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Heel Pain in The Distance Runner - Three Common Causes

Robert Raines, M.D.
Lone Star Orthopaedics
Cincinnati, Ohio

Pain in the heel and achilles tendon area is the most common musculoskeletal complaint of distance runners. Heel pain can afflict any runner, As in all medical conditions, the key to a successful outcome relies upon the correct diagnosis. In this article I will outline the causes, symptoms and treatment for the three most common causes of heel pain in runners: plantar fasciitis, achilles tendinitis, and heel stress fractures.

Plantar fasciitis is the most common cause of heel pain in runners and non-runners. Plantar fasciitis is an inflammatory reaction to small tears of a large tendon-like structure on the bottom of your foot. These tears are believed to be caused by a combination of a tight achilles tendon and plantar fascia tendon in the face of repetitive loading. This inflammatory process results in the tell-tale symptoms of plantar fasciitis: sharp pain that originates on the bottom of the heel that is most severe after a long period of rest (typically the first few steps in the morning or after long car rides or movies.) This area may be slightly swollen and red, but is always tender to touch.

When it comes to treating plantar fasciitis, the news is both good and bad. The good news is that it can almost always be cured without surgery(over 95% in one study); the bad news is that complete resolution of the symptoms may take 1 year. As for running, let pain be your guide. If it hurts, stop. I prescribe a 5-step program for my patients that I have never seen fail in those patients who follow the rules. The steps are:

  1. Achilles tendon stretches: the cornerstone of treatment, this must be performed for two to three minutes at least 5 times daily and should endure even after resolution of pain. Healthy feet depend upon a well-stretched achilles tendon

  2. Plantar fascia stretches: this should be done for 10 minutes before getting out of bed. Pass a luggage strap or belt loop around the balls of your foot and gently pull your toes and forefoot towards you with your knee straight

  3. Icing of the heel: icing for 10 minutes before bed will reduce you swelling and pain. You need only do this for 2-3 weeks until most of the swelling recedes

  4. No barefoot walking: your heels need cushioning to reduce pressure. Keep slippers by your bedside and don’t walk without well-padded shoes

  5. Heel cups: I prefer over-the-counter silicone heel cups. They are inexpensive, portable from shoe to shoe, and provide the cushioning your heel needs.

Most importantly, remember that throughout the process you will have good and bad days. Monitor your progress monthly, not daily. Also, most of your relief will come after the 3rd month of treatment. Don’t be impatient. Follow the program.

Achilles Tendinitis is the second most common cause of heel pain in runners. The cause of achilles tendinitis is thought to be similar to plantar fasciitis: an overtight achilles tendon in the face of high repetition activity. As the tendon begins to wear, inflammation develops which leads to pain with activity, redness, tenderness to touch and often a swollen knot in or around the achilles tendon. One of the best ways to discriminate achilles tendinitis from other forms of heel pain is its location: on the back of the heel (never on the bottom of the heel) where the achilles tendon inserts into the heel bone.

The most important factor in treating achilles tendinitis is to control the inflammation. The inflammation significantly weakens the tendon, and in chronic cases can predispose the patient to an achilles tendon rupture (where the tendon rips off the heel bone completely.) This is a devastating injury that will require surgery and may permanently hamper your ability to run. Therefore, I treat patients with tenderness, redness, swelling, and pain that causes a limp in a short leg walking cast for 4-8 weeks. Once the inflammation is reduced, I start them on a devoted achilles tendon stretching program and give them a heel lift. If the inflammation is moderate, I prescribe a removable walking boot for a month then stretching. Mild tendinitis is treated with icing, a heel lift and achilles tendon stretches until the pain resolves. Chronic cases recalcitrant to casting may require surgery.

A Heel Bone (Calcaneus) Stress Fracture is less common than those above, but can afflict runners and other athletes who perform repetitive weight-bearing activities. These injuries affect women overwhelmingly but can occasionally occur in men. Women of all ages are susceptible. Generally, the pain develops during periods of increasing mileage. The pain is a deep soreness that is relieved by rest. Unlike plantar fasciitis, it is unusually with the first steps in the morning. The sine qua non of the diagnosis is pain on the sides of the heel bone, not on bottom (plantar fasciitis) or back of the heel (achilles tendinits.) Swelling and redness are rare.

Calcaneal stress fractures are treated in a removable walking boot for 4-6 weeks. No weightbearing exercise is allowed during this time. Activities are resumed when running causes no heel pain. Unfortunately, stress fractures can recur.

Most runners will experience heel pain at least once in their lives. A prompt diagnosis and correct treatment will relieve the pain in nearly all runners non-operatively. Prevent the problem before it occurs: train wisely, increase mileage gradually, and stretch your achilles tendon daily. 


Women in Motion May 2001