Shoe Advice For Those That Work Long Hours On Their Feet

work shoes

Many people out there have jobs that require long hours on hard floors, and their feet suffer for it.  In the next two posts, I want to discuss some tips on how shield the feet from the strain that those long hours can inflict on them, and how appropriate shoes and inserts can help make a difference.  I am splitting it up because the topic is so broad, but it is important to discuss.

The feet can withstand many hours of activity, but unfortunately we are not necessarily genetically predisposed to being able to withstand flat, hard surfaces for long hours.  In that regard, our feet need help, and that help comes in the form of shoes and sometimes inserts that go into the shoes to provide support, comfort, and foot endurance.  Shoe choices are influenced from a number of different factors, ranging from fashion to employer mandate.  People select their shoes for both personal and professional reasons, but do not always make the best choices and have to suffer the consequences.  Unfortunately, there is not one or even several specific shoes or even shoe styles that are best for the human foot.  Everyone has different structural needs that are influenced by the direct structure and shape of one’s foot, their body weight, their activity level, and the surface they walk on.  All these factors make for a very confusing picture in respect to selecting a good shoe, but there are a few ways around this. 

The first place to start is with one’s foot ‘structure’.  Foot structure simply refers to what shape of foot one has in relationship to the ground.  Some people have flat feet, some have high arches, and some are in between.  Those with very flat feet and high arches will be able to easily see what their structure is when they stand.  Those who have more subtle forms of either one of those structures may not be able to necessarily appreciate that when looking at their feet when standing, and may assume they have a ‘normal’ foot structure.  This is because many of those changes are hard to externally see, but a biomechanical exam by a podiatrist and/or an x-ray of the foot taken standing will show the true structure.  The foot’s position, incidentally, when one is seated, gives a false picture as most of the structural changes of the foot occur during standing, except for those with severe and rigidly flat feet that can be seen when seated.

Once foot structure can be determined, a few rules can be applied to shoe selection.  In general, those with flat feet need shoes that are more structurally stable.  This kind of shoe is more rigid across the bottom, and should only bend in the part of the shoe where the ball of the foot rests, not the middle of the shoe.  The shoe should also not be ‘twistable’ like a towel- it should resist attempts to twist it around.  These areas of firmness can help resist the arch collapse seen in flatter feet.  The area on the back of the heel should also be firm, and resists efforts to push it in so that it can more firmly cradle the more flexible heel area a person with a flatter foot has.  The bottom of the shoe should also be wide, hourglass shaped soles are not helpful for flat feet as the foot will spill over the narrow part of the sole.  Obviously, all these components work best in an enclosed oxford style shoe, or more ideally an athletic shoe.  Other shoe types can provide some elements of this support, including newer forms of sandals that are designed with firmer arch beds that cradle the arch better.  Shoes that are to be avoided in this category are flip flop sandals, flimsy cloth or canvas shoes, and most types of women’s  flats.  High arched feet, on the other hand, need much more cushioning, as they cannot absorb the shock generated by the ground contact when walking (something done when the foot is able to normally flatten more).  The shoe for a high arched foot needs to have a nicely cushioned sole, usually with greater thickness, to displace the shock away from the foot.  It should also be deeper to accommodate for the greater depth a high arched foot has within a shoe.  These characteristics are relatively easy to achieve in an athletic shoe, but are harder to find in a dressier style.  When selecting a dressier style of shoe for high arches, one has to more seriously consider the thickness of the sole material, as well as the softness of the material.  It should be a denser rubber or foam composite material, and should be stable as well.  People who have feet that fall in somewhere between flat and high arched should use a stable shoe similar to what one would wear if they were flat footed, as a stable shoe will provide better protection against foot fatigue over the course of a long day standing on hard surfaces.

