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By Dr. Simon B. Small, a member of the Medical Advisory Committee of the USSRA

(United States Squash Racquet Assoc.) 

Reprinted from Squash News

Rx for Squash

Heel Pain

You’re on the court to play hard: winning is the object. But walking off the court with a winning score may be a hollow victory if your feet lost the match. In squash, you are pushing the envelope in ways you can’t imagine in terms of the normal range of motion in foot muscles and skeletal structure.

To say the feet take a pounding is an understatement. Your feet perform unusual movements—twisting turning, running, jumping—driven by short bursts of speed and unpredictable directional changes.

You know you’ve done something wrong when you limp off the court with a strain or sprain. But constant, repetitive stress to the arch and heel can be the root of much of the evil of lower extremity pain and injury. These problems may not surface for weeks, months, or years. At best, the injuries mean staying off your feet (and sidelined) for a few days—at worst, they can lead to debilitating injuries requiring surgical solutions or permanent problems that can’t be resolved, injuries that can end a career.


You know the song. Nothing in the body happens in isolation. Injuries to the rear foot can involve the ankle joint, the calf, the knee, and even lower back pain. A major cause of rear foot problems is a dysfunction of motion in the sagittal plane. Simply stated, sagittal plane motion is the flipper action of the foot that is the basis of all ambulatory movement. The motion is most readily observable when you swim.

In the normal walking cycle, sagittal plane motion is the natural roll of the foot from the first contact of the heel with the weight-bearing surface to toe-off with the foot swinging forward in the air. The major muscles controlling this motion are the long muscles on the front of the leg, the calf muscles, and the plantar fascia on the bottom of the foot. The calf muscles act to decelerate the foot and leg. The calf muscles are counterbalanced by the extensor tendons which arise on the front of the leg and attach to the top of the toes. Their job is to raise the foot, bend the ankle upward, and move the leg forward to allow forward motion. In many sagittal plane problem cases, the plantar fascia and calf muscle/Achilles tendon are either too tight or too strong in relation to the extensors on the front side. This tightness creates tension, stress, or overstretching in attempting to bring the foot-to-leg relationship past a 90-degree angle (with the body erect and the knee fully extended).

The tension on the calf or plantar fascia then transmits a pain signal to the brain, triggering an accommodative process in the body which: (1) raises the heel and shifts the weight bearing to the forefoot alone, (2) bends the knee, thereby weakening the pull of the calf muscle, or (3) shortens the stride length.

In all of these compensations, balance is reduced, and efficient motion and court covering are diminished. You need better conditioning to cover the same part of the court. As compensation continues, the opportunity for overuse problems in other areas arises, e.g., low back pain. Repetitive stress on the arch and heel can be the basis for a variety of lower extremity complaints and injuries.


Pounding the foot on the court over prolonged periods puts so much stress on the arch, the plantar fascia can become inflamed (plantar fasciitis) or truly rupture. These syndromes manifest as pain in the bottom of the foot. The constant pulling of the muscle at its origin on the heel bone can also lead to what is commonly called heel spur syndrome. When you are walking, maximum stress on the plantar fascia occurs when the foot moves from midstance to toe-off (the point where the toe lifts off the floor). The increased force that presses on the plantar fascia during movement on a squash court is far more stressful than the pressure brought to bear during normal walking (perhaps two to three times more pressure is exerted). And the foot is rarely in a straightforward motion position. Generally, the sagittal plane stress to the plantar fascia is compounded by side to side and tilting movements. If abnormal stressful motions are combined with certain foot types that are predisposed to a variety of conditions (through heredity or training errors), inflammation and heel spurs are even more likely.


The constant irritation of the heel bone from the stress and pull of the plantar fascia muscle causes separation with the covering of the bone at the point where the muscle is connected. This separation fills with fluid which becomes fibrosis (scar tissue) and then later turns to a bony projection or icicle-like spur at the back or bottom of the heel (ossification). This painful growth and/or concomitant muscle inflammation will prompt compensating movements that can throw other joints and muscle groups out of alignment. A great deal of pain can be experienced even without a fully developed spur. Before actual ossification, inflammation of the muscle at the origin of the heel bone can be quite severe. It can also include bursitis (a fluid-filled sac that acts to protect the area but creates increased pressure and pain locally).

The most common sign of heel spur syndrome is a sharp, stabbing pain first thing in the morning. The pain usually subsides within 10 to 30 minutes of getting out of bed and walking. You may also notice the pain after other resting periods. The most likely pain sites are the back and bottom of the heel, although pain is also common under the arch and sides of the foot with plantar fascitis. Whatever the source, heel pain increases your reluctance to put weight on the rear foot, leading to imbalance and malalignment problems.


The Achilles tendon also attaches to the heel bone and can become inflamed. You can develop painful bursitis in the space between the bone and tendon. In extreme cases, ossification can occur here as well, forming a Tenocalcinosis (calcification of the Achilles tendon at its junction with the heel bone). In some athletes (Roizen, this article’s editor), overdevelopment of the calf muscle shortens the Achilles tendon. As a result, the heel is lifted and unable to make full and proper contact with the floor. Without corrective action, weight-bearing and gravity will keep forcing the heel to try to make contact with the ground, adding to the stress on the Achilles. Inflammation and eventual rupture are the products of this prolonged stress. Additionally, a dysfunctional Achilles, by preventing contact with the surface, will create imbalance when stability (through surface contact) is needed. It can leave you vulnerable to ankle twists and sprains as well as calf pulls.

