How to Treat Heel Pain: The Truth About Plantar Fasciitis

 Heel pain can be excruciating and stubborn. Here’s what the experts recommend .

When your heel hurts, it’s a real pain in the butt: Every step feels like the pad of your heel’s stripped away, as if you were slamming bare bone onto concrete. And even if you rest, the pain doesn’t, throbbing and aching even as you sit.

The main culprit is plantar fasciitis, a stubborn, painful malady that impacts 7 percent of all adults, and 12.7 percent of runners. It’s even more common as you age, and if you’re an athlete, if you’re overweight, or if your work requires you to stand for hours at a time.

According to Adam Shapiro, DPM and president of Foot & Ankle Associates, plantar fasciitis is becoming more common among people trying out the fastest-growing sport in America: Pickleball.

You may have experienced it without even realizing it, he says. That’s because this heel fascia[fash-ee-uh]nounConnective tissue that supports muscles and helps with movement.Learn MoreClose pain doesn’t usually show up during the activity itself, but afterwards.

“Classically, you might have a little pain during the activity, but one symptom that is fairly common is what’s called ‘post-static dyskinesia,’” he says. It’s a science-y way of saying that after you engage in activity, you’re static… and the pain sets in. “When you are sitting for any length of time or you are sleeping, and you go to get out of bed in the morning, you may have intense pain on those first six to 15 steps on your heel.”

Fifteen steps of pain isn’t so bad. But over time, plantar fasciitis can build up, resulting in stubborn pain that lasts all day, and is often resistant to efforts to alleviate it.

Here, Shapiro and Mike Stella, a corrective exercise specialist and founder of The Movement Underground, explain why this pain starts, how to prevent and manage it, and what a doctor can do to help.

What is plantar fascia? And what causes the “fasciitis”?

Fascia is a type of connective tissue that separates muscles and organs. It supports and protects muscles, keeps them from rubbing together, and makes compartments within the muscle.

“If you think of the white rim around a tenderloin steak, that’s fascia. It’s this very dense, fibro-connective tissue,” says Shapiro. The plantar fascia is fascia that starts on the heel bone, and spreads out to your forefoot.

“It operates like a spring,” Stella says. “It’s a stiff cord that when you load energy through it, it transmits that energy really well.”

Plantar fasciitis happens when the spring gets damaged. Micro-tears develop in the fascia, and the tissue becomes irritated. And these micro-tears can be caused by all kinds of small traumas, Shapiro adds.

“It could be increased standing at work on a concrete floor. It could be pushing your mileage on running or distance walking, or going for a hike,” he says. “We see a lot of it on vacation, where people are traveling and walking a lot more than usual.”

This can even happen if you’re an athlete that exercises regularly. When Stella, who strength trains religiously,  joined his mother-in-law for his first taste of pickleball, the stop-and-start lateral movement triggered heel pain the next morning.

“It usually means people have done too much, too soon, and they’ve irritated that connective tissue,” he states. The trouble is, fascia doesn’t heal as quickly as other types of tissue, like muscle. And when it’s on your foot, it’s hard to rest it — you’ll still likely take 6,000 more steps on it the next day. And as we age, the fascia becomes less elastic, which makes those micro-traumas more likely to occur, and slower to heal.

The inability to let the injury heal, Shapiro says, is why plantar fasciitis builds up and goes from a one-time, after-pickleball pain session, to a chronic condition.

“You get caught up in this pain cycle where it won’t resolve on its own.”

How to prevent plantar fasciitis pain

Plantar fasciitis is an “overuse” injury, kind of like a tire wearing out on your car. That wear can happen suddenly, or it can slowly erode at the tissue over time. Both of these cases occur when we do too much, too soon, Stella says.

You can help stave off fasciitis by warming up before activity, Shapiro says. Focus on stretches and movements that warm up your hamstrings, calves, and Achilles. This can include classic calf stretches, like pressing against the wall and hamstring stretches like placing a straightened leg on a chair or bench and reaching for it. Moving the tissues in advance of exercise also helps—lunges, short hops, skips, and even going up and down on your toes before a walk or run can help the fascia be more supple and less prone to injury.

Some other strategies that can help reduce your risk of fasciitis include:

• Wear supportive shoes: If you’re going to be standing a lot (especially on hard surfaces), or if you’re suddenly increasing the amount you run or walk, wear shoes with cushion and arch support. 

• Build up to minimalist footwear slowly: Minimalist shoes, or shoes with a wider toe box, can be great for your health and movement, Stella says. But many people go all-in on them all at once, triggering heel pain. If you’re interested in transitioning to this kind of footwear, Stella suggests doing so gradually: Start with small doses of short walks or workouts, and wear more cushioned shoes the rest of the time. Build up the dosage of minimalist footwear over time.