The next thing to consider when trying to keep one’s feet comfortable all day is the need for inserts into the shoes.  Shoes alone can make a big difference in general foot comfort, but rarely do they actually contact the foot to the same degree that an insert in the shoe will.  Selecting an insert is a relatively simple process.  People with very flat feet generally need a rigid custom made orthotic to stabilize the arch and keep the foot from fatiguing after standing all day.  People with more moderate flat feet can benefit from either a custom orthotic or a semi-rigid over-the-counter insert like Footsteps or Powerstep Pro.  Those with high arches benefit from either a well padded custom orthotic or a well padded over-the-counter insert, of which there are multiple brands.  Those who have foot structures in between can benefit from over-the-counter inserts in general.  I do recommend that my patients avoid hard plastic inserts from retail insert stores, as these hard inserts are not made specifically for a single foot like hard custom orthotics.  Because of this, they may eventually irritate the foot more than they help as the ridges of the arch will not match the foot shape exactly.  Given the excessively high price one usually pays for the inserts in these stores, a custom orthotic can be manufactured, often for the same or less.  I also recommend that thin inserts like flat gel or foam inserts not be used for support or shock absorption, as they easily compress down to nothing when stepped on, and essentially are only a replacement for the sock liner padding that already comes in the shoe.

One other factor that needs to be considered is one’s bodyweight.  For many, this is a sensitive topic, but it does have a factor in general foot comfort by the end of the day.  Obviously, people who are of normal weight or mildly overweight do not need to consider their weight in selecting shoes.  Those who are very overweight or obese do have to consider their weight.  In cases of very heavy bodyweight, regardless of the foot structure, the shoes that one chooses needs to be very stable, with strong rigid material in the sole to help resist the pressure on the foot from the bodyweight.  Inserts in the shoes that provide additional rigid support are also very helpful in stabilizing the feet and improving comfort throughout the day.

I will continue this discussion next post, where I will discuss what role activity level and walking surfaces actually have on the feet and the life of the shoe, and whether some foot discomfort needs additional treatment beyond simply good shoes and inserts.

Flat Feet Explained Final Part: Surgical Treatment

flat foot

This week, I will conclude my discussion on the treatment of flat fee by discussing surgical correction.  Surgery is usually reserved for people who have failed orthotic therapy, or those who have rigidly flat feet that generally will not benefit from orthotic inserts.  Each surgeon has their own criteria regarding how early they consider surgically correcting flat feet.  Some surgeons wait until all other options are exhausted, and others consider surgery much sooner in the treatment process.

Surgery must correct all components of a deformity that can be quite complex.  There are three different lines of motion that are involved in the flat foot deformity.  Each individual case has a different arrangement, where some feet are more deformed in one or two lines of motion compared with others.  The abnormal motions that dominate the deformity are the ones the surgeon needs to concentrate on, as this will affect their choice of surgical procedure.  Different surgical procedures have been developed to deal with the many nuances of the flat foot deformity.  A typical flat foot reconstructive surgery involves several different individual procedures to correct each component of the deformity.  The flat foot deformity can involve a shifting of the foot outward, a bending of the foot upward, and/or a rolling of the foot inward toward the big toe side.  By addressing the components that dominate the deformity, a surgeon can effectively reconstruct the foot to obtain better foot structure.  These procedures involve various combinations of bone cuts and soft tissue procedures that rotate, flex downward, or lengthen the foot.  More flexible deformities can tolerate the use of a blocking cone-like implant that keeps the foot from flattening, especially in younger patients.  Given the nature of the bone cuts, the foot and leg is usually immobilized during the recovery period, which can take two to three months before regular shoes can be worn.  Patients with the implant recover much faster.

Many people who have flat foot reconstructive surgery do quite well.  Such surgery does carry with it potential complications, including over or under correction, non-fusing bones, infection, and scar tissue formation.  Depending on general health, some people may not be good candidates for what amounts to be a mildly extensive foot procedure.  Proper following of all postoperative instructions is very important, as that alone can sometimes be the difference between a successful surgical outcome and a poor result.  These procedures are generally performed in an outpatient, same-day setting.

