Heel Pain Blog
The Battle Between Night and Day
For a number of years I have been the consultant lead for a tertiary referral heel pain clinic which takes referrals from other hospitals for heel pain resistant to treatment. Regardless of the presenting site of pain (i.e. Achilles tendon or Plantar Fascia), every patient describes that the worst pain they experience is on the “first step out of bed in the morning”. Have you ever wondered why it’s the “first step out of bed in the morning”? Logically, the foot has been at rest all night, so why would the worst pain be immediately after.
A number of years ago I started exploring this oddity by asking people with heel pain what position in bed did they sleep at night. Although most said on their belly (i.e. prone) or on their side, with further questioning it became apparent that the foot or feet was predominantly being forced into a “pointing downward” (i.e. equinus) position. This inevitably causes stiffness, especially in the calf muscles (i.e. Gastrocnemius muscle). As the greatest amount of stiffness in the calf muscles occur after being in the abnormal position over night. Therefore, it is obvious why the “first step out of bed in the morning” would be the most painful as it’s the time of the greatest stiffness.
The first line of treatment for any cause of heel pain (e.g. plantar fasciitis and Achilles tendinopathy) is physiotherapy, especially focused on stretching of the tight calf or plantar fascia. This is successful in the majority of cases, however recent evidence has shown when combined with gel spots and night splints there is a much greater and quicker effect. This is because there is an obvious battle between the night stiffness and day exercises. By not solving the abnormal position of the feet at night, daytime exercises will have a limited effect.
Rigid night splints are on the market, which are cumbersome and very poorly tolerated. They are generally used for very short periods of time, if not completely discarded the first night. I have personally trialled them myself, and because I am a belly sleeper, it was close to impossible for me to use it. They are certainly not a long-term solution.
A pillow used on the bed (like the Foot-ZZ) have been designed to enable comfortable long-term use as changing the foot position should not be a short term solution. By placing the specially designed pillow under a fitted sheet, the foot takes a natural position and is no longer held in a downward pointing position. This usually makes sleep more comfortable rather than causing a disturbed night sleep. The other option is to move to the bottom of the bed where possible and hang the leg over the side of the bed.
People utilising this method of foot position change have generally reported significant improvement in pain within the first 2 weeks, as the calf tightness markedly reduces. I have personally used a pillow for over 3 years, and when I’m away from home, my calf stiffness returns and so does my heel pain. For anyone with heel pain, I advise you to analyse how you sleep and do what you can to prevent the calf tightness occurring at night. This alone will usually improve your problems but is also synergistic with any stretching exercises to have a significantly greater effect.
Prof Lyndon Mason
The Runners Nightmare
Understanding the biomechanics of running is something that takes years of training, although it is still a developing field with advancements in sensor and monitoring technology propelling the science forward. However, in basic terms, there are five phases of running gait. The five phases are:
1. Stance - When your foot first strikes the ground.
2. Loading - From when your heel hits the ground to the moment your forefoot touches down.
3. Mid-stance - The point at which your heel starts to lift and the forefoot flexes.
4. Toe-off - When your foot leaves the ground.
5. Swing - The time between your foot leaving the ground and touching it again.
The gastrocnemius muscle has one of the greatest influences on the foot during running gait as its pliability directly correlates with what part of your foot first hits the ground, when the heel hits the ground and how early the heel lifts off the ground during each stride. The gastrocnemius is unique in the lower leg as it spans both the knee and the ankle, and therefore affects the foot position more when the knee is straight. Therefore, if the gastrocnemius is tight, as the body weight shifts forward causing the knee to straighten, the front of the foot is more likely to strike the ground first (given rise to metatarsalgia, forefoot pain) and the heel will hit the ground earlier and lift earlier in the gait cycle (given rise to plantar fasciitis and Achilles tendinopathy).
In people who are belly/side sleepers the foot or feet are forced into a “pointing downward” (i.e. equinus) position (as above). Over time, this inevitably causes stiffness, especially in the calf muscles. Although most muscles in the lower leg are affected by this abnormal position of the foot at night, the Gastrocnemius muscle is particularly susceptible. Early morning running (when the stiffness is at its greatest), will further predispose to injury. Although stretching clearly helps, long periods of abnormal position of the foot at night is very difficult to overcome.
