Whole Foot
According to Greek mythology, Achilles was a hotheaded hero of the Trojan war who seemed invincible until he was killed by small wound on his heel. Randall was beginning to understand how he felt. He was a 36-year-old computer consultant with two young kids, Brent, six years old, and William, two years old, and Bristol his wife whom he met nine years ago. He also jogged nearly every day except when the kids needed rides to and from their many activities.
One morning in June, he woke up with a stiff feeling in his right heel. The day before, he had gone for a jog of 5 miles that was a little longer than what he is accustomed to. Initially, he put it down to “overdoing it”, but that was three weeks ago and it seemed as if the pain was just getting worse. Now, it was beginning to hurt every time he got up from a seated position, which was a lot since most of his job was sitting in front of the keyboard troubleshooting problems. For the first couple of steps, he limp so badly that his coworkers asked him what was wrong. It would usually go away after that, but now it was also beginning to hurt at the end of the day and he had the sharp stabbing sensation that felt like a ice pick being jabbed up his heel. He had given up running because it felt like he had a tearing sensation in his heel after only a few blocks. He was also having more and more difficulty playing with his children in the backyard, and they had a hard time understanding this. When he had to stop chasing them after only a couple of minutes because his heels felt like they were on fire, they would plead for more, but he just couldn’t. It hurt too much. What was he going to do?
The plantar fascia is a layer of gristly connective tissue which lies over the small muscles in the arch of the foot. Many people think that this is a tendon, but technically it is a ligament because it connects the heel bone to the toes and stabilizes the arch. If it were not present, the muscular forces and the weight of the body would work the bones until they broke and wear out joints in the arch. The best way to illustrate this is to compare it to a radio tower. If you constructed a radio tower without those little guide wires that supported it. The wind would blow the radio tower over. Why? Because the force of the wind and the long lever arm of the tower would compress the far side of the tower and stretch the near side of the tower until it bent and toppled over. But the plantar fascia were not present, the force of body weight would compress the top of the joints and stretch the ligaments on the bottom until the joints were destroyed (destroyed joints = arthritis/pain). So, in spite of the pain that it is causing Randall, the plantar fascia is a very important structure.
If it were cut, which is sometimes done to treat the pain, your arch would drop a few millimeters. You may not notice this initially, but the muscles that work with your plantar fascia, the joints, and the bones would be adjusting to it. Fortunately, many times they adjust to these changes just fine. Occasionally, however, when the plantar fascia is cut surgically or torn through an accident, these changes are not tolerated well and people go on to having chronic and possibly activity limiting pain.
A bone spur is simply a projection or point of bone in an area where the bone is usually smooth or round. Spurs can occur in many different areas. They can occur around the joints where they are usually the result of arthritis or healing within the ligaments from a previous sprain. Spurs can also occur around tendon or fascial insertions onto bone. When the tendon or fascia is injured in any way, a repair response will begin. The tissue near a tendon or fascial attachment has cells in it that may react much like bone cells. When those cells are told by the body to begin repairing, they will act very much like bone cells and react by laying down more bone, the same way that they might repair of fracture. This results in the appearance of calcification or bone within or around the tendon or fascia.
A heel spur, therefore, is not a diagnosis by itself. The reason that this is important is that you do not have to have the heel spur removed in order for the pain to go away. Many people have heel spurs and do not even know it. Other people may have severe heel pain and yet on x-ray have no heel spurs. Even people that require surgery for plantar fasciitis (less than 15% of people with plantar fasciitis) can get a good result without removing the heel spur.
So, don’t worry about whether you have a heel spur or not, 99% of the time it has absolutely nothing to do with what you need to do to treat your plantar fasciitis.
Plantar fasciitis is a painful injury of the plantar fascia. It usually occurs on the inside and front of the heel although I have seen people that had tenderness in the arch or along the outside border of the foot. Many people, even doctors, call it inflammation, but it is probably more accurate to call it scarring and injury to the ligament. This area of the heel, the front and inside of the heel pad, is interesting because, not only is it the attachment site for the plantar fascia, it is the weight bearing portion of the heel. Because of this, the tissue at the attachment site for the plantar fascia has to be designed to withstand the traction of the ligament, and the pressure of weight-bearing. This tissue is therefore very special, but it also makes it very vulnerable.
People they get plantar fasciitis tended to be heavier, they work in occupations that require a great deal of standing, tend to be in their 40s 50s or 60s, and often have stiff tendons, especially in the heel, calf, and hamstrings. With all this being said, I have seen people with significant plantar fasciitis who are young, flexible, athletic, and have jobs that are not particularly physically demanding. Which leads to the question, why do people get plantar fasciitis? And this is an important question because knowing why something happens gives us many clues as to what should be done about it.