A short Achilles tendon also limits the ability of the ankle to flex upward (dorsiflexion), or you can extend it and rupture your Achilles as Roizen did three years ago. When the range of motion is limited here, it puts inordinate pressure on the knees. Conditions resulting from too much knee pressure include patellar tendonitis (a painful knee cap condition also known as jumper’s knee) and genu recurvatum (known as back knee, caused by hyperextension of the knee as it is pulled backward by the calf muscle).

The Achilles muscle can also become overstretched. In this condition, it fails to control the foot’s ability to flex upward. It allows the heel to hit the ground and causes trauma to the heel bone and can lead to stress fractures.


The type of foot you inherited can mean you are more likely to sustain certain kinds of injuries, so it’s helpful to identify the structure of the feet you’re standing on. Then you won’t fall victim to common and frequently preventable maladies. Feet fall into three broad categories: neutral, pronated, and supinated (see diagram). In the supinated foot, the heel leans to the outside of the body. In the pronated foot, the heel is angled toward the midline of the body. In the neutral foot, you are standing squarely on the center of the foot.


In a high-arched foot, known as a cavus foot, essentially you lean on the outside of the foot (supinate). The outside of the foot tends to hit the ground surface harder than weight bearing starting at the heel, transferring along the outer foot border, and ending with weight distribution in the forefoot. The ankle joint is stiffer and less able to flex upward. This predisposition leaves the ankle less stable and the foot more rigid and is associated with excessive shock and stress to the bones and supporting structures. Potential injuries include plantar fascial tears, plantar fasciitis, bursitis, Achilles tendonitis and rupture, and ankle sprains.


Severe pronation is seen, for example, in a hypermobile (excessive up and down motion) flat foot. It is the opposite of the cavus foot and represents a complete collapse of the arch upon weight bearing, although the foot may look quite normal when lifted. It is characterized b decreased stability with splaying of the bones in the forefoot. The muscles try to stabilize the foot and become fatigued. The result is overuse injuries, loss of shock absorption in soft tissue structures and muscle pulls.

While performance usually suffers from too much supination or pronation, there are some exceptions. A high arch (supinated) foot can be well adapted for quick cutting, pivoting, and speed. Some amount of pronation is actually required for "setting the inside edge" in some sports (like skiing for the position in the golf stance). But the trade-offs—instability and potential injury—are costly when these conditions are severe or excessive.


Many stabilization problems and resultant imbalances in the foot can be addressed through orthotic appliances. The power of orthotic devices is the ability to supplement structural deformities by providing extra support and shock absorption. State-of-the-art materials and techniques now create a molded device that is resistant enough to take stress yet pliable and soft, allowing a full range of motion in the sagittal plane. Orthotic devices can mitigate against the accommodative shortening of musculature that results from a range of motion limitations.

But in the treatment of injury, the prescription of orthotic devices is not a static process. As the deformity responds to treatment, the device must be adjusted and refitted periodically to remain effective.

For prevention as well as therapeutic tools, orthotic devices provide stabilization, biomechanical control, and balance to enhance performance. Several world-class squash players are now strong proponents of these custom-made shoe inserts. Azam Khan, Jamie Bently, and Bret Newton use custom-molded orthotic appliances. These devices essentially make your shoe fit and feel like a glove. They are made from an exact impression of your foot. The doctor makes a mold from the impression and constructs the device according to your weight and level of activity.

Getting fitted for an orthotic device is a lot like getting contact lenses. It may take a few days to adapt, but it becomes second nature to put them in your shoes before you work out. You don’t necessarily notice they are there, but you do notice a significant difference if you forget them.

See if you can answer yes to any of the following questions: Do you feel that you might turn your ankle when you run or jump? Is the area around the heel or sole tender after you work out? Is your Achilles tendon tight when you run or jump? Do you experience tenderness in the calf; does it stiffen when you stretch in the morning? Do you experience pain in the shins after activity? If the answer to any of these questions is yes, you may benefit from an orthotic device.


A few exercises before and during a workout will go a long way to ensure that your feet are ready to work with you. Try this simple routine: Limber up by walking or jogging in place. Draw imaginary figure eight’s with your feet to stretch the ligaments in your ankles. Do the following series of Achilles tendon exercises:

Stretch 1: Extend your left foot in front of the right one: stretch the Achilles tendon of the rear leg by bending the front leg with hands-on knew. Force your weight back toward the ground the back heel.

Stretch 2: Step up on a stair with the front half of your feet only, with your feet shoulder-width apart and parallel to each other. Without bouncing, relax and allow gravity to pull your heels downward for about 20 seconds.

Stretch 3: Face a wall with both heels on the ground; place your hands on the wall at shoulder height and width apart; extend your chest so that it and your nose touch the wall’ keep your heels on the ground and your body straight, except for bending at the ankle joint.

The good news is, you don’t have to suffer the agony of your feet. But you do have to treat them right.

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