July 15, 2018

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Injuries aren’t always caused by running, even if that’s when you feel the most pain. Your everyday lifestyle and footwear (or lack thereof) contributes significantly to injury risk. Unfortunately, many people (both runners and non-runners) develop heel pain during their down time, particularly during the hot summer months when wearing thongs and being barefoot becomes almost second nature for many Australians.

Footwear choice and injury risk
When barefoot or wearing unsupportive footwear (including thongs, slides, ballet flats and many other casual shoes), the soft tissue structures within your feet and lower limbs work much harder to maintain good foot position and dampen impact forces, because there is no help from footwear.
Think about a typical day. How much time you spend wearing your running shoes or supportive shoes vs unsupportive shoes or barefoot? Balancing this to suit your foot type and strength is important in managing and preventing injuries, particularly heel pain.

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Many injuries cause heel pain, with Plantar Fasciopathy, Achilles injuries and fat pad injuries being the most prevalent. Each of these injuries affects a different region of the heel, so can usually be differentiated by determining the primary source of pain.

Which heel injury is holding you back?

What is Plantar Fasciitis?
Plantar Fasciitis is one of the most common complaints addressed by podiatrists among both runners and everyday individuals. Fasciitis refers to an acute presentation, whereas Fasciosis refers to more chronic pain. Pain is typically localised to the medial plantar heel (inside of the heel) at the insertion of the plantar fascia, and sometimes also extends through the medial (inside) arch of the foot. Although the plantar fascia is a soft tissue structure, it’s very inflexible and is responsible for containing the muscles of the foot, maintaining arch integrity and stabilising the foot during both stance and gait. The plantar fascia can quite easily become strained and overworked if your footwear is offering insufficient support, because the plantar fascia is working much harder to maintain it’s function.
Plantar Fasciitis and Fasciosis respond very positively to wearing supportive footwear. Your shoes should offer a more structured arch contour and more rigidity through the midfoot. They don’t need to be over-controlling, but more rigidity will help to prevent excessive arch collapse and movement through the midfoot. Arch contour can also be beneficial for providing more proprioceptive feedback (sensitivity to foot position). Supportive thongs and enclosed shoes with an arch contouring insole are more ideal options, whilst sometimes the addition of a specific orthotic or more supportive insole will be necessary for more support.

Posterior heel pain (Achilles injury)
Posterior heel pain (back of the heel) is most commonly caused by Achilles Tendinopathy and related injuries such as Achilles Bursitis. Tendinopathy is a generalised term encompassing both acute (tendonitis) and chronic (tendinosis) pain. Pain may affect the mid-potion of the tendon and/or the tendon insertion lower on the back of the heel bone. Symptoms, including the type of pain and palpable feel of the tendon, vary between these injury presentations.
The Achilles is a common tendon for the calf muscles, and is responsible for pointing the toes and pushing off the ground during walking and running gait. Compared to wearing high heels or conventional running shoes (10-12mm heel pitch), being barefoot or in flat shoes places significantly more stretch and strain on the calf muscles. There is subsequently also more strain through the Achilles tendon. Injury occurs when loading and strain is greater that what the tendon can withstand, either from inappropriate footwear choices, excessive running, or a combination of both factors.

Footwear’s role in Achilles injuries?
Footwear again plays a significant role in resolving Achilles injuries. Structure and support are important, but targeting shoes with a higher heel pitch (difference in height/cushioning under the foot between the heel and forefoot) is most important. Increased heel pitch will reduce strain and stretch on the calves and Achilles, and promote active recovery during every day walking and standing without excessive load. Sometimes the opposite approach can be employed.

Wearing shoes with lower heel pitch is suggested to help by passively stretching the calves and Achilles to developing strength. However, with this approach most people are more likely to suffer in the short term due to overload and increased strain. It depends how your body responds. The most suitable approach will be dependent on your specific symptoms and injury presentation.

Plantar heel pain (fat pad injuries)
Plantar heel pain (underneath the central heel) can be caused by a number of injuries, with most being related to the calcaneal (heel) Fat Pad. The fat pad is designed to dampen impact forces and work as the body’s self-defence cushioning system. Fat Pad injury causes structural damage and jeopardises function, meaning that the heel bone is subjected to much larger impact forces in stance and during gait. Contusion (partial damage) or complete rupture may occur, with the later typically resulting from a sudden traumatic event such as landing very heavily (usually from a significant height) on a hard surface. Excessive load on the fat pad from long periods of standing or repetitive landings on an unforgiving surface can lead to contusion, particularly if footwear is not providing additional protection.
Fat pad injuries respond best to plenty of cushioning underneath the foot, so again barefoot and unsupportive footwear should be avoided. Your shoes are required to work for the fat pad and prevent excessive force to the heel. Having a structured heel counter can also be beneficial in helping to contain the fat pad soft tissue underneath the heel.

So how do you avoid runner heel pain?
Whilst the presentation and treatment required for each of these injuries is different, wearing more sensible and supportive footwear is an essential part of the treatment plan. Being barefoot or wearing unsupportive shoes can be a primary contributor to injury in each case, so whether you’re trying to prevent injury or resolve heel pain, think about your footwear choices and make changes to ensure you are comfortable in your running shoes and your everyday shoes.

Article by intraining coach, podiatrist and triathlete Emily Donker. For more information or to book an appointment visit here.