As you can see, the flat foot deformity is a very complicated condition that requires very careful consideration of all it’s components for treatment to be successful.  While most people do well in orthotics, surgery is needed in more advanced cases.

Flat Feet Explained: Part 2 Non-Surgical Treatment

flat foot

This week, I am continuing my discussion on the treatment of flat feet in teens and adults. We are now ready to discuss treatment options. In basic terms, there are two options for treatment, as there are two basic types of flat feet.  The options are supportive shoes and prescription orthotics inserts, and surgical reconstruction.  The two basic types of flat feet are flexible and rigid.  Flexible flat feet (which are most common), can be pushed and held out of a flat position.  Rigid flat feet are stuck in that position, due primarily to inflexibility of a deformity that is mostly bone in nature.  Today I will discuss shoes and inserts, which are primarily helpful for most cases of flexible flat feet (but not rigid flat feet).

Over the last fifty to sixty years, our understanding of how the foot functions mechanically has grown significantly.  The mechanics of the foot are complex, and not easily measurable by direct means given the complexity with which the various joints work together to push us forward.  Our current understanding of this function is advanced, but not perfect.  Regardless, the development of the field of foot biomechanics has led to the development of the prescription functional orthotic, a device that has made it possible for countless people to enjoy their lives foot pain-free, or at least with considerably less pain.  This device is not the same as over-the-counter arch supports found in stores and TV commercials nationwide, and it is not the same as pricy off-the-shelf plastic inserts masquerading as ‘orthotics’ in numerous national retail chains.  A prescription functional orthotic is a medical device that is made of a plaster mold or 3D laser scan of the foot.  This mold or scan is created while the foot is being stabilized in a mechanically neutral position, otherwise known as the subtalar joint neutral position.  In this position, the foot is neither in a flat orientation, nor a high arch orientation.  It is roughly a position that research has determined should be the model resting position of the foot, when the foot has stopped rotating inward or outward during the walking cycle.  Many different factors contribute to getting the foot in this position, as the foot has numerous ways of compensating for any variation in structure between one part of the foot and another.  A true functional orthotic takes into account these variations, and subtle ways of angling or shaping the insert arise in the prescription process that make the resulting orthotics function even better.  Because these inserts are constructed based on the specific foot mold or scan, and slightly altered based on a complete biomechanical exam of the foot and lower leg, they will actually correct abnormal foot structure in a predictable way.  Over-the-counter inserts simply shove wads of padding or plastic into the arch blindly and hope it will be close enough to give proper support to the foot.  These kinds of inserts are usually comfortable, and do provide more arch support that a shoe alone can give.  However, they do not provide the exact level of foot structure control that a condition like flat feet often requires. Only prescription orthotics can fill this role completely.

The use of prescription orthotics allows for stabilization of the flexible flat foot when worn from shoe to shoe.  This device reduces much of the strain the bottom of a flat foot endures with standing and walking, and it can indirectly slow down the progression of flat feet related deformities, like bunions and hammertoes, by correcting the underlying cause.  The proper choice of shoe also contributes greatly to this treatment.  In general, people with flexible flat feet need a shoe constructed with that foot structure in mind.  A better choice of shoe is one that is only flexible at the ball (front) of the foot, and not in the middle of the foot. It should have a stiff sole, a stiff area that cradles the heel, and should be wide enough that the sides are not tight against the foot when it widens out as it flattens.  Most importantly, it should fit the orthotic and be comfortable to wear after many hours of activity.

For the vast majority of people with flat feet, a prescription orthotic and supportive shoe will be sufficient treatment, much like eyeglasses or contacts are sufficient for those with vision impairment. However, those that have rigidly flattened feet are not generally helped by orthotics, as the foot must be flexible for the orthotic to change foot structure.  There are also times with flexible flat feet in which orthotics do not provide enough support to control pain symptoms.  In these cases, the physical structure of the foot needs to be permanently changed to relieve pain and improve foot function.  Next post, we will discuss surgery to treat flat feet, and some of the advantages and pitfalls of that approach.

