Heel Pain Advice that can make things WORSE

[00:00:00]So, everything you've been told to do for your heel pain, the night splint, the calf stretches, the heel drops off of a step, they all have one thing in common. Every single one of these pulls your foot upward toward your shin bone.

[00:00:17]And if your pain is in the wrong spot, every single one of these things can be making it worse. Hi, I'm Dr. Saul. I'm an orthopedic foot and ankle surgeon.

[00:00:27]And I want to show you something that no one's talking about enough, and I see in my clinic constantly. Heel pain is not just one condition, and the treatment that fixes one kind could truly irritate the other. Now, here's a quick note before we get started. This is general education, not medical advice. It's not a substitute for being examined by your doctor who can actually take a look at your foot. If your pain is severe, if the pain's changing, or it's just not improving, get evaluated in person by your doctor. So, here's the thing that could change everything. Where your pain lives tells you what you actually have.

[00:01:10]If your pain is at the bottom of your heel, and it's at its absolute worst after that first step out of bed in the morning, you most likely are dealing with plantar fasciitis. This is the one that everybody's talking about. But if your pain is at the back of your heel right where the Achilles tendon meets the heel bone, sometimes you'll even notice a bony bump right back there at the back of your heel, which you can feel. And if the pain is worse when you push off, when you climb up a hill, or you go up the stairs, this is an entirely different animal. This is usually something called insertional Achilles tendinopathy. The Achilles tendon is irritated and damaged right where it attaches into the calcaneus bone. So, I want you to do this right now.

[00:02:02]Press at the bottom of your heel right near the arch. Then, press on the back of your heel right where the tendon anchors into the bone. Which one really makes you flinch? The answer to this can change your entire treatment plan. And here's what you need to understand. Most of the advice out there online and in YouTube videos is going to assume you have the first one. And if that's you, pain's at the bottom of the heel, worse in the morning, classic plantar fasciitis, I actually have a free guide called Heel Pain to Pain-Free Playbook. And it walks you through five exercises for plantar fasciitis. It gives you a progress tracker that keeps you accountable. Look for the link in the description. But here's where I need to be straight with you. That playbook is built for patients with plantar fasciitis. So, if the pain is in the back of your heel, what I'm going to show you next matters most. So, stick with me through the rest of the video before you download anything. So, why is this a problem? Why does this matter so much? Well, your Achilles tendon doesn't run straight down and stop. It wraps around the back of your heel bone before it attaches.

[00:03:14]So, when you pull your foot upward toward your shin, what we call dorsiflexion, you're not just stretching the tendon. You're pressing it against the bone and it's getting compressed and pinched. For a healthy tendon, this isn't a problem. For a tendon that's already damaged and inflamed at the attachment point, you're grinding on the exact spot that hurts. Now, look at the standard heel pain protocol with that in mind. Night splints. They hold your foot pulled up for six, seven, maybe eight hours while you sleep. Now, if you got plantar fasciitis, that's the whole point. That's going to benefit. If you have a different type of Achilles tendinitis that's further from the insertion, you can still get a lot of benefit from this. But, if your problem is insertional Achilles tendinopathy, that 6 or more hours of compression on the tendon at its insertion every single night is it going to aggravate things.

[00:04:09]Next, looking at calf stretching, the classic wall stretch. This is the one where you lean into it against the wall.

[00:04:16]Same problem, the harder you push into that stretch, the more you're compressing the Achilles tendon at the insertion. Another exercise I really like for plantar fasciitis is heel drops off of a step. This is one of the most recommended exercises you're going to see online. You stand on a step, you let your heel drop down slowly below it. And for the right kind of Achilles problem, this can work beautifully. But, that drop is the exact position that compresses the insertion. So, here's the data that really drives this problem home. And I want to go through it with you. So, there's a study where researchers took that classic full range eccentric heel drop protocol and used it on both types of Achilles problems. So, for mid portion Achilles tendinopathy, this is pain further from the insertion, usually about 2 to 4 cm away from the insertion. 90% of patients were satisfied and got back to their activity level with less pain. Same protocol applied to patients with insertional pain, right at the Achilles tendon insertion onto the calcaneus, and they only got about a third of the patients that were satisfied and had a significant pain reduction. Same exercise, same tendon, wildly different results depending on where the pain was.

[00:05:43]Now, then they ran a follow-up pilot study. They kept everything the same with one change. They kept the heel at floor level.

[00:05:53]No dropping the heel below the step. No deep dorsiflexion. They kept the load on the tendon, they just took away the compressive element. Satisfaction in this group nearly doubled. So, this is the whole point of the video. It wasn't that the loading was wrong, it was that the range was wrong. So, if your pain is at the back of the heel, right near the insertion, here's the adjustments you need to make.

[00:06:21]The principle simple.

[00:06:23]Keep the tension, lose the compression.

[00:06:26]So, you want to do those heel raises from flat ground, not off the edge of a step. You rise up, raise up those heels, and lower slowly and under control, but stop when your heel gets back to level with the ground. You still get the full loading through the tendon, you just never take it into that deep compressed position. Keep your calf stretching gentle, short of its end range of dorsiflexion. You're not trying to win a flexibility contest here when you have insertional Achilles tendinopathy.

[00:06:59]And cranking that deep stretch is exactly what's going to irritate the insertion. So, with insertional Achilles tendinopathy, go ahead and skip that night splint, or at least talk to your doc before you sleep in one. Another thing you can do is get you a gel cup or a heel lift in your shoe. This is going to do the opposite of everything I just warned you about. It's going to slightly reduce the dorsiflexion when you walk, and take some pressure off that insertion. This is a very reasonable short-term tool that's validated by studies that can help with your pain while you build strength. It's not something you want to do forever cuz you want to maintain that dorsiflexion mobility long term. But short term, it's great. Now, what if you have plantar fasciitis and insertional Achilles tendinopathy? This is a tough one. Some people have both these problems. When this happens, the two treatment plans can point in opposite directions. That night splint that helps at the bottom of your heel may be aggravating the back of it. Same thing with those deep calf stretches. So, I don't want to pretend that I can solve this in a YouTube video. This is really a case where ideally, you need an actual exam or an evaluation by your doctor. Somebody putting hands on your foot and your heel and trying to figure out which problem is driving the bus.

[00:08:21]If that's you, go get seen by your foot and ankle doc. So, in summary, don't ask what fixes heel pain. Ask, "Which heel pain do I have? The bottom or the back?"

[00:08:32]Get that right, and you'll finally stop treating the wrong thing. If this video helped you, subscribe to the channel.

[00:08:39]The next few videos are going to go deeper into Achilles tendinitis and some treatment options.