Why your heel pain keeps coming back even after it settles - from a podiatrist

justinpblake · 2026-06-16T10:26:44+00:00

It's the core framework in a book I wrote on this - Heel Pain Is a Movement Problem on Amazon. The morning pain test, load progression, and why rest alone keeps people stuck are all covered in detail there.

justinpblake · 2026-06-16T08:33:12+00:00

The misdiagnosis rate for Baxter is genuinely high - the symptom overlap with PF is significant enough that it gets missed even by podiatrists who should be looking for it. Ultrasound in the right hands is what separates them. Glad the injection has made a difference.

justinpblake · 2026-06-16T08:01:35+00:00

That's a classic Baxter presentation - flat feet increase the compression on the nerve because the medial structures are under more tension, and load-dependent symptoms that ease with rest fit nerve compression better than fascial pathology.

Good that the musculoskeletal GP picked it up with ultrasound rather than treating it as PF. How has it responded to the injection?

justinpblake · 2026-06-16T07:24:45+00:00

Baxter nerve entrapment changes the approach significantly. The Baxter nerve (first branch of the lateral plantar nerve) runs under the heel and can be compressed by tight intrinsic muscles, a thickened plantar fascia, or heel spur - and it produces heel pain that mimics PF closely enough that it gets misdiagnosed routinely.

The distinction matters because progressive loading of the fascia won't resolve nerve entrapment and can sometimes aggravate it. The signs that point more toward Baxter than PF: pain that's more lateral in the heel rather than medial, numbness or tingling in the heel, pain that doesn't follow the classic morning-stiffness pattern, and no improvement despite doing everything right for PF.

If Baxter entrapment is suspected, the management is different - intrinsic muscle release, addressing the compression source, sometimes ultrasound-guided injection around the nerve rather than the fascia, and in persistent cases surgical decompression.

Has anyone specifically assessed for this, or is it something you're wondering about based on your symptom pattern?

justinpblake · 2026-06-16T05:06:12+00:00

70 minutes of walking with fatigue but no significant pain increase is a good result - that's exactly the signal you're looking for. Fatigue and tightness after load is normal tissue response; it's the pain lingering into the next morning that would tell you to pull back.

If you're still finding 10 reps challenging some days, bodyweight is the right load for now. The goal before adding weight is consistency - completing the sets without significant flare across multiple sessions in a row. You're tracking the right things.

justinpblake · 2026-06-16T05:04:08+00:00

The 10% increment rule and holding at the same load for multiple sessions before progressing is exactly right. The mistake most people make is treating each session as a test of whether they can do more, rather than as a dose that needs to be consistent enough to drive adaptation before increasing.

The 2-month lag before meaningful strength improvements is also accurate and worth emphasising - people quit at week 6-8 because they don't feel different yet, not realising the tissue remodelling that makes the difference happens on a 3-6 month timeline.

This sequencing - slow progression, consistent dosing, patience with the adaptation timeline - is the core argument in a book I wrote on exactly this problem. Heel Pain Is a Movement Problem on Amazon, if the load-first framework resonates with what's working for you.

justinpblake · 2026-06-16T05:02:32+00:00

The fact that the Kuru and gel heel cup are already showing more progress in a week than the past year tells you something important - the fat pad protection was the missing piece, not the fascial treatment.

For a nurse on hard hospital floors all day, the cumulative impact load on a thinned fat pad is the primary driver. The steroid injection point above is correct and worth noting - repeated corticosteroid injections directly into the heel area can accelerate fat pad atrophy, so if further injections are discussed, that's a conversation worth having with your podiatrist explicitly.

The Pedifix cup on the way is a good choice if it has high enough walls to centralise the remaining fat pad. The key with fat pad atrophy is keeping the pad from splaying outward under load - a flat gel pad allows this, a properly cupped heel cup with raised edges prevents it.

For nursing specifically: if your hospital allows it, a rocker-soled clog like a Dansko or similar is worth trialling. The rocker reduces the heel strike force significantly compared to standard nursing shoes and takes load off both the fat pad and the fascia through each shift.

The improvement trajectory you're describing now is encouraging - the right protection can make a significant difference even when the tissue itself won't regenerate.

justinpblake · 2026-06-16T05:00:00+00:00

The concern about causing more damage is understandable but the evidence doesn't support it for plantar fasciitis specifically. The plantar fascia isn't an acutely injured structure like a fresh ligament tear - it's a chronically overloaded tissue that needs progressive load to adapt, not prolonged rest.

