Heel Pain in the Morning? Learn How to Fix it

Nothing can ruin a good morning like a sharp, intense pain in your foot the second you take the first step. This heel pain could also occur when taking the first step after some period of resting or sitting. For some people the pain will reduce after a few steps. However, the pain might re-appear after walking for a considerable distance. If this sounds like you then keep on reading.

What causes heel pain in the morning?

There exists a long list of disorders that could could cause heel pain in the morning, these include; Plantar heel pain syndrome, Rheumatoid Arthritis, Gout, Achilles Tendinopathy, Diabetic ulcers, Osteomyelitis, Lumbar radiculopathy, Nerve entrapment (branches of posterior tibial nerve), Neuroma, Tarsal tunnel syndrome (posterior tibial nerve), Plantar warts, Ewing sarcoma and calcaneal fractures. Of all these, plantar heel pain syndrome accounts for the bulk cases of heel pain in the morning.

Over the years a lot of research has been carried out in an effort to ascertain what exactly causes plantar heel pain. Various terms like plantar fasciitis, plantar fasciosis, calcaneal spurs, joggers’ heel, heel pad syndrome etc. have being used to describe this pain and its presupposed causes. Sadly though, the research on the plantar fascia, heel pad and bone spurs has not provided substantial proof that these indeed are the causes of pain below the heel¹. It seems that the cause of heel pain is a complex combination of multiple factors some of which are unknown to us. Due to this, plantar heel pain syndrome (PHPS) has been found to be an acceptable description for pain under the heel where there no differential diagnosis exists.

Risk factors for plantar heel pain syndrome

A few factors have been found to be associated with plantar heel pain. These factors include;

1. Middle-aged to older sedentary individuals (40-60 years) with high body mass indexes³
2. Very active people with high training volumes, such as runners⁸
3. People with calcaneal spurs. Moroney et al² found that patients with calcaneal spurs are more than twice as likely to have foot pain than individuals without spurs

A test for plantar heel pain syndrome.

There are three tests that you can perform to check if you have plantar heel pain syndrome. These tests include;

1. Single leg stance test
   • With some support for balance, stand with your affected leg for 30 secs. If you feel any pain, then the test is positive.

2. Single leg Mini Squat Test
   • Find some support for balance,
   • Raise your non-painful leg from the ground
   • Perform mini-squats at a consistent rate and depth with your painful leg.
   • Perform up to 10 repetitions, if the leg becomes painful then the test is positive

3. Single leg heel raise
   • With some support for balance raise the non-painful leg from the ground
   • Stand on the painful foot then perform heel raises at a consistent rate and height.
   • Perform up to 10 repetitions if the leg becomes painful then the test is positive.

If one or more of these tests are positive then you’re likely to have plantar heel pain syndrome.

Should you be concerned about plantar heel pain syndrome?

A reasonable criterion to decide whether to seek specialist help would be;

1. Is the pain limiting your productivity, lifestyle and work?
2. The duration in which the pain has lasted
3. Is the pain getting worse or better?

Plantar Heel Pain is generally a self-limiting and 80% of the patients improving in 1 year without treatment⁷. Seeking specialist treatment will help you improve faster.

Best Treatments for plantar heel pain syndrome

Deep friction massage and myofascial release of the calf Muscles

It is not completely clear why but deep friction massage and myofascial release of the calf muscles helped relieve heel pain for many people^4,5,6. Deep friction massage work by breaking down adhesion’s in muscles, allowing muscles to contract and relax optimally. Deep friction massage and myofascial release is best performed by a specialist and will be more effective that way. No research has been performed on the effect of calf self-massage on heel pain patients. However, it wouldn’t hurt to try.

Calf Stretching Exercises

Calf stretches have been found to be very helpful in relieving heel pain^4,5. The advantage of the stretching exercises is that they can be performed at home.

The following are three exercises you can perform at home to relieve your heel pain;

1. Lunge calf stretch exercise

Aim; Stretch to the posterior calf muscles

Position; Stand a few feet away from a secure wall and use the wall as your support.

• Take one step back with the painful leg keeping the foot flat on the floor.
• Bend the other knee so that your weight shifts into the bend leg. Keep the knee of your painful leg straight and the back heel on the floor.
• You should feel some stretch on your painful leg.

Common mistakes:

1. Externally rotating the foot of the leg which is being stretched, it should be kept straight to maximize the stretch.
2. Allowing the knee of the leg being stretched to bend into flexion. It should be kept in extension to maximize the stretch.

perform the stretch for 20 seconds 3 repetitions with a short break between repetitions

2. Ankle Plantar-flexion stretching exercises

Aim; Stretch the plantar flexor muscles.

  Position; in four-point kneeling with feet parallel.

• Move buttocks back to sit on the heels
• You can place hands on bed for support

Common mistake: feet turned inwards which limits the available range of plantarflexion

Placing a rolled-up towel under the toes increases the range of motion and thereby increasing the stretch

3. Ankle Dorsi-flexion Stretching Exercise

•  Position; kneeling on the bed with hands on bed for support

•  Tucks toes in with the ankles in dorsiflexion and then sits back on heels taking the weight on the toes

Other Useful articles

References

1. “ Risk Factors for the Development of Plantar Heel Pain Syndrome – A Literature Review.” Physiopedia https://www.physio-pedia.com/Risk_Factors_for_the_Development_of_Plantar_Heel_Pain_Syndrome_-_A_Literature_Review
2. Moroney PJ, O’Neill BJ, Khan-Bhambro K, O’Flanagan SJ, Keogh P, Kenny PJ. The conundrum of calcaneal spurs: do they matter?. Foot & ankle specialist. 2014 Apr;7(2):95-101.
3. Van Leeuwen KD, Rogers J, Winzenberg T, van Middelkoop M. Higher body mass index is associated with plantar fasciopathy/‘plantar fasciitis’: systematic review and meta-analysis of various clinical and imaging risk factors. British journal of sports medicine. 2016 Aug 1;50(16):972-81.
4.  Saban B, Deutscher D, Ziv T. Deep massage to posterior calf muscles in combination with neural mobilization exercises as a treatment for heel pain: a pilot randomized clinical trial. Manual Therapy. 2014 Apr 1;19(2):102-8.
5.  Renan-Ordine R, Alburquerque-SendÍn F, Rodrigues De Souza DP, Cleland JA, Fernández-De-Las-Penas C. Effectiveness of myofascial trigger point manual therapy combined with a self-stretching protocol for the management of plantar heel pain: a randomized controlled trial. Journal of Orthopaedic & Sports Physical Therapy. 2011 Feb;41(2):43-50
6. Pollack Y, Shashua A, Kalichman L. Manual therapy for plantar heel pain. The Foot. 2018 Mar 1;34:11-6.
7. .Trojian T, Tucker AK. Plantar Fasciitis. Am Fam Physician. 2019;99(12):744-750. https://www.aafp.org/afp/2019/0615/p744.html#afp20190615p744-b15
8. Di Caprio F, Buda R, Mosca M, Calabrò A, Giannini S. Foot and lower limb diseases in runners: assessment of risk factors. Journal of sports science & medicine. 2010 Dec;9(4):587.