Injury to the plantar fascia can be caused by a number of things. Roughly, whether something breaks or not can be broken down to the stress that’s applied to something and that object’s ability to withstand stress.
So let’s look at the things that are likely to increase stress on the plantar fascia. Certainly, if you are heavy, very active, or your foot is very flexible, that is likely to increase stress on the plantar fascia. If you walk in such a way that you put a great deal of pressure on the front of your foot or you bear weight on the front of the foot for a large portion of your step, this will also strain the plantar fascia. This is especially true if there is a sudden change in your activity level. The types of shoes that you wear, the stiffness of the shoes, the heel height, and the arch supports that you use (and this does not mean that you have to wear arch supports, more on this later), all of these things affect the amount of stress that the plantar fascia has to withstand.
The other side of the coin is the foot’s ability to withstand the stress. This gradually changes with aging. Not only does the connective tissue become less flexible and less able to repair itself, the heel pad, the protective slick doing on the sole of the foot, becomes thinner and subjects the tissue where the plantar fascia attaches to more focal pressure and therefore injury. Just as important, is what the foot has become accustomed to. If you have become accustomed to a sedentary lifestyle and you suddenly decide to become more active, the tissue may not be resilient enough to withstand the sudden changes in stress. This can lead to injury (for more about this read about Wolf’s law). The good news is that gradual increases in stress allow the body to become stronger over time. The bad news is that if you do it too fast you may be prone to stress injuries including fractures and plantar fasciitis.
The majority of heel pain is caused by plantar fasciitis, but there are other causes too. If you have swelling, severe pain, or are not getting rapidly better, seeing a physician to ensure that you do not have something other than plantar fasciitis is strongly advised.
There are certain nerve problems that can cause heel pain. Some foot and ankle specialists believe that nerve injuries are actually a frequent cause of heel pain. I feel that it can be occasionally involved.
Stress fractures of the heel or other bones within the arch can also sometimes be confused with plantar fasciitis. The recovery and treatment of these problems can be slightly to very different than the treatment of plantar fasciitis.
People with plantar fasciitis can be broken down into three simple different degrees of severity.
The least severe are those that have symptoms only occasionally (grade 1). If you have grade 1 plantar fasciitis, you have symptoms only occasionally. You usually feel it only when you been sitting for a while. Many people have said with plantar fasciitis, “the first step is the worst step”. The reason that it hurts when you stand up or when you get up after sleeping all night, is because the tissue around the plantar fascia has been allowed to relax. Muscles, ligaments and tendons contract slightly when tension is taken away from them, such as when your feet are allowed to flex to the floor. You cannot use the foot in this position. The sole of the foot has to essentially be at a 90° angle with the leg in order to walk very well. Getting the foot into this position requires pulling the muscles, ligaments, and tendons out to working length. After resting, pulling them out to this length requires extra force when compared to these tissues after they have been stretched out. You will feel that extra force as painful around injured tissue such as plantar fasciitis. When you have grade 1 plantar fasciitis, you can do most of the activities that you normally do, work, lift, run, and other athletic activities, but it may ache temporarily after these activities. Many people with plantar fasciitis of this severity do not see a medical professional.
A middle amount to severity is the grade 2 plantar fasciitis. At this level, the plantar fasciitis pain limits something that you can do. It may mean that you avoid physical activity, such as recreational walks, certain work activities, or personal activities such as shopping. The pain is appreciated to some degree all of the time, but it may be possible to do the activities that you need to do. Most people who have this degree of plantar fasciitis will seek out help and began to actively treated it.
Occasionally, plantar fasciitis can get so severe that it makes any activity extremely painful. This is grade 3 plantar fasciitis. At this degree, even everyday activities are difficult. People at this level may consider going to the emergency room for treatment. Often, they seek narcotic pain medication to help with the discomfort. People at this severity require help to do everyday activities and are potentially unable to do many work activities.
Treatment of plantar fasciitis may include:
Reducing activities that might aggravate plantar fasciitis is an important part of treatment. In most cases, this does not mean that he would have to completely stopped doing your normal everyday activity, but certain activities, especially the ones that cause considerable strain to the heel, such as prolonged standing, running, and jumping, may have to be decreased in order to key of the plantar fascia a rest. As the plantar fascia heals and becomes less painful, it is important to increase your activity. This accomplishes two things: It helps you return to more normal activity and it helps strengthen your muscles, the muscles to help protect your plantar fascia.
If you are a runner, this means that you should switch to other aerobic activities or decreased your mileage temporarily until the pain allows you to resume them gradually.
