Morning Heel Pain – Why Do My Heels Hurt First Thing in the Morning?

If your heels hurt first thing in the morning as you step out of bed, you probably have a condition called plantar fasciitis. This condition is the most common cause of morning heel pain which affects about two million people annually.

What is Plantar Fasciitis?
Plantar fasciitis or inflammation of the plantar fascia may result from a repeated over pronation of the feet. This condition is one of the most common orthopedic complaints related to the foot and is seen in both men and women. However, it is more common in active men ages 40 to 70.

The plantar fascia is a thick band of ligament at the bottom of the foot next to the skin. It supports the arch of the foot and runs from the heel to the front of the foot. This fascia or ligament is designed to absorb the stress placed on the feet when we are up and about, but too much repeated stress on it can lead to damage or tears which lead to inflammation and pain.

The normal process of walking involves landing the foot on the outer side of the heel, followed by passing one’s weight on the inner edge of the sole, and then back to the outer side of the foot. This is normal pronation. In some people however, the body weight remains on the inner edge of the foot, resulting in excessive pronation.

When the foot over pronates, there is a mechanical overload imposed on the plantar fascia which supports the medial (inner) arch of the foot. This leads to the collapse of the arch which results in lengthening of the foot, which in turn strains all structures between the hell and the toes, including bones, muscles and the plantar fascia of the foot.

Excessive pronation therefore results in the flattening of the arch of the foot which strains the plantar fascia and irritates its insertion at the heel.

Causes and Risk Factors
In many cases, plantar fasciitis develops without apparent reason. However, there are some factors that can make people more prone to it such as:

• Having tight weak calf muscles that make flexing the foot towards the shin difficult

• Being overweight or obese

• Having a very high foot arch

• Having flat feet

• Engaging in repetitive high impact activity such as running

• Doing any new or increased activity involving the feet

• Using poor quality footwear with soft soles or poor arch support

Plantar Fasciitis and Morning Heel Pain
How does plantar fasciitis lead to heel pain in the morning? After experiencing so much stress during the day, the plantar fascia rests and cools at night. This results in shortening of the ligament, as does all other tissues when cooled. However, upon rising from bed in the morning, the foot rolls or pronates the same way as the day before, thus causing the shortened fascia to suddenly stretch and pull the heel. This results in greater amount of pain than normally experienced. As the fascia warms up and stretches with repetitive foot movements the pain is reduced and walking becomes less painful. However with repeated movements the plantar fascia continues to be injured and stressed by over pronation. This pain may increase during the day when the inflammation is severe and again in the morning when rising from bed.

Other symptoms of plantar fasciitis include heel pain or foot pain which is more pronounced after activity (not during activity) or after prolonged rest (such as a long car ride).

Treatment for Morning Heel Pain
There are several options of treatment for morning heel pain caused by plantar fasciitis. These can be used in combination and most cases improve after several months. These include rest, using exercises, over-the-counter medications, supportive devices, and other treatments under medical supervision.

Acute pain can be immediately relieved by rest and avoiding high impact activities. Another effective way to relieve acute pain is to roll the foot over ice or a cold water bottle for 20 minutes, and this may be done 3- 4 times a day.

Foot Exercises
Foot exercises can be done anytime and anywhere, but when doing them in the morning, do some warm-up exercises first to reduce morning heel pain. Do not attempt exercises if you have an injury that could worsen. Consult a doctor before performing exercises which could affect an injury.

To do foot and ankle exercises, sit up straight on a comfortable chair or recliner with adequate back support. Extend your leg and let it rest straight on a second chair, allowing your foot to hang over the edge.

With your toe pointing outward, trace each letter of the alphabet in the air, beginning with lower case letters, while making small movements. Follow this by tracing uppercase letters then cursive letters using a larger range of motion. A stretching sensation must be felt but not pain. Repeat this procedure with the other foot. These exercises can be done once or twice a day. Do not perform these exercises while wearing heavy footwear (like winter shoes) since these might increase strain on your ankle and foot.

Another way to exercise the foot is to do toe crunches by curling the toes downward two to five minutes before getting out of bed. However, before taking that first step out of bed, plant your foot firmly on the floor to allow the plantar fascia to fully stretch.

Calf Exercises
To strengthen and stretch the calf muscles (the muscles at the back of the leg) and the Achilles tendon which connects the calf to the heel, face a wall while standing and place your hands on the wall at about your eye level. Position one leg to be stretched a step behind the other leg.

Bend the front knee while keeping the back heel on the floor until you feel the back leg being stretched. Hold the position for 15-30 seconds and repeat the exercise 2-4 times. These exercises may be done 3-4 times daily, 5 days a week.

Another way to stretch the calf muscles is to do towel stretches by placing a rolled towel under the ball of the foot while holding the towel at both ends. Pull the towel gently towards you, keeping the knee straight for 15-30 seconds. Repeat the exercise 2-4 times.

Wear Good Shoes
To control over pronation of the feet it is advisable to wear good quality, well-fitted shoes. The shoes should provide good arch support and a cushioned sole.

Use Orthotics
Use an orthotic insole to correct the alignment of the foot, cushion it foot from excessive stress and limit injury during the day. This consists of a molded piece of plastic, rubber, or other materials that can be inserted into the shoe.

Anti-inflammatory Meds
Over-the-counter non-steroidal anti-inflammatory drugs (NSAIDs) may be taken to reduce pain and inflammation. Examples of the include acetaminophen (Tylenol), or ibuprofen (Nurofen, Advil, Motrin). It is best to take these with food to avoid gastrointestinal irritation. Do not take these medications continuously for more than a few weeks without consulting a doctor for advice.

Night Splints
Most people relax their feet pointing down while sleeping, leading to morning heel pain. In these cases, a night splint may help stretch the plantar fascia while sleeping. Although this may be difficult at first, it is an effective way to prevent heel pain in the morning and can be discontinued when the pain is gone.

Cortisone Injections
Cortisone is a type of steroid which is a powerful anti-inflammatory drug. It can be injected by a doctor into the plantar fascia to reduce pain and inflammation. Multiple injections are not advisable because they can cause the plantar fascia to tear, leading to flat foot and chronic pain.

In cases where conservative treatment fails, surgery may be needed, especially in people with anatomical changes that result in collapse of the arch. Surgery should be considered if aggressive nonsurgical treatments have failed after 12 months.

Surgical procedures for plantar fasciitis include gastrocnemius recession and plantar fascia release. The calf muscle (gastrocnemius) is surgically lengthened in people who have difficulty flexing their feet even after doing calf stretching exercise for a year. In people who have a normal ankle but experience heel pain, the plantar fascia may be partially released to release tension. Bone spurs (calcifications) in the heels may also be removed.

Most patients recover with good results from surgery. Common complications that may arise from surgery include incomplete pain relief and nerve damage.

Start your heel pain treatment today.