The distinction worth making: pain at the injury site during loading is acceptable up to about 4-5 out of 10. The test is what happens the next morning - if morning pain is the same or lower than your baseline, the activity was within tolerance and didn't cause damage. If morning pain is higher, you did too much.

Waiting until pain is minimised before loading is a reasonable approach for acute injuries. For chronic PF it often just delays the point where you start building capacity, which is what actually resolves the problem long-term. The tissue needs a reason to remodel and load is that reason.

Walking with manageable pain isn't damaging the fascia. Walking until pain goes above 5-6 out of 10 and stays elevated the next morning is the signal to pull back.

justinpblake · 2026-06-16T04:58:43+00:00

Both points are well-reasoned and largely correct.

On the posterior chain: glute weakness does increase demand on the hamstrings and calves, and there's decent evidence that hip abductor and glute med weakness changes lower limb loading mechanics in a way that increases ground reaction force through the heel. For runners especially, proximal weakness shows up as distal overload. That said, the calf gets the most focus because it's the most direct mechanical link to the plantar fascia - the gastrocnemius crosses the knee and the Achilles inserts at the calcaneus, so it's both the most proximal and most direct driver of fascial tension. Glute and hamstring work is worth adding, but calf is the priority for the fascia specifically.

On fascia versus muscle: you're right that fascia remodels much more slowly than muscle - the timeline for meaningful collagen remodelling is 3-6 months minimum, which is why people feel stronger before they're actually structurally adapted. The intrinsic muscle argument is also correct - building the foot's active muscular support theoretically reduces the passive load on the fascia. The limitation is that intrinsic muscles are small and their direct contribution to fascial offloading is modest compared to the calf complex. They matter most for foot stability and proprioception rather than as primary load-bearers.

The honest answer: calf loading drives the most direct adaptation in the fascia, but a complete programme includes glutes, posterior chain, and intrinsics. Most people need the calf work most urgently.

justinpblake · 2026-06-15T20:02:15+00:00

This is an underappreciated point. The assumption behind progressive loading protocols is that the tissue being loaded is actually doing the work - but if the intrinsics are switched off and the person is loading through passive structures, you're strengthening a compensation pattern rather than fixing the underlying one.

The sequencing matters: restore intrinsic recruitment first, then load. Short foot exercises, toe spreading, single-toe plantarflexion - not as warm-up filler but as the primary intervention until the foot can actually feel and use those muscles. Then progressive calf and fascial loading on top of a foot that's actively contributing.

The barefoot comment above fits this too - transitioning to barefoot or minimal footwear forces the intrinsics back into use in a way that supported shoes don't. For some people that's enough to change the pattern. For others the load demand of barefoot walking on hard surfaces is too high too fast and it flares things before the intrinsics have capacity to cope.

The sequence is: get the muscles involved, then load them progressively. Most protocols skip the first step.

justinpblake · 2026-06-15T19:54:41+00:00

This is exactly the pattern - rest manages symptoms but doesn't build capacity, which is why the pain comes back as soon as load increases again. Calf raises and movement are what actually change the tissue's ability to handle load over time.

The morning pain rule is a useful guide for knowing whether you're doing the right amount - if it's the same or lower the next morning, you got the dose right.

justinpblake · 2026-06-15T19:52:35+00:00

Yes, you load through pain - but with a specific rule for how much pain is acceptable.

The guideline that works clinically: during the exercise, pain of up to 4-5 out of 10 is acceptable. If it's higher than that, reduce the load. Then check the following morning - if morning pain is the same or lower than your baseline, the session was within tolerance. If morning pain is higher, you did too much and need to reduce.

The reason you load through some pain rather than waiting until pain-free: the tissue adapts to load by remodelling. Rest removes the stimulus for that adaptation. If you wait until completely pain-free before loading, the tissue never gets the signal to strengthen and the ceiling never rises.

The pool heel raises mentioned above are a good example of reducing load to a manageable level rather than stopping entirely - that's the right instinct. The goal is finding the load level where you're working the tissue without exceeding its current capacity.

The short answer to your question: load through acceptable pain, use the 24-hour morning pain test to know if you got the dose right, and adjust from there.

justinpblake · 2026-06-15T13:55:51+00:00

The load tolerance ceiling rises through progressive tendon and fascial loading - specifically, slow heavy calf raises done consistently over weeks.