Shoe wear affects the mechanics of the foot. This is both good and bad. The good part is that you can use as shoe to help rest the plantar fascia. A shoe that is firmer will restrict the motion of both the toes and the arch, an important contributor to stress on the plantar fascia. To test the firmness of the shoe, put the toe in one hand and the heel in the other, then tried to bend the shoe. If the shoe bends easily, that is a flexible shoe and will put the plantar fascia under more strain. If the shoe does not bend easily, that shoe is firmer and will protect the plantar fascia from strain. That being said, firmer shoes are sometimes off work to walk on, clumsy, and noisy. Some people also find that the shoes may bother there ankle, knee, hip, or back. Unfortunately, you can never tell until you try them. A type of shoe that I have found helpful has a rocker sole. There are a number of companies that make them with a number of price ranges. (For more on this, see rocker soled shoes).
The bad part about using shoes to protect the plantar fascia is that they also can protect the plantar fascia from stress which strengthens it in the muscles around it. It’s kind of like wearing a cast for a fracture. When your arm is fractured, a cast canprotect it and help it to heal. However, using a cast beyond the healing time can lead to muscle wasting which is counterproductive. Like a cast, rigid, protective shoes and arch supports should only be used while the plantar fascia is healing. After that point, using protective shoes and arch supports can actually make the foot weaker. So, it’s important to return to normal shoes or even going barefoot after the plantar fascia has healed and has been pain free for a couple of months.
When I used the term orthotics, it refers to nearly anything it is put into the sole of the shoe that does not come over the ankle. Many people referred to as inserts or arch supports. The terms are, to me, interchangeable. Orthotics are helpful in the treatment of plantar fasciitis. Because of the pad in the arch, they limit and restrict motion of the foot. This reduces the traction on the plantar fascia. In addition, the pressure that the orthotic places on the plantar fascia protects the plantar fascia insertion point where most of the damaged ligament lies. There have been studies that demonstrate that, over the short-term, arch supports help people heal plantar fasciitis (reference). It does not seem to make a difference whether the arch supports are custom or over-the-counter. The success rate, satisfaction rate, and amount of pain relief seemed to be about the same, but over-the-counter inserts (link) are generally much cheaper ($20-60) than custom inserts ($150 and up).
Heel pads are also commonly used. I had seen much less success with the heel pads than with the arch supports, but they’re worth a try especially when there is a great deal of tenderness on the heel. There seems to be a great deal of variability as to which specific heel pad works the best for any given individual. I recommend starting with a silicone heel pad (link) if the arch supports do not work and switching to a felt horseshoe pad(link) or a Tuli cup(link) if the silicone pad is not successful.
Exercise therapy is the most important part of the plantar fasciitis treatment program. My own feeling about plantar fasciitis is that it is an overuse of the plantar fasciitis ligament. This overuse is caused by the activities that you do, your flexibility, and the condition of the muscles that support the plantar fascia. Exercise improves this by increasing the flexibility, increasing the strength of the muscles that support the plantar fascia, and improving the mechanical properties of the plantar fascia itself.
Useful Exercises
Flexibility
Strengthening
Resilience
Pain medications including acetaminophen (Tylenol) or anti-inflammatory medications (e.g. Motrin or Aleve) can be effective ways of helping control pain, but it should be realized that these medications most likely do very little to actually cure plantar fasciitis. The benefit of taking these medications is for their ability to help with pain and little else. If they do not significantly decreased pain, there is probably very little benefit to taking them. In addition, all these medications have significant side effects that may make them dangerous if taken over a long period of time. Some of them have even been taken off the market because of concerns that they may increase the possibility of heart attack. Even the over-the-counter brands of anti-inflammatories may have this risk. It is fairly common for blood pressure to be more difficult to control when these medications are taken. Anti-inflammatories may interfere with the benefits of taking low-dose aspirin for cardiovascular problems.
Applying ice and heat to an injury is an excellent way of helping with discomfort, but it is unlikely that it actually helps with healing. Studies have been done (reference) which have shown that application of the ice to the skin is not affect the temperature of the tissue very deep beneath the surface of the skin. So even if cooling healing tissue has some benefit, and there is very little evidence of this, placing ice on the surface of the skin is not do this.
What ice and heat do is to stimulate the nerves that detect cold and hot in the skin. The stimulation of these nerves affects the perception of pain by our brains or our ability to sense the discomfort, so we simply feel it less. So when the question comes up “what should use, a heat pack or an ice pack?”, the answer is whatever feels better and only for as long as it helps with the discomfort.
Cortisone is a hormone that your body uses to regulate stress (injury, illness). The chemical is related to cholesterol and diffuses into the nucleus of the cells, and binds to proteins that regulat the proteins that are manufactured in the cells. Specifically, changes that occur cause the cells to manufacture more of the proteins that reduce inflammation and less of the proteins that cause inflammation. Steroids have a temporary affect on the cells, but can reduce pain for periods that range from a few days to forever, depending on the condition of the tissue and underlying problem which varies between injuries. Steroids also reduce the repair activity of the cells that heal an injury and one potential complication of steroid injection and pills is reduced ability to fight an infection and tissue rupture (ligament or tendon).
