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  • Kiley Holmes, PT

Heel Pain Sucks

What to do about Achilles Tendonitis and Plantar Fasciitis

At least once a week someone asks me about what to do about their heel pain - and by heel pain I mean either plantar fasciitis or Achilles pain. Yes, they're different, but the underlying problem is usually the same. At the very least their solution is nearly identical.

Let's start by going over calf anatomy: the gastrocnemius and the soleus come together to form the Achilles tendon and attach onto the heel - called the gastroc-soleus complex - the strongest muscle in the entire body. This muscle is responsible for jumping and for running. It's the muscle that propels you forward.

I like to think of the Achilles tendon continuing past the heel to form the plantar fascia. They work together as a unit. The plantar fascia is an incredibly thick fibrous tissue that attaches onto the ball of your foot. When you extend your first toe the plantar fascia tenses, increases the arch. This is called the windlass mechanism.

Tendonitis, or the more correct term, tendinosis, is caused by chronic overloading of a tendon. We've all been there when it can't handle what’s on it's plate. Tendonitis is a warning of near failure. While this sounds harsh it's still fixable. You just have to decrease the amount of tension going through the tendon, and the time the tension is going through the tendon.

Now with plantar fasciitis there are countless good studies which try to figure out the cause. The only thing that they can consistently tie to plantar fasciitis is limited dorsiflexion, meaning that more than likely the gastroc-soleus complex is tight.

This means that the cause of both Achilles tendonitis and plantar fasciitis is a tight/weak gastroc-soleus complex. We could say that it's because it's tight, and it is, but stretching it may not be the best plan as this is due to already overloading a tissue - our best bet is to calm the muscle down and then rebuild the tendon.

First and foremost you have to get the tension off of that tendon and fascia. The fastest way to do that is to wear a heel - I know, probably the weirdest thing you've ever heard a physical therapist tell you to do - wear heels! Wearing a heel allows your calf to be shortened. It is a short-term fix, but it is a great fix and you will start feeling better nearly immediately. I don't mean wear six inch heels, I mean if you are wearing flats wear wedges instead, if you are wearing loafers, make sure that the loafer heel is at least half an inch, if you were wearing tennis shoes make sure that it's got a bit of a lift in the back. Whatever it is, if you're going to be spending a good amount of time on your feet, make sure that you are taking the tension away from the heel.

Massage is a really effective way to get blood flow into that the gastroc-soleus complex and the plantar fascia to start promoting healing. If this has been going on for awhile, it will hurt quite a bit so be careful. I recommend a foam roller for your calf and a golf ball for your plantar fascia.

Foot strength plays a big role in both achilles tendonitis and plantar fasciitis. There are four layers of muscles in your feet designed to provide you a strong base of support. A great way to get started is toe yoga:

Standing barefoot, try and grip the floor with your toes, spreading them out. Once you feel like you've got that down, try and lift all of your toes off of the ground a couple of times. If you master that, practice lifting your big toe while keeping your other toes on the ground and then the opposite, keep your big toe on the ground while lifting all of your other toes up. There are so many versions of toe yoga that it would be a post in and of itself (maybe later), but for now, that's a good start.

And the second exercise is the commuter:

Standing barefoot, with your feet close together, try and bring your weight as far forward as you can while keeping hips/knees straight and feet flat on the ground. Then see how far you can lean back - a lot like trying to stand up on a train or metro.

Be careful to keep these exercises pain free. There are some other great exercises, like marble pickups and towel curls, so if you would like more please feel free to message me.

I like to use this time to also address accessory issues. Some of the other areas of your body that are associated with tight/weak calves are glutes, core, and quads.

Once the pain has become more tolerable and you are able to do your daily activities without wanting to scream, it's time to add some strengthening into your regime. The tendon gets the most out of the lowering portion of any exercise, so for now it's important to slow that part down to get the most benefit.

For this exercise stand on stairs, dropping your heel down, then quickly come up onto your toes, putting most of your weight on your big toe, and slowly lower back down to the first position. I would recommend starting out on both feet, then, slowly, start putting more and more weight onto the affected leg until you're able to switch to just one leg. Just for reference sake a healthy young person should be able to do 20-24 of these in a row perfectly on on leg.

It used to be that we would recommend wearing insoles to prevent this from ever happening again, but I'm going to give the exact opposite recommendation. Unless you have something seriously wrong with your feet you don't need to have orthotics. Y aou have just put some significant effort into strengthening your feet, and are already almost there, start transitioning out of those insoles into regular shoes. You would be doing yourself a favor - at some point you're going to want to walk at a beach or somewhere else

without insoles and you're going to be back at square one. However, if you start letting your feet work for you this will be a thing of the past.

There are some other issues that your heel pain could be:

  • Heel pad syndrome is pain directly over the actual heel. It's just an irritated fat pad and you need to stay off of it as much as possible, give it time, and when you do stand on it make sure you invested in a heel pad (message me for a list).

  • If you are worried about spurs, only continue to worry if this didn't help.

  • Behind the achilles tendon there is a fat pad that can get irritated so don't go gung-ho behind the tendon.

  • If there is numbness that is a subject for another post.

  • In kids there is a risk for Sever's disease, which is a fancy way of saying that the bone is still growing so it is affected instead of the tendon, however, the treatment is the same.

If you have any questions or comments or need anything please do not hesitate to contact me. I am here to help you.

#tendonitis #pain #physicaltherapy #heelexercises #PlantarFasciitis #AchillesTendonitis

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