When it’s not plantar fasciitis; other sneaky causes of heel pain

This article was originally published in The Raider Patch: Magazine of the U.S. Marine Raider Association

If you feel pain on the bottom of your heel, the instinctive reaction might be to attribute it to the ubiquitous culprit—plantar fasciitis. While this condition is undoubtedly common, it’s not the sole source of heel discomfort. Two often-overlooked causes deserve awareness: heel fat pad syndrome and Baxter’s nerve entrapment.  

The trouble with this trio is that they are commonly considered solo acts. However, they tend to run together in people who run, ruck, or spend countless hours on their feet. In this article, we’ll go over each problem, identify key similarities and differences of each, and introduce self-treatment options that you can experiment with to identify the source of your heel pain.

Plantar fasciitis occurs when the thick band of tissue (the plantar fascia) that connects your heel bone to your toes becomes weakened and inflamed. Sufferers know the familiar “first step” morning pain of sharp, stabbing quality that is a hallmark of the condition. For active individuals, the three most common causes I see are shoes that are too narrow, combined inflexibility of the lower leg muscles and the big toe, and weak calf muscles. 

The most common treatment mistakes are inattention to one or more of the previous three causes and inadequate direct fascia treatment. While stretching is commonly prescribed for plantar fasciitis, it’s just one part of the recipe and rarely works by itself. Once the fascia injury has progressed to a state of disrepair (which can occur in just a few short weeks), treatments such as instrument-assisted scraping, dry needling, and cross-friction massage are necessary to stimulate the remodeling and repair process. 

Ok, but what if you’ve tried all that and still have heel pain? Here are the most common mimics to know: the fat pad and the nerve. 

While we don’t have quite the paw padding compared to our four-legged friends (my dog hates it when I play with his toe beans!), we do have fat pads that are crucial to the function and comfort of the foot. The calcaneal (heel) pad is built like a sack of oranges: tiny balls of fat are contained in a mesh-like bag under the bone. 

Direct heel trauma can damage the pad and result in a decrease in its shock absorption abilities. Repeated trauma from prolonged standing or excessive pressure on the heel accelerates the natural aging process, leading to fat pad atrophy (breakdown). Suppose you’ve noticed tenderness under your heel, like you’re stepping on a small stone directly in the center of your heel, or you develop a gnawing ache as the hours pass while you’re on your feet. In that case, you might have a heel cushion in crisis. 

Baxter’s nerve is a bundle of communication fibers that courses across the bottom of the foot, directly in front of the heel bone. It’s responsible for some of the movements of the pinky toe, but it’s also good at sensing and relaying pressure changes around the heel. When this nerve becomes entrapped, pinched, or compressed, it can lead to heel pain, tingling, or burning sensations. 

In my experience, a troubled Baxter’s nerve can be missed because the root cause of the problem – entrapment or compression – is caused by one of the other heel problems. For example: 

  • Fat pad injury or atrophy that causes a loss of shock absorption can alter heel bone alignment and make surrounding muscles cramp up, putting pressure on the nerve. 
  • Plantar fasciitis that develops into thickened, swollen tissue can encroach on or tangle up the nerve. 

Some sources say up to 20% of patients with persistent plantar fasciitis may suffer from Baxter’s nerve sending distress signals. Heel pain that’s really close to, but not precisely tender on, the heel bone and possibly accompanied by burning or tingling may be signals from Baxter’s nerve. 

Here is a brief overview of how I troubleshoot heel pain for my remote/TAD/TDY clients who have been doing plantar fasciitis stretches but are not seeing results: 

Test 1: Tape the fat pad. Google “heel fat pad taping” and apply using rigid medical tape, leukotape, or white athletic tape (not KT/kinesiology tape). Wear the tape while on your feet during the day, and repeat daily for one week. If this relieves the pain, the fat pad is likely the main issue.

Test 2: Massage the abductor hallucis muscle. This fleshy, rounded muscle is located on the inner side of your foot, just past the heel bone at the beginning of your foot’s arch. Baxter’s nerve courses between it and another muscle deeper in the foot, the quadratus plantae. Again, Google can be your friend here to learn about these muscles. Using a malleable massage ball (like a tennis ball) or your fingers, massage the muscle in clockwise and counterclockwise circles for 1-2 minutes to relax and loosen the muscle. Don’t massage directly on the heel bone. If this exercise relieves the pain, the Baxter’s nerve may be experiencing compression. 

If Steps 1 and 2 fail, add an over-the-counter arch support such as Dr. Scholl’s or Powerstep to your shoes or boots. Arch supports can relieve pressure on all three structures, the fascia, fat pad, and nerve, but may lose effectiveness over time. However, any pain relief you achieve will give you some lead time to get a professional assessment and treatment beyond stretching.  

Pain on the bottom of your heel is often caused by plantar fasciitis. When treated correctly, it’s a straightforward issue to resolve. However, if plantar fasciitis solutions aren’t working, look for an alternative cause of heel pain. You might also need to consider a “yes, and” situation where multiple issues are in play. Consider experimenting with the self-tests outlined above to see if you can tease out the most prominent problem. 

Remember, good judgment is your responsibility! If you have worsening or concerning foot pain, a qualified professional, such as a physical therapist, podiatrist, or orthopedic specialist, can provide accurate diagnosis and targeted solutions to get you back on happy feet!

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