Flat Feet Explained: Part One

flat foot

Over the next couple of weeks I would like to discuss the nature of painful flat feet in the older child/teen and adult, and share some of my thoughts on treatment of this foot deformity.  Since this is a fairly involved topic, splitting the discussion up will help keep the post from getting too ‘wordy‘.

To start with, I would like to explain why we use the word ‘deformity’ to describe flat feet.  Flat feet are simply a normal anatomic variation of the human foot, as much as ‘normal’ or ‘high’ arches are.  It is likely mostly genetic, and passed to our children.  This variation is quite common, but does pose a unique challenge to modern humans, who tend to wear shoes most of their lives to protect the foot skin from the dangers of civilized living.  In populations where shoes are not worn, the foot’s muscle and support system is usually able to adapt to this flat structure from an early age.  By wearing shoes, we take away some of this adaptation.  However, the danger to the foot by walking barefoot in public or on concrete, gravel, and other hard surfaces far outweighs the lack of structural adaptation, and the notion that one should walk barefoot to keep this ‘natural’ process active is potentially harmful.  Unfortunately, because of the infrastructure we have paved our ground with for thousands of years, we are far better off in shoes.  However, those of us with flat feet must now deal with the issues that come with an unadjusted foot structure.  Even though flat feet are not a deformity in the same vein as an extra toe or clubfoot, we still refer to it as a deformity because in essence it functions as a foot deformity by being the source of numerous foot problems over time.

The foot problems that develop due to flat feet are generally due to instability that is present in the foot when it is allowed to over flatten.  This instability will gradually cause numerous other actual foot deformities by forcing the foot’s muscle and support system to change the way it anatomically is supposed to function.  The change in the way certain muscles and tendons pull on the foot, and the change in how ligaments and joints are positioned, will often lead to foot deformities like bunions and hammertoes.  These deformities in and of themselves can become painful over time in certain people.  However, of more importance to this discussion is the role flat feet play in causing tissue injury, which leads to chronic pain.  When flat feet are subjected to lengthy or strenuous activity, the overly flexible nature of this foot type can allow other parts of the foot to become overly stretched and strained.  This includes the plantar fascia, a thick cord on the bottom of the foot that is the source of the common heel pain when it is injured, as well as a large tendon under the inner side of the ankle called the posterior tibial tendon.  When this tendon is injured and not treated properly, it can lead to a debilitating degenerative process that can actually allow the foot to flatten further.  Other injuries directly related to flat feet include nerve inflammation in between the long bones of the foot known as a neuronal, as well as various arthritic conditions.

Since we now understand how and why feet are flat in some people, as well as what problems they can cause, we should move on to what is typically done to treat this condition so that it does not lead to pain and suffering.  This can be done by modifying the foot structure externally (better shoes and orthotics inserts), or by physically changing the internal structure of the foot (reconstructive surgery).  On the next couple of posts, I will discuss the reasoning behind each approach, and what I feel is the appropriate situation for either external or surgical treatment.

Pain Under the Big Toe Joint: Sesamoiditis

sesamoid pain

Pain under the big toe joint can be a significant nuisance, and can make walking, squatting, and jumping painful.  This pain is typically due to a common condition called sesamoiditis.  Sesamoiditis is inflammation of one of two small, egg-shaped bones found under the big toe joint., known as the sesamoid bones.  Every human has them, although some can have sesamoid bones that form in two or three separate pieces.  They provide an assisting role in bearing weight across the big toe joint and stabilizing certain tissue structures around the joint.

Injury to the sesamoids can immediately occur when falling onto the ball of the foot, directly kicking an object that forces the big toe upwards, or a direct crushing blow to the bottom of the foot.  The sesamoid bones can also become injured over a longer period of time when there is repetitive pressure on the ball of the foot from activities such as dancing, as well as during repetitive work-related activities, like pedal use in machinery or platform standing.

