heel is already inflammed. Going back to the over inflated water balloon reference. Adding more fluid to an already swollen area causes everything to expand more, causing more pain.
The good news being, the pain is very short lived. Steroids are mixed with an anesthetic that quickly takes away any pain you had. In clinic, I also use a cold spray which makes the needle stick much less painful. I always chuckle when someone says the cold spray hurt worse than the needle. Definitely means the cold spray did its job!
Most providers will offer you 1 injection a month, up to 3 injections in a 6-12 month period. I routinely tell people, if you need any motivation to do your stretches… just remember this needle! In compliant people who get improved motion in the ankle and Achilles tendon, I rarely give more than 2 injections.
Physical Therapy
In some patients, the Achilles just doesn’t seem to stretch out as fast as we would like. In those cases, physical therapy can really get the ball going much faster. These musculoskeletal wizards of the stretching and manipulation world can give you more guidance and stretch you more in a day than you can usually get by yourself in a week. I find that people with back issues, upper body injuries/pain, some elderly, and children do much better under a PT guidance. They get a safe, monitored area and constant guidance on the stretches to make sure they are done correctly.
Surgical Options
Surgery like mentioned before is not very common with plantar fasciitis, but is an option if you have tried and failed 6-12 months of conservative treatment. I’ll briefly go over some of the options, the bulk of this material will be covered in a surgery guide later in much greater detail.
Regardless of which scenario you fall in to below remember only about 5% of people with plantar fasciitis go to surgery and of those less than 1% have anything done to the heel spur.
The surgical selection will be based on what part of the conservative therapy has failed. Below are the most common scenarios:
Could we not get your Achilles tendon loosened up?
Is the heel pain still there, even with excellent response to the stretching?
Do you have a lot of burning, tingling in your heel along with the pain?
Scenario 1:
Surgery would be aimed at addressing your tight Achilles tendon. The surgeon will determine if it is the Gastroc, Soleus, or Both muscles that are holding your treatment back. This usually requires a single or multiple incisions along the back of the leg to allow the Achilles tendon to move more freely. Post operatively you will be non-weightbearing or minimally weightbearing in a cast or boot for 2-6 weeks depending on which procedure is needed. Usually the doctor will also perform scenario #2 or #3 depending on other findings still lingering to make sure you don’t have residual issues.
Scenario 2:
Your Achilles tendon is moving like a champ now! You can do stair and towel stretches all day and you can almost touch the foot to the front of your leg, but you are still having heel pain!
Sometimes what happens is the scar tissue from the constant small tears can leave the fascia unable to accommodate even the new, decreased stress after your stretching success. In those cases, the doctor will go in and release part of the plantar fascia from the heel bone usually no more than 50%. In the absence of burning and tingling, this is usually done through a minimally invasive approach. The surgeon will either use small, single stitch incisions on both sides of your foot to insert a scope and blade or will do it blind through a small incision on the inside of your heel or the bottom of your heel. Post operatively you are usually walking in a surgical shoe or boot from day one, though some will have you off for up to 2 weeks while the incision heals.
Scenario 3:
Sometimes with plantar fasciitis you get double unlucky and get a nerve trapped as well. The biggest nerve in your foot runs behind the inner ankle bone where it splits and sends off lots of smaller nerves. One of those smaller nerves, called Baxter’s nerve, runs right by where most of your plantar fasciitis pain is located. This nerve gets squeezed and trapped in the surrounding inflamed tissues which causes a lot of other symptoms like burning, numbness, tingling along the bottom of your heel. If this is present, called Baxter’s Neuritis, then your surgeon may have to do an open procedure with an incision about 1-3cm in length on your inner heel to find the nerve and free it up. Post operatively you are usually walking in surgical shoe or boot from day 1, but you may be kept off of it for 2 weeks until the incision heals.
Conclusion
Plantar fasciitis is a very painful and often disabling pain. I find most people think it will just go away on its own, but this is rarely the case and the pain just keeps worsening. People who catch it early will clear the pain in a couple of weeks with aggressive stretching. The longer you wait, the longer it will linger. For the majority of my patients I tell them that if they are good about their stretching they will be 50-80% better in about 4 weeks.
In patient’s that are over a 6/10 pain more than not, I will usually recommend that injection as this is the fastest way to get over that severe pain. Just remember the injection is purely for the pain and plantar fasciitis can be healed without it, so don’t feel it is an absolute must
I hope this gives you a starting place for your heel pain! If you heel is causing you pain and keeping you from living life, please see your foot and ankle provider. The faster you act, the faster you are out of pain! The treatment for plantar fasciitis is very patient dependent, I can’t stretch for you so make it a priority. Don’t be bullied in to expensive custom inserts or surgery at your first appointment, the vast majority of people will not need these so work hard enough to make sure you are in the 95%!
If you get unlucky and need surgery, work with your doctor to make sure you get the best outcome for your current pain and situation.
Stay tuned for more of the heel pain series including Achilles tendonitis, Haglunds’ deformity, and fractures as well as the surgical options for all of these!
Last Updated 2/2/2025
