I’m sitting on a plane as I write this flipping through the airline magazines.  I notice a few things that drive me nuts.  There are suggested exercises to do while seated.  Ankle rotation, foot flex, and heel lift.  You’re not serious are you?  Have you done these?  Who is this supposed to help?  So I flip past it and come across a section of foot products where there are 2 flimsy night splints, orthotic sandals, inserts to make you taller, and a stretchy thing.  OK I’m in a bad mood because I just paid to bring my luggage on the trip, but come on!  We’re talking plantar fasciitis.  This is severe pain in the heel of your foot.  Why do people buy this stuff?  Then I remember the single question I ask of all my residents when discussing heel pain, “why?”.

Why does your heel hurt, but mine does not?  Why are your first steps out of bed so painful?  Why did my aunt say that wearing cowboy boots is one of the best heel pain treatments?  Why is your right foot heel pain seem so much worse than your left foot?

Enough already, the flight attendant just spilled water on me.  Let’s get technical.

Why do we call it plantar fasciitis?

The plantar fascia is a broad ligament that runs from your heel to the ball of your foot.  If you pull your toes back (up) you can feel your plantar fascia in the arch of your foot.  Because there is this severe pain in the heel of your foot and into the arch it seemed reasonable to the first doctors who described this condition to call it inflammation of the plantar fascia.  They never asked “why?” or “what else could it be?”.  Here’s the technical part.  Inflammation at its’ most basic level is increased blood flow to an area that has been injured.  That’s why you can sometimes feel throbbing like your heart beat in your foot.  The plantar fascia is a ligament.  That means it is a thick, tough band that doesn’t have any space for wimpy, soft, little arteries.  How can you have increased blood flow to something that has no arteries?  Ha, ha you can’t.

We now know that the problem in your heel is the muscles not the plantar fascia.  The small muscles in your foot also run from your heel to your toes.  Bend you toes back and feel the fascia again.  The muscles are right under that, so how can you tell which one hurts by pushing on the heel or arch?  You can’t!  MRI has shown that plantar fasciitis type heel pain is really inflammation in the muscles where they attach to your heel.  Have you heard of a heel spur?  Well the spur actually develops from the muscles pulling away from the heel bone.  The plantar fascia attaches to the heel bone in a different area not at the spot where a heel spur is seen.  A classic heel pain treatment is injecting steroids.  The shot goes in the area where the muscles attach to the bone, not the plantar fascia.

Why are my first steps out of bed so painful?

That feeling of a hot poker sticking into your heel when you get out of bed is a classic complaint if you’re suffering from plantar fasciitis.  In order to explain this severe pain in the heel of your foot, I need you to keep in mind that the problem lies in the muscles.  Ligaments resist stretch up to a point then they break, like spraining your ankle.  Muscles can stretch.  It takes a very special set of circumstances all occurring at the same time to break a muscle.  When muscles work they are happy.  Lots of fresh blood circulates through bringing oxygen and washing out the used stuff.  If you stretch a happy muscle too far or too fast what happens?  That muscle is not so happy anymore and lets you know it my fighting back, in other words, cramping.  So you’re walking along, doing your own thing.  The muscles in your legs and feet are working so they’re happy.  Eventually you go to sleep and the muscles get what seems like a well deserved rest.  Of course from the muscles point of view it is not working anymore so tightens up a little to try to keep active.  You wake up and step on your foot, stretch the muscles all of a sudden, and they fight back.  Zing, zang, zoom you’re seeing stars and thinking you have a harpoon stuck in your heel.  Gradually the muscles relax with a few more steps and you feel better.  If I place your foot in a night splint that holds your foot muscles stretched slightly while you sleep the muscles stay happy because they are taught so working a little and when you get out of bed there is no harpoon because there is no sudden stretch.  This is no flimsy piece of fabric night splint like in the airline magazines.  I have a night splint in my office that goes along the top of your foot and ankle so it’s more comfortable than other rigid splints and not slippery if you have to get up to go to the bathroom in the middle of the night.

Why do people tell me to wear cowboy boots for my heel pain?

This was a big topic not too long ago when Eli Manning, the quarterback for the New York Giants, was following the advice of his old coach by wearing his cowboy boots for heel pain.  Why the cowboy boots?  Because wearing a slight heel and I’m not talking high heels here, but wearing a 1 1/2 to 2 inch heel relaxes your ankle.  This will decrease the pull of your Achilles tendon just enough to decrease the stretch on the muscles in your arch.

Try this:
Feel the arch of your foot with one hand.  With your other hand pull your foot back until you feel pulling in the back of your calf.  The muscles in your foot just became firm.

Relax your foot and feel the arch again.  Now using your other hand pull your toes back (up) but not your ankle.  The muscles in your foot are not as tight.  That’s what a cowboy boot or low heel does to the muscles in your foot.

Wearing heels or cowboy boots all the time causes other problems so this is not a long term treatment or prevention.  Remember what I always say, “ you can’t begin to heal until the inflammation is gone”.  Sometimes a patient who has a decent pair of cowboy boots or low heels will ask and I will tell them that wearing these shoes or boots is a good idea for a week or two, but stretching is the real treatment.

Ok, the plane is about to land so let’s wrap this up.  This has been a little more technical than other pieces on this website.  It’s ok to read it over a time or two.  When you think you have it then I want you to ask yourself one more question:

Why can one heel hurt and not the other?

I’ll answer that and other questions in another technical article about the nuts & bolts of how the foot works.