Doc, why do my heels hurt? I hear this question at least once a day in my office. When I think about it I wonder why I don’t hear this complaint more often than I do. It is estimated that the normal person takes 1 million steps per year. With each step, each foot is required to hold one to one and a half times body weight. When you run you put two to five times body weight on each foot. Then when you add the force of impact the load sky rockets. So it is really amazing how much stress is put on the heels and how well they hold up under all this stress. The short answer to Why do my heels hurt? is inflammation. Heel pain is usually due to inflammation where the plantar fascia attaches to the heel. As with all inflammation the proper initial treatment is rest to allow healing and then correct the problem to prevent it from happening again. However for most people this simply is not practical. You need to walk around. You just can’t put your feet up for a few days. Who among us in our busy lives can take a couple of days off our feet. Even if we could rest for a few days if the problem that caused the pain is not corrected, the pain will return. The key is to correct the problem. In order to correct the problem we have to know the cause.
Causes of Heel Pain
While it is possible to bruise the fat pad of the heel by stepping on a stone, this is not the kind of heel pain I typically see in the office. The (why do my heels hurt?) type of heel pain I see in the office is usually from a condition called plantar fasciitis (plant-tar-fass-she-eye-tis). The heel pain from plantar fasciitis is usually worse in the first few steps in the morning and also when you get up and take those first few steps after sitting for a while. In the early stages, the pain subsides as you walk for a while and everything gets stretched out. However as the condition progresses the pain lasts all day long and may get worse throughout the day.
The plantar fascia is a band of fiber tissue that connects the heel to the bones of the toes. The plantar fascia acts like a spring and it is the tension in the plantar fascia that creates the arch of your foot. As you take a step, the plantar fascia stretches out a bit to allow the arch to flatten out and allow the foot to pronate (rotate toward the floor) This action of pronation allows the bones of the mid- foot to unlock. The loose, unlocked bones of the mid-foot allow the foot to adapt to uneven surfaces. The spring action of the plantar fascia also allows the foot to act as a shock absorber. At the end of the step the plantar fascia helps reverse the process. As the weight is transferred from the mid-foot to the fore-foot the plantar fascia tightens up again and allows the foot to supinate (rotate away from the floor). Supination relocks the bones of the foot and the foot becomes rigid so it can push-off from the floor and propel you forward.
The pain associated with plantar fasciitis comes from inflammation where the plantar fascia attaches to the bottom of the heel. This area of attachment becomes inflamed if the foot over-pronates and stretches out the plantar fascia too much. The over-stretching causes the plantar fascia pulls away from the bone. The body protects itself by building-up the bone where the plantar fascia attaches to the heel. The resulting build-up of bone is called a heel spur. On x-ray the heel spur looks like a hook shaped piece of bone coming out of the heel. However the heel-spur itself is not what is causing the, why do my heels hurt, type of pain. The heel pain comes from the inflammation of the fascia where it attaches to the bone.
Another cause of heel pain is at the site of attachment of the Achilles tendon to the back of the heel. The pain from this condition is bursitis. Bursitis is inflammation of the bursa. A bursa is a pillow-like sac of fluid that is found anywhere a tendon comes in contact with or curves around bone. The bursa acts like a cushion to protect both the tendon and the bone. Too much pressure or friction on the bursa causes the bursa sac to become inflamed and painful. Thus bursitis is usually the result of over-use and this type of pain in the back of the heel known in medical terms as retrocalcaneal bursitis (retro means behind, the calcaneus is the medical term for the heel bone). Usually this is caused by excessive running but can also be caused by the shoe being too tight and putting too much pressure and friction on the area.
The Solution To Heel Pain
Now that you know the answer to, why do my heels hurt, the next question you may ask is What can I do about it? The treatment for these conditions is usually relatively simple and straightforward, seldom requires surgery and may not even require a visit to the doctor.
Since the cause of plantar fasciitis is usually due to over pronation and excessive stretching of the plantar fascia the treatment is to limit the amount of pronation and stretching. This is most easily accomplished through the use of a simple arch support. However the arch support must do precisely that, support the arch. Some people use the term arch support to refer to the cushions you can but over-the-counter in the drug store but this is not what you need. The over-the-counter arch supports seldom provide enough support to correct the problem of over-pronation. An arch support with the rigidity to support the arch must be custom fit to the contour of the foot or it will cause pain. That is why the over-the-counter arch supports are soft. If they are soft they do not need to match the exact contour of the foot. However if they are soft they will also not support the foot. Therefore the proper treatment requires a custom arch support. Fortunately custom arch supports no longer have to cost an arm and a leg. New technology allows custom arch supports to be made that are only slightly more than what you would pay over-the-counter.
The pain from retrocalcaneal bursitis (pain behind the heel) is treated by rest, anti-inflammatory medications such as ibuprofen and a simple heel insert that lifts up the heel slightly to put a little bit of slack in the Achilles tendon and allow the inflammation to subside. However if a heel insert is put in one shoe it is important to also put the same size insert in the other shoe to balance the leg lengths.
Pain in the heel is your body’s way of telling you that something is wrong with your foot biomechanics. If you have a problem with your foot biomechanics you could also have a problem with knee, hip and low-back biomechanics. If you ask yourself, why do my heels hurt, then it is important to have this condition diagnosed and corrected as quickly as possible.