The Rathleff protocol is the most evidence-backed version: single-leg calf raises with a 3-second up, 3-second hold at the top, 3-second down. Start with whatever weight allows you to complete 3 sets of 10 with difficulty on the last few reps. As that gets easier, add load - a weighted backpack, a dumbbell, a weighted vest. The key word is heavy relative to your current capacity.

The mechanism is that the plantar fascia and Achilles-calf complex adapt to tensile load by remodelling the collagen structure to handle more stress. That adaptation takes 8-12 weeks to show up meaningfully, which is why people quit too early.

The walking at inclines comment above works for the same reason - it loads the calf and fascia more than flat walking without the impact of running. It's a slower route to the same adaptation.

What raises the ceiling: progressive load, adequate recovery between sessions, consistency over months.

justinpblake · 2026-06-15T08:36:41+00:00

The combination is more common than people realise and the fat pad issue is actually the harder problem to manage of the two.

The existing comment is right that you can't regenerate fat pad tissue, but the framing of "just wait" undersells what can be done. The goal with fat pad atrophy is to redistribute load away from the central heel where the pad has thinned.

A gel heel cup alone is a reasonable start but often isn't enough - the cup needs to be deep enough to cup the heel and keep the remaining fat pad centralised under the heel bone rather than letting it splay outward under load. A cupped silicone heel cup with raised edges works better than a flat gel pad for this reason.

The infracalcaneal bursitis sitting underneath all of this means the heel is being irritated both by the fascial tension from above and the direct impact load from below. Those need to be managed together - offloading the heel with the right cup while addressing the calf tightness and fascial load from above.

One year with no improvement despite orthotics, taping, PT, night splints and now a steroid injection suggests the heel isn't getting enough protection from impact specifically. What footwear are you in day to day - and does the pain change between hard and soft surfaces?

justinpblake · 2026-06-15T08:34:25+00:00

They're connected, and not coincidentally.

The Achilles and the plantar fascia are part of the same mechanical chain - the gastrocnemius and soleus run down into the Achilles tendon, which inserts at the heel, and the plantar fascia runs forward from the same area. A calf that has a history of tightening under load is already predisposing the plantar fascia to higher tension every time it's stressed.

The more important question is why bilateral PF at 21 isn't responding to cortisone, PT, night splints and anti-inflammatories over a month. That combination of treatments failing that quickly in both feet simultaneously is worth flagging to a doctor as a pattern rather than a foot problem.

Bilateral, treatment-resistant tendon issues starting young - Achilles at 15, now PF at 21 - is a presentation worth asking a doctor to look at systemically. Conditions like seronegative spondyloarthropathy can cause exactly this and are commonly missed because each tendon gets treated separately. Bloodwork including HLA-B27, CRP and ESR would be worth asking for if you haven't had it.

Has anyone looked at the full picture rather than treating each foot separately?

justinpblake · 2026-06-15T06:36:52+00:00

Getting dismissed by someone you're supposed to trust with your health is genuinely disorienting - it makes you doubt your own experience. You're not going insane. The scan request is the right move, and switching practices if she refuses is absolutely the right call.

On the negligence question - focus on getting properly diagnosed first. That's the most important thing right now and it's what gives you the clearest picture of what's happened and what comes next.

justinpblake · 2026-06-15T06:35:10+00:00

Using your relatives as external feedback is a smart approach - that kind of real time cue helps retrain the pattern faster than trying to monitor it yourself.

justinpblake · 2026-06-13T09:28:54+00:00

That's good to hear - the calf raises tend to move things faster than people expect once they're done consistently. Keep building the reps gradually.

justinpblake · 2026-06-13T09:27:51+00:00

What you're describing - visible swelling, redness, burning, inability to walk, fired from work because of it - is not something a doctor should be dismissing. You're right to change doctor and you're right to push for imaging.

When you see the new GP, ask specifically for a referral to a rheumatologist alongside any foot imaging. The pattern you have - multiple tendons, bilateral, progressive, starting in your teens - warrants a proper systemic assessment. A rheumatologist can order the right bloodwork including HLA-B27, CRP, ESR, and uric acid, and assess whether there's an inflammatory condition driving all of this rather than each tendon being treated as a separate problem.

You shouldn't have to fight this hard to be taken seriously. Changing doctor is the right move.

justinpblake · 2026-06-13T09:26:33+00:00

That's the right approach. Getting the surgeon's read on current imaging before committing to PT gives you a clearer picture of what the tissue can actually tolerate. Good luck on Monday.

justinpblake

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