• Build up treadmill incline over time: Same idea here, Shapiro says. If you’d like to use incline treadmill walking as a cardio modality (as with the 12-3-30 workout, a popular low-impact treadmill routine where you set the incline to 12%, walk at a speed of 3 mph, for 30 minutes) don’t start at that 12 percent incline. Walking with your ankles flexed up in this way may trigger heel pain. Instead, work your way up to this incline over time.

The same goes for walking-intensive vacations: Instead of going from zero to 16,000 steps, plan to increase your step count gradually in the weeks leading up to your trip to stave off after-hours pain.

• Concentrate on nutrition and sleep: “When [fascia] is injured,” Stella says, “it’s very difficult for your body to repair or heal it.” But you can help, he mentions, using the same things that help your body heal from muscle soreness and other damage: A diet with protein, fruits, and vegetables, plus consistent, restorative sleep.

How to manage plantar fasciitis pain

Just as with prevention, Shapiro says, you can manage minor heel pain by warming up. Instead of diving straight into a workout or long walk, stretch your Achilles, calves, and hamstrings, and get the joints moving.

After your workout, studies have shown that deep friction massage of the arch — either manually, or using a lacrosse ball, massage gun, or roller — can help.

While these treat the pain, Stella adds, you can also make your plantar fascia more resilient to stress by turning “too much, too soon” into a gradual build-up of stress resistance.

“If the goal is to get back to pickleball or basketball or running or high-impact, ballistic loading, we have to expose people to it,” he cautions. Add some skips, jumping jacks, and short pogo hops before your workouts, gradually increasing the amount of bouncy, ballistic loading your feet can handle.

Increasing your mobilitymoh-bil-i-tee]nounThe ability to move freely and easily through a full range of motion.Learn MoreClose may help take strain off the plantar fascia, too, Stella says. If your big toe can’t flex upwards, for example, you can’t use that big digit to push off with each step. Your foot instead collapses inward, using your arch — which is held up by your plantar fascia — to push off.

“You don’t ‘have flat feet.’ You stole the arch as mobility,” he says. “You used that range of motion to get around a lack of range of motion somewhere else. You’ve over-leveraged that tissue, and now you’ve taken away the spring [created by the plantar fascia].”

Stella points out that you can increase this range of motion with three simple movements for your feet:

• Gas pedal press: Place your big toe and the ball of your foot up against the corner of a wall. Press down against the wall as if you’re pushing the gas pedal of a car, focusing on your big toe so that it raises up compared to the rest of your foot. Hold this position, and increase the intensity and duration over time.

• Full range toe raises: Simply stand on the ground in bare feet, and push yourself as high as you can on your toes, focusing on a full range of motion. Hold at the top, and try to increase the range and duration of the position over time.

• Slow, eccentric calf raises: “Eccentric” just means the “lowering” part of any exercise. In this case, you’ll stand on the edge of a step, with the balls of your feet and toes on the step. The rest of the feet should hang over the edge. Press up onto your toes, and then slowly lower yourself back down so that your heels go below the balls of your feet. You’ll feel a huge stretch in your calves.

How your doctor can help with plantar fasciitis

For most people with chronic plantar fasciitis, the pain won’t resolve on its own, and a doctor or physical therapist will be needed to help. The good news: Almost all cases can be resolved without surgery.

Different doctors will approach plantar fascia pain differently, Shapiro states, but here are some procedures and methods to expect:

• X-Ray: Shapiro starts with imaging to make sure that the pain is really plantar fasciitis. “You could have a nerve impingement in the heel, and that mimics fasciitis,” he mentions. “You could have a minor rupture, or a stress fracture of the heel bone.”

• Home exercise and stretching program

• Arch supports and orthotics: These custom inserts can help support the arch, which may drop with plantar fascia injury. Doctors may also recommend certain shoes that have more support.

• Cortisone injection: Corticosteroids can reduce inflammation[in-fluh-mey-shuhn]nounYour body’s response to an illness, injury or something that doesn’t belong in your body (like germs or toxic chemicals).Learn MoreClose and pain. With too many of these shots, though, tissue may degrade.

• Sleeping splint: This boot holds the foot in a position with the big toe pressed slightly up. It can reduce the morning stiffness and pain, Shapiro says.

• Shockwave therapy: In this method, high- or low-energy shock waves are sent into the foot, in the hopes of stimulating the fascia to heal on its own. This therapy is usually not covered by insurance, Shapiro adds that in his experience this only works about half the time.

One or more of these methods usually works, Shapiro says. If not, a minimal incision surgery, called endoscopic fasciotomy, may be recommended. This procedure takes about 30 minutes, with 6 to 8 weeks for recovery.

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