Symptoms of sesamoiditis can include a sharp pain or dull ache on the bottom of the big toe joint.  This pain becomes worsened when the toe is flexed in an upwards direction. Any activity that stresses this joint, including walking, running, and jumping, can cause pain.  This is especially true while one is barefoot. The use of supportive flat shoes tends to decrease the pain, while the use of high heeled shoes magnifies the pain. The tissue under the big toe joint may feel swollen or full, and may even be warm to the touch in less common cases.

Sesamoiditis is diagnosed by a simple foot exam, although x-rays and sometimes MRI is used to rule out a more significant injury like a fracture or stress fracture.

Sesamoiditis is treated with anti-inflammatory medicine, either taken orally or injected in the form of a steroid compound (provided no stress fracture is suspected). The big toe joint is supported with padding or specialized inserts to reduce pressure underneath, or by modifying the activity that caused sesamoiditis in the first place.  The use of stiffer-soled shoes is also helpful.  More serious cases may require immobilization in a walking boot or in a cast for up to several months.  Cases that simply won’t heal with any of these measures may require surgical intervention.  Surgical removal of one of the sesamoids is typically effective at eliminating the pain, and is sometimes also necessary when stress fractures or true fractures won’t heal.

While sesamoiditis only involves one small part of the foot, it nonetheless can be very painful and can limit both athletes and simply active people in a significant way.  Fortunately, it can be treated, but the road to recovery can be long if not treated early on and with all the necessary measures to address both the inflammation as well as the underlying cause of this condition.

Don’t Ignore Achilles Tendonitis and Pain In the Back of Your Heel

pain on the back of the heel

The Achilles tendon- a potential weak point of many an athlete and warrior.  It can hobble the mighty, and make life difficult for anyone unfortunate enough to injure it.  So-named for the weakest part of the great Greek warrior Achilles, who was invulnerable through being dipped into the river Styx at birth, except for the back of the heel where he was held.  Many professional athletes have been felled by this tendon, and many more non-athletes develop his condition with negative consequences to their lives.

The Achilles tendon is a large tendon located on the back of the heel.  It is incredibly important, and imparts a significant amount of the movement the foot has on the leg.  When this tendon is ruptured, walking becomes nearly impossible as the foot simply flops upward when the body puts full weight on it.  Even when only strained, the Achilles tendon can limit walking due to significant pain.  Inflammation of the Achilles tendon, called Achilles tendonitis, is very common and is seen in athletes, older people with chronically damaged tendons, those taking certain medications that weaken tendon fibers, and those with spurs on the back of their heel bones.  Symptoms can either be acute, meaning that they suddenly develop due to a specific injury, or chronic, meaning that the injury has developed over a long period of time due to gradual tendon strain.  The symptoms run a range from a sharp pain to the back of the heel when the foot bends upward, to a dull ache during any ankle motion.

As Achilles tendonitis worsens, the strain placed on the tendon can weaken it, potentially leading to a rupture at the worst and long term pain in the least.  An athlete with Achilles tendonitis can see an immediate and severe decrease in their performance, and non-athletes can see a significant disruption in their daily lives and ability to perform at work.  If untreated, Achilles tendonitis can be long-term and very disabling.  I treat many cases of Achilles tendonitis, and have seen the havoc this condition place on an individual.  If you are developing pain to the back of your heel, stop your activity and rest.  If it continues, go see a foot specialist for treatment.  Even simple tendonitis cases often worsen if not treated properly from the start.

When Should I Have My Bunion Operated On?


Bunions, for those who suffer with them, can be very painful, or may never cause a moment of discomfort.  This foot deformity, in which the base of the big toe is prominent on the inner side of the foot and the big toe itself is angled toward the second toe, has been covered by me in a previous post.  For an in-depth review on bunions and bunion treatment, see my other article explaining bunions.