This puts some perspective in the appropriate use of steroids. They are appropriate for temporary reduction of pain so that rehabilitation can be begun and to help with pain in particularly severe situations. Much of pain is psychological and, so, someone who is particularly anxious about their pain can focus more on productive treatment when they find that there are ways to alleviate it. Steroids should not be used as a “stand alone” treatment or be thought of as a cure, even though sometimes they are injected and the pain does not seem to come back. It probably would have gone away eventually even without the steroid.
Other injectible treatments have come up in both the lay press and scientific journals. PRP or platelet rich plasma is a treatment that has received a lot of attention and I have talked about several times before. The trouble with PRP is that it is a soup of growth factors which varies from person to person and between preparation techniques. No one knows which growth factors are promising and which may actually make plantar fasciitis worse or what concentration they should be in. It’s a little like saying that water is important for life and then saying that fluids (mouth wash, gasoline, scotch, or diet soda) should be taken at any amount desired. I think that growth factor therapy holds great promise for problems like plantar fasciitis, but they should be delivered in a controlled way after they have been completely and independantly tested for effectiveness. Doing anything different is guaranteed to be an ineffective way of treating your heel. Nine times out of ten, these treatments do not pay off and the initial studies on PRP on many forms of tendinitis have not been overwhelmingly positive.
Botox is a protein made by clostridium botulinum, a bacteria found in the soil. It was initially notorious for causing botulism, a paralytic condition that can be fatal that comes from eating contaminated food. When purified and injected into muscles, it causes long term local paralysis which has become useful medically especially in cosmetic procedures where the paralysis decreases facial wrinkles. Some initial studies has suggested that it may be helpful in reducing pain in plantar fasciitis. Since the plantar fascia is a fibrous tissue and not a muscle, it is not clear how it does this. Is the Botox reducing pain in some other way? Are the muscles important in cause plantar fascia pain? No one knows. The long term effect on plantar fasciitis is not clear yet. It would not be expected to result in long lasting improvement unless the underlying causes of plantar fascia are address (such as poor muscle conditioning, poor flexibility, obesity, etc.)
Wearing a brace, cast or cast boot is a method of reducing stress on the plantar fascia. The plantar fascia experiences stress through direct pressure from the weight of the body placed on the heel and through tension on the plantar fascia as weight is applied to the front (or ball) of the foot at the end of the step. Using a brace, cast, or cast boot reduces both stresses. This is good in that reducing stress helps tissue heal. It is bad in that reducing stress weakens and deconditions muscles, ligaments and bones (Wolf’s law). Braces, cast, or cast boots should be used initially in the treatment of particularly severe plantar fasciitis and weaned as soon as possible. Only in rare and particularly severe cases should it be considered a permanent part of your wardrobe.
Many minimally invasive treatments for plantar fasciitis have come out. These techniques are assumed to remove damaged tissue or “increase blood flow”. In few cases have the proper studies been done to truly substantiate this. However, there are some situations where it has been found to be helpful. I suspect that in many cases the effect of these procedures is probably temporary because the techniques do really nothing to heal the problem unless the reaction to the trauma that all of these techniques cause leads to strengthening of the tissue. This is unknown. These techniques, if used, should be used in addition to exercise rehabilitation.
These techniques do the same thing. Essentially what is accomplished during these procedures that a part of the plantar fascia is cut. It makes sense that this helps with plantar fasciitis. It the tension across a painful part of the plantar fascia is eliminated (by cutting it), the pain will go away. On the other hand, the lengthening of the plantar fascia has been shown to flatten the arch some. It has been theorized that this loss of function of the plantar fascia leads to changes in the stress in the bones and joints of the plantar fascia that causes the foot pain and stress fractures sometimes seen after plantar fasciotomy. It would also place more stress on the parts of the plantar fascia which are left uncut (the cut in the plantar fascia is partial. Complete release of the plantar fascia to result in painful complications.)
Open plantar fasciotomy takes a little longer to recover from, but the techniques are essentially equivalent.
Is plantar fasciotomy a good idea? Again, in certain cases, when nothing else is effective, there are cases when it seems to help a long time (70-80%). However, it can take some time to recover from this and there are some people that seem to get much worse afterward. Some people that were avid joggers before their plantar fasciitis are unable to return to these types of sports. In my opinion, it does not take the place of rehabilitation; it is used carefully and with consideration of the possibility of a poor outcome when no other reasonable form of treatment is effective. It is not a sure-fire or easy cure and should not be used instead of aggressive non-operative treatment.
I know very little about alternative techniques such as acupuncture, massage, and other althernative techniques. Tell me about your experiences so that I can include them.
