Heel pain in the morning can make the first several steps excruciating. Given that, what are the causes of pain in the heel? What is plantar fasciitis? Can plantar fasciitis go away on its own? Are steroid injections helpful? Let’s dig in
Heel pain is a common foot disorder and impacts approximately one-third of patients older than 65 years of age (1). It is most common in active individuals over the age of 40 years of age (2). There are multiple causes of heel pain include the following.
Stress fracture
Calcaneal (heel bone) stress fracture is the second most common stress fracture in the foot (3). A stress fracture is a small crack in the bone. It is typically the result of trauma or repetitive overloading of the heel. Onset can occur with an increase in activity or changing to a harder walking or running surface. Pain typically occurs with activity but can occur at rest and is associated with swelling and bruising in the heel.
Achilles tendinitis
The Achilles tendon, the thickest tendon in the body, attaches the calf muscles to the heel. It allows for flexion of the foot. Inflammation of the tendon is called Achilles tendinitis and is thought to be due to overuse. Other essential causes of Achilles tendinopathy include muscle weakness, alcohol, ankle instability, steroids, and fluoroquinolone antibiotics (4). Pain is the cardinal symptom and generally occurs at the beginning or end of a workout (5). The Achilles tendon is often swollen and tender to the touch. Conservative therapy is first-line treatment and includes a reduction in activity, footwear modification, stretching exercises, and physical therapy (6).
A heel spur is an abnormal growth bone that occurs on the base of the heel. It can involve the plantar fascia and 50 percent of the patients with plantar fasciitis have been found to have bone spurs (7). Heel spurs can be caused by multiple factors which include long term stress of the plantar fascia, trauma, muscle dysfunction and ankle, and foot instability.
Bursitis
A bursa is a fluid-filled sac between bone and muscle, tendons and ligaments that reduce friction. The bursa allows for easy movement of these structures across boney surfaces. There are several important bursae in the ankle which include the plantar calcaneal and retrocalcaneal bursae. Inflammation of these bursae is called bursitis and can result in heel pain. Treatment includes rest, activity modification and physical therapy.
Trapped Nerve
The tibial nerve and its branches are susceptible to compression and entrapment as they descend the lower extremity making sharp turns around bones. Pain is typically burning in character with accompanying numbness and tingling. In severe cases, there may be muscle weakness. Tarsal tunnel syndrome and Baxter’s nerve entrapment are two common disorders with nerve compression that can result in heel pain.
Sever’s Disease
Sever’s disease, also known as calcaneal apophysitis, is an inflammation of the growth plate in the heel for growing children. It is the most common cause of heel pain in children and adolescents, usually occurring between 5-11 year of age (8). It is related to the overuse of the heel and typically resolves when bone growth is complete.
Sciatica
Low back nerves provide important information to the muscles in the lower extremities. They also provide feeling (sensation) to specific areas in the leg and foot. The S1 nerve provides sensation for the posterior thigh and heel. The S1 nerve exits from the lowest level of the spine which is susceptible to injury. Disc protrusions, disc herniation, and small joint overgrowth can cause S1 nerve irritation or compression resulting in heel pain. If severe, muscle weakness can occur.
Plantar Fasciitis
The plantar fascia is a thick band of fibrous connective tissue that connects the heel bone with the toes. It supports the arch of the foot and is susceptible to injury, which will be discussed below.
What is Plantar Fasciitis?
Plantar fasciitis is the most common cause of heel pain and affects up to 2 million individuals annually (9). It affects both sedentary and athletic individuals. The highest incidence is in those aged 45-64 years of age. Females are 2.5 times more likely to affected (10). Plantar fasciitis is a chronic injury due to repetitive stress with micro-tears and degeneration of the fascia (11). Risk factors include obesity, flat feet, loose ankle ligaments, weak foot muscles, deconditioning and hard surfaces. Pain is localized in the heel and occurs with the first few steps in the morning or after extending sitting (12). Plantar fasciitis is the most common cause of heel pain in the morning (13).
Can Plantar Fasciitis Go Away on its Own?
Conservative therapy is first-line therapy and includes activity modification, physical therapy, stretching, alteration in footwear, safe anti-inflammatory agents such as curcumin and fish oil. Conservative care is effective in approximately 90 % of patients (14) but can take months to years (15)
What Causes Heel Pain in the Morning?
As we sleep there is no significant pressure on the tendons, ligaments, nerves, and fascia in the foot and heel. Furthermore, many of the tissues have stiffened overnight due to a lack of activity. The fascia and tendons have nerves within them and are sensitive to pressure and movement. Upon arising in the morning or after prolonged sitting the weight of our bodies is immediately placed upon these structures. Taking a step places additional pressure on the plantar fascia. Hence If the plantar fascia is irritated the first few steps in the morning can result in debilitating pain and audible expletives!
Will Steroid Injections Help?
When conservative therapy fails, steroid injections are often recommended. Steroids have significant side effects that include cartilage injury, increasing the risk for spinal fractures and poisoning stem cells. Most importantly steroids are toxic to orthopedic tissue. PRP is effective in the treatment of plantar fasciitis. In a recent study when compared to steroids. PRP was found to be a safe, more efficient and long-lasting treatment option (16). The Centeno-Schultz Clinic has extensive experience in the treatment of plantar fasciitis and other causes of heel pain. While patients may not have actual low back pain, many have low back nerve irritation that is contributing to their debilitating heel pain. When conservative therapy fails or plantar fasciitis returns, low back nerve irritation most likely is present but not recognized or treated. Treatment options at the Centeno-Schultz Clinic include x-ray and ultrasound-guided PRP by board-certified fellowship-trained physicians.
In Conclusion
Heel pain in the morning can be debilitating and make for a very poor start of your day. There are multiple causes of heel pain which include stress fracture, Achilles tendinitis, bursitis, sciatica, and nerve compression. Plantar fasciitis is the most common cause of heel pain in the morning. It typically resolves with conservative treatment. Steroids are dangerous due to multiple side effects. PRP injections are a safe and effective treatment option for plantar fasciitis.
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15. Thomas JL, Christensen JC, Kravitz SR, et al.; American College of Foot and Ankle Surgeons Heel Pain Committee. The diagnosis and treatment of heel pain: a clinical practice guideline-revision 2010. J Foot Ankle Surg. 2010;49(3 suppl):S1–S19.
16. Jimenez AE, Gonzales-Arabio D. Clinical and imaging effects of corticosteroids and platelet-rich plasma for the treatment of chronic plantar fasciitis: A comparative non randomized prospective study. Foot and Ankle Surgery. Volume 25, Issue 3, June 2019, Pages 354-360. doi.org/10.1016/j.fas.2018.01.005
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