The big question on many patient’s minds is when should a bunion be corrected.  Fixing a bunion is a fairly straightforward process: it involves a surgery that cuts the bone, moves it back over into a corrected position, secures the bone with a metal screw or pin, and tightens up the supporting tissues.  Healing is generally complete in 6-8 weeks in most cases.  The question that must be answered is ‘what is the optimal time to do the surgery?’  Unfortunately, there is no simple answer.  A number of different factors go into figuring out if a bunion needs correction.  The most important factor is whether or not the bunion is even painful at all.  If the bunion hurts enough to limit shoe use and activity, then yes, the time is probably right to fix it.  If it does not hurt, then surgery may not be necessary.  However, depending on one’s age, other factors may need to be considered.  For example, if one is middle aged, there is a reasonable expectation that surgery in the future when and if the bunion eventually becomes painful may not be possible due to future health problems.  Increasing arthritis in the joint may also force a different kind of surgery that is more involved or has to accomplish a completely different goal like replacing the eroded joint surface.  Younger patients may have to consider job restrictions or family life with young children that may make the recovery period difficult, if not impossible.  Other factors to consider is the reason behind the desire for fixing the bunion.  Bunion surgery will reduce pain and improve the function of the big toe joint and the side of the foot in general.  It will not grant the recipient a free pass to wear exceptional high heeled shoes, restrictive fashion shoes, or other such inappropriate footwear without the consequence of pain or discomfort.

Essentially, there is no opportune time a bunion should be fixed due to the complexity of life.  A good guideline is that if there is pain enough to affect your life in some way, or if the deformity is visible and bothersome enough that you are anticipating and worried about pain or limitation in the near future, then surgery is right for you.  It is a six to eight week inconvenience, but restoration of a more normally functioning foot will reap great future rewards for a lifetime.

Plantar Fascia Tears: A Dreaded Sports Injury

painful heel

Plantar fascia tears are infrequent but relatively common athletic injuries involving a ligament on the bottom of the foot in the arch, and can cause significant pain and disability in sports and daily activity.  It usually is an injury that sidelines most lower level athletes and makes daily walking difficult for non-athletes.

The plantar fascia is a series of three tight rubbery bands that stretches from the heel bone to the ball of the foot.  It acts as a stabilizer of the arch as well as tissue that helps contain the vital structures of the bottom of the foot.  Strain and damage to this tissue is the most common cause of heel pain and arch soreness, and occurs in many people on a chronic, daily basis.  Actual tearing or rupturing of the plantar fascia fibers is a far less frequent injury.  It can occur in a chronically strained fascia that simply ruptures out of weakness.  More commonly in athletes, it occurs as a direct result of force that drives the front part of the foot up, with the back part of the foot near the arch remaining stable.  This results in excessive stretch to the plantar fascia, and the fibers that compose this tissue tear in a partial manner.  Stepping on a small blunt object can also sometimes force a rupture of the fascia.

The plantar fascia will not tear all the way across it’s width, as it is composed of several bands.  However, a tear can form lengthwise that runs along the distance of the arch.

Symptoms include a sudden popping or snapping sensation in the bottom of the arch, or a sensation that something there ‘gave’.  It is followed by significant pain in the heel or arch, and swelling and bruising may also be seen.  Simple pressure into the arch may produce excessive pain, as does simple standing and walking.

Treatment of plantar fascia ruptures essentially involves rest, icing, and immobilization of the foot in a walking boot or less commonly in a cast with crutches.  As the fascia tear heals over the course of a month, it may require further treatment to improve its tissue integrity and flexibility, including physical therapy.  Orthotic shoe inserts are of great importance to keep the fascia stable after the tear has healed, and help prevent re-injury.  High level athletes may be able to advance their recovery with concentrated taping and continuous therapy programs, but most people will need about 4-6 weeks to recover from this injury.  In some cases, pain can persist in the form of chronic plantar fasciitis, and require a different kind of treatment in the long term to relieve pain.  Finally, surgery may be needed in rare cases that do not respond to any other kind of treatment.