Since the COVID-19 pandemic, there has been an explosion in people taking up running. Unsurprisingly, I have also seen a massive increase in patients seeking medical advice with heel pain associated with running. As stated above, stretching and changing the foot position at night significantly improves plantar fascia/Achilles pain. The use of a night splint pillow (like the
Foot-zz) or hanging the foot over the bed can significantly improve the pain and stiffness allowing running.
The term ‘weekend warrior’ has been used to define people who only do sporting activity in their spare time. In my experience, this tends to happen when people hit their thirties. It certainly did for me and my close friendship group, when increasing hectic lifestyles, work commitments and parenting shifted sporting activities to a lower echelon of importance. This results in catching any kind of physical activity in whatever spare moment you can muster. With my physician hat on, I can assure you this is not great for the body. The ‘weekend warrior’ tends to be stiff, over-weight, lacking muscle memory and with worse general fitness. Couple this with thoughts of grandeur to their ‘glory days’, and it is a recipe for disaster. It should be no surprise then, that the rate of injury in this group is considerably higher than in those who take regular exercise. Achilles’ tendon ruptures are particularly common in the ‘weekend warrior’.
In regards to heel pain, I see in my practice a recurring theme every year. I always get a significant increase in referrals in March-April, after failed conservative treatment of heel pain that started in January-February. The characteristics of the people this refers to is very predictable. They tend to be male ‘weekend warriors’, who had a period of inactivity over the winter, who over indulged at Christmas and decided to go on a ‘get fit’ drive for their new years resolution. On their ‘get fit’ drive, they start doing early morning runs. If they are belly/side sleepers, where their feet are in a ‘pointing down’ (equinus) position all night, we have a ‘perfect storm’ situation.
Breaking this down logically, this situation causes an over-weight individual, lacking pliability in their muscles, to go for a run when the calf muscles are at their greatest level of stiffness due to their problematic foot position at night. Bearing in mind that 4-8x your body weight goes through your heel (plantar fascia and Achilles) when you run, there is no wonder why the heel starts hurting. I see in equal measure Plantar fasciitis and Achilles tendinopathy turning up to my clinic as the result.
Treatment is difficult, because a large component is the excess weight. Shifting this weight becomes an unenviable task as the heel pain now prevents running. What we now know is that improving calf tightness (especially the gastrocnemius muscle) can be the most modifiable factor in significantly improving the heel pain. This is usually achieved by stretching exercises, but changing the poor foot position at night (treating the night equinus position) markedly improves the effectiveness. The Foot-ZZ achieves this whilst also being comfortable. In belly/side sleepers this has been a great addition to the armoury of heel pain treatment. I would also advise its long term use to prevent such problems, especially if ‘weekend warriors’ are contemplating a fitness drive.
The Weekend Warrior Effect
"over-weight individual, lacking pliability in their muscles, to go for a run when their calf muscles are at their tightest"
The Ageing Tendon
Although none of us want to admit it, age doesn’t come alone. Flexibility in tendons is considerably greater when your young. For example, gymnastics (which requires the greatest level of flexibility in sport) has the lowest average age of any Olympic sport. This is because as the athletes age, their decreasing flexibility means they are unable to compete. Bearing this in mind, when even elite athletes are susceptible to significant stiffening of their tendons and joints, in the average person the stiffening is considerably greater.
To my patients, I often give the analogy to the hair on our heads. As peoples hair thin, grey and become brittle so do their tendons (not grey, but you get the picture). One of my friends described it like the difference between “soft toffee” and “hard toffee”. After a year out of rugby, when he tried to return to the game he kept getting injured. He said he had become a ‘hard toffee’ and was brittle. Being flexible is very important. The less flexible, the more stress that goes through the tendon and therefore the more susceptible to injury.
In my medical practice, I see tendon stiffness causing the most problems in plantar fasciitis and Achilles tendinopathy. In people who belly sleep (i.e. prone) or on their side, the foot or feet are forced into a ‘pointing downward’ (i.e. equinus) position. With this there is an inevitability of calf stiffness (especially the Gastrocnemius muscle). As people hit their thirties, this becomes a major problem, especially if compounded by weight gain. Studies back in the late 1990’s showed that with increasing age, the number of positional changes at night reduces. Therefore, if you are a belly/side sleeper and your positional changes at night decrease, this will result in longer periods of the foot/feet being forced into a downward position.
If you are a belly/side sleeper it is really important to look at altering your foot sleep position and to stretch where ever possible. Exercises like Yoga and Pilates can be very beneficial. As you people hit their 50's, heel pain becomes much less of a problem as back sleeping is much preferred due to breathing capacity declining.
