I often see patients complaining of heel and sole of foot pain. They may identify it as plantar fasciitis, or they may simply point to the spot that hurts. Most of them have shown the classic pattern, in which they have the most pain on first stepping out of bed in the morning, then feel better for a while, then have more pain again after being on their feet for a long time through the day. So many people have this pain going on that I want to get the word out more generally about how to relieve it, instead of just telling my own patients one at a time.
This common condition usually responds well to self-care, which is crucial whether one is working with a health-care professional or not. Let’s look at what’s going on in the leg and foot and what you can do about it.
The term plantar fasciitis refers to inflammation of the fascia, the connective tissue, in the sole of the foot. (Plantar means anything having to do with the sole of the foot, as in plantar warts, often mismentioned as “planter’s warts.”) Very often, the pain is felt mainly or entirely in the center of the heel. There is a simple reason for this. The Achilles tendon connects with the foot right there, and when the tendon is tight, it pulls on its attachment to the bone, which hurts, sometimes quite a lot. This can affect one or both feet.
Generally speaking, although the pain can feel like you’ve got a rock in your shoe or like there’s a sharp object inside your heel itself, this is not necessarily being caused by a heel spur, which is a growth of extra bone on the calcaneus (heel bone). Heel spurs often cause no symptoms at all, and may or may not exist at the same time as plantar fasciitis. If you do have a heel spur, don’t panic. The usual treatment is the same as what I am describing here, and it is very unlikely that you will need surgery or any kind of drastic intervention.
Why is the pain worse first thing in the morning? During the night, your ankle extends, since you are not putting weight on your foot, and the back of your calf is allowed to shorten (as is the sole of your foot). As soon as you do put weight on the foot, your ankle must flex so that your foot is flat on the floor, which pulls on the back of your calf. The tight muscles and tendon suddenly yank on that attachment at the heel and on the sole of your foot in general. After you walk around a bit and get things loosened up, the discomfort eases. Then, after some hours of weight bearing, your inflamed, upset fascia starts to get more irritated and lets you know. Sitting for long periods may cause a similar effect to lying down overnight.
You can see that a big part of the solution is to open up the tight tissue so that it’s not pulling this way and can let the plantar fascia calm down and heal. If you have this problem, you will probably find distinctly tight, tender knots in your calf muscles and/or above your heel. Podiatrists typically prescribe stretching of the calf, which is good and necessary, but the trouble is that if you stretch aggressively without doing anything to loosen those tight knots first, you will probably just irritate and aggravate the situation more.
So here’s what you need to do: Feel around throughout your calves and ankles for tight areas, which may be exquisitely sore to the touch. When you find them, gently press and massage them. Experiment with the amount of pressure; you need to be firm enough to make a positive change, but you don’t need to torture yourself. Keep at it until the knots release and the spots aren’t so tender. I recommend doing this before you go to sleep and before you get out of bed in the morning, but anytime is OK. For some reason, massage of the calf is virtually never mentioned by podiatrists or in articles on plantar fasciitis, but I find it to be the most important aspect of treatment. You should start feeling improvement pretty quickly, maybe even immediately. You can also massage the soles of your feet themselves.
Heat may be helpful to help the muscles relax. Ice or cold packs may feel good on your feet to reduce inflammation. You may need to rest from your usual activities, especially if sports or excessive standing or walking are causing pain— but you don’t want to be so immobile that you end up with more stiffness and tension. Whatever makes you feel better is fine with me. I treat patients with acupuncture for the knotted muscles and inflammation, and I use microcurrent stimulation on the feet, since needling directly into the sole can be unpleasant. Professional massage, osteopathic manipulation or other manual therapy, or chiropractic could also be useful. Whatever you choose, self-treatment is going to be extremely important.
What caused the calf muscles and Achilles tendon to get so tight to begin with? There could be a number of factors, such as lack of exercise, too much muscle-building exercise without enough attention to flexibility, a previous injury that has led to muscle imbalances, or wearing inappropriate shoes.
Often adding arch support will go a long way toward solving the problem— although an overly intense or rigid arch support, or one that doesn’t fit well, can contribute to causing it, as once happened to me. Try different shoes and different arch supports to see what seems to work best for you. You don’t have to spend a fortune on orthotics to start with; begin with inexpensive store-bought types and see how you do. It’s possible that you will in fact need custom orthotics in the long run, but you don’t need to start there, and if someone tries to sell you on very pricey ones, I suggest that you put them off for now. Also, some people are comfortable with very firm arch support, while others need as much softness as possible to comfort their sensitive soles.
I have seen a couple of cases that didn’t respond to these basic strategies, but they are rare. It may take a number of weeks or even months for the pain to resolve completely, but you should be seeing definite improvement soon. If that doesn’t happen, something else is going on and you will want to look further.