Is a neuroma really a pinched nerve?


A neuroma is a common foot malady that does indeed involve a nerve in the foot, and is often described by health care professionals, general medical doctors or orthopedists, and even podiatric specialists as being a pinched nerve. This is often done to simplify the medical language for a patient, but I think when my colleagues do this they do a disservice to their patients as that description is in actuality not very accurate. I try to avoid the term pinched because it conveys a different sense of what is going on in the foot as opposed to a ‘pinched’ nerve in the back. Nerves in the feet can get pinched in narrow tunnels, primarily at the ankle level. However, the neuroma is a different condition that has more of a mechanical irritation externally causing the nerve damage rather than a constricting band around the nerve itself causing pinching.

In a traditional neuroma, the nerve at the center of the pain is one of five found on the bottom of the foot, between one of the long bones (metatarsals). As this nerve reaches the toe bases, it splits into two branches, each supplying sensation to two adjacent toes. It is at this spot, near the head of the metatarsal, that the nerve becomes inflamed. There is a ligament that sits on top of this nerve that, when bowed down as the foot flexes and flattens a little, can irritate the outer covering of the nerve. Over time, this irritation causes the outer layer to swell and become fibrotic, or scarred. The process is similar, but slightly different, in a high arched foot where there is more direct pressure on the nerve from the prominent and inflexible position of the ball of the foot on the ground. Regardless of the cause, as the nerve covering thickness increases, external pressure on the foot from standing and walking can cause pain to develop. If the scarring is thick enough, the pressure from the adjacent metatarsals can also cause pain if a shoe is tight enough to constrict the foot.

The distinction between this and ‘pinching’ may seem trivial, but in regards to treatment the correct understanding of the underlying cause of a neuroma is very important. Because it is mechanical irritation, and not nerve constriction (pinching), treatment does not necessarily have to involve surgery. In mild to many moderate cases, the simple use of shoe inserts designed to reduce pressure to the ball of the foot can help prevent the nerve from becoming irritated again one the inflammation is reduced with medication. This can in many cases preempt surgery, and still result in long and lasting relief. Although I have performed many surgeries for this condition, I have just as much, if not more, success treating it without surgery.

Did you know you can get bursitis in your heel?

heel bursitis pain

While most cases of pain on the bottom of the heel are caused by plantar fasciitis, some are not.  A common alternate cause of heel pain is a condition called bursitis, and it can lead to severe pain directly on the bottom of the heel.

Bursitis is inflammation of a bursal sac, which is a pad of tissue that can be found throughout the body, protecting bony prominences as well as other sensitive tissue.  In the bottom of the heel, the bursa is not necessarily a naturally occurring object.  In general, unlike many other bursas, this bursa is more reactive, meaning that it forms as a result of abnormal pressure and irritation under the heel.  The bursa becomes irritated when the heel bone of a person with a flat foot rotates excessively as it will naturally do during walking, generally exposing the bottom of the heel tissue to a more irritating part of the heel bone that is not usually prominent on the bottom of the heel.  Eventually, a bursal sac will form to protect the irritated soft tissue under the heel bone, and in turn this will become irritated itself.  Other causes for bursitis include walking for extended periods on rocky or bumpy surfaces, high arched feet with poor shock absorption capabilities, as well as poor heel fat pad in older people with a prominent heel bone resulting.  I have even often seen this condition in people who have a more angular shape to the bottom of the heel bone as opposed to a more normal rounded shape.

Bursitis can often be present at the same time as plantar fasciitis.

Treatment of bursitis under the heel is relatively simple.  Steroid injections often take care of the inflammation in and around the bursa, usually more effectively than anti-inflammatory medication taken orally.  Ice helps, as well as increased shock absorption via gel heel inserts or orthotics with soft heel padding.  Surgery is typically not an option, as the attempt to find and remove the bursa can lead to more damage to sensitive tissue such as nerve bundles within the heel, making things worse.