Managing your heel pain

 

Question: I am increasing my weekly mileage in my marathon training, but now I have heel pain when I run. What do I do?

 

Heel pain for runners and walkers are incredibly common; I had it on and off for several years myself. Most likely, you have a condition called “Plantar fasciitis,” which is THE most common foot injury we see. Although there is such thing as a stress fracture of heel bone (calcaneus), that is a rare condition to happen, unless you are a high-mileage runner with 100+ miles per week, or you just completed an ultra marathon. 

 

Plantar fascia is a band of ligamentous tissue that connects your calf muscles to your heel bone, and it eventually connects to the ball of your foot (see image). This is a “Pulley” system to propels you forward when you walk and run. Out of the entire foot and leg system, the plantar fascia attachment to the bottom of your heel bone is often the weakest point; hence an overuse can lead to the inflammation (—itis) of your plantar fascia (= fasciitis), causing pain. 

 

There are many things you can do; Let me list them one by one.

 

1.  Stretch: stretching out your calf muscles diligently will take stress off your plantar fascia and it is highly encouraged. There are a device called night splints that you wear in bed to stretch out your calves, although I don’t recommend them right away as they may be uncomfortable to wear in bed. 

2.  Shoes: review your running/walking shoes. Are they worn out? I see many running injuries caused by worn-out shoes, and the injuries go away gradually when you get new shoes. Are your shoes supportive enough for your activity and for your weight? I recommend enough protection and cushioning for your feet if you are a road runner/walker, based on your weekly mileage and body weight. 

3. Mobilization: Remember, “Motion is lotion.” As long as your heel pain is controlled, you should be waking/running/biking/swimming as much as you can. Strengthening your foot and leg muscles would only help your cause. Cross-training with less impactful exercise (swimming and biking, even elliptical machine may work) is always encouraged when you have running injuries. 

4. In-home physical therapy: Among many modalities that you could try to manage pain, I am a big fan of TENS unit (about $30 on Amazon, pictured), which is a non-drug method to increase blood flow, massage and reset the nerve signals that conducts pain sensation. RICE (Rest, Ice, Compression, Elevation) is also a simple method to alleviate acute running injuries and inflammation. We usually recommend icing the painful area, 20 minutes on & 20 minutes off, and be careful of developing frost bite (perhaps, don’t sleep with ice on).     

5.  Over the counter topical medication: Topical pain creams including voltaren gel (diclofenac), salonpaas (menthol), Lidoderm patch (lidocaine) and various CBD creams. They all work differently and one of them is bound to work well for you. Quick tip: Voltaren gel is very effective for knee and ankle and foot pain and it’s now generic and much cheaper now, about $20 per tube.

6.  Over the counter oral medications for pain: I usually recommend starting with over-the-counter acetaminophen (Tylenol) 500-1000mg around the clock (every 6 hours, or at each meal plus bedtime), You can take up to 4000mg per day of Tylenol safely. That’s two extra strength Tylenol 4 times a day. I shy away from recommending NSAIDs — ibuprofen (Advil), naproxen (Aleve), Diclofenac (Voltaren) etc — due to concern of GI bleeding and kidney stress, but it is probably safe if you limit it for two weeks or occasional use. 

7.  Weight control: This is all about physics, not vanity!! If you have excess weight to lose, just losing 5-10 pounds may make a world of difference in your foot and ankle pain, as you exert 2-5 times the amount of body weight to your feet when you run. For weight control, I am a big proponent of plant based diet (I’m a vegan), I practice 16-8 hour time-restricted eating methods (also called intermittent fasting). I have been following a (relatively) low-carb diet, after checking my diet with a continuous glucose monitor for 4 weeks. I recommend USC’s ProLon diet (fasting mimicking diet) program when my patients want to lose weight for their health reasons.

8.  Seek help from a medical professional: Lastly, if your heel pain persists more than two weeks, it’s probably time to seek a medical professional help. Podiatrists (foot and ankle doctors) or orthopedists can help you in making the diagnosis of plantar fasciitis, rule out stress fracture (you may need X-ray and MRI imaging for that) and coming up with the treatment plan. My treatment for you would include all of the above, plus prescription medication as needed, as well as injection of corticosteroids (Kenalog), which is VERY effective in calming down the inflammation and pain. I find that a series of 1-2 heel injections often make the heel pain go away and get you back into running/walking activities.  In addition, I may write you a prescription to go see a physical therapist; they can help you in guiding you through various stretches and apply physical therapy treatments. There are many “newer” heel pain treatments like shockwave therapy and botox injections, but I don’t recommend them as I haven’t seen convincing medical evidence for them.

 

Dr. Suzuki is a Boston marathon qualifier/finisher and an Ironman finisher. He is a foot and ankle surgeon, an attending staff of the Cedars-Sinai Medical Center. He welcomes your running or health-related questions via email (Kazu.Suzuki@cshs.org), which may be featured in our weekly emails and in our website.