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What does plantar fasciitis feel like?
Not one of my patients would be in my office if they weren’t experiencing pain. The pain is usually worse for the first couple of steps after getting out of bed or getting up from a seated position. The description attached to this is “The first step is the worst step!”. What is happening is that the muscles in the calf and arch are contracting during rest because of the foot is allowed to relax. The stretching that occurs on the first step increases the force within the plantar fascia and the sensitive plantar fascia becomes painful. This pain often radiates into the calf and forefoot. The location of the pain is very characteristic. It is usually found on the inside and front of the weight-bearing heel. Pain is found in other locations usually have other underlying problems besides plantar fasciitis. This often leads people to conclude that they do not have enough padding under their heel, that they strike heel too hard. This is not the case.
When we look at the tissue of plantar fasciitis under a microscope, as we can do after surgery, what we find is both interesting and counterintuitive. First, we do not find inflammation in the tissue. We also don’t see that the tissue damage is located on the spur. What we find is that the damage consists of small tears within the ligament that do not completely heal, leading to blood vessel proliferation and deterioration of the tissue.
Who gets it?
Certainly, it is more common in people that are overweight. You would expect this because the more that you weigh, more pressure that you are putting on the plantar fascia. People that have restricted ankle range of motion either naturally or after an injury or surgery, also seem to develop it more frequently. So impaired flexibility seems to be an issue. I also see up frequently in athletes and in people with sedentary occupations.
So where doesn’t all go wrong?
Well, my belief is that plantar fasciitis is rooted in a poorly functioning and weak arch muscles. The weakened muscles fail to protect the plantar fascia, which gradually weakens and tears. The underlying problem is our shoe wear. Our feet were designed without shoes in mind. Our natural state is to walk, shoeless, on rocks, tree roots, and uneven surfaces on the forest floor. In this state, our feet are asked to do a different job than when they are in shoes. When we walk barefoot, our toes are flexing and grasping for purchase in the mud and dirt. This conditions our feet, especially the small arch muscles. In addition, our feet are constantly twisting to adjust to the uneven surfaces. This twisting and torquing of the arch is also a function of the small muscles. When we walk in shoes, the jobs that are feet are asked to do is much more crude. The toes really do nothing. The foot hits the floor as one unit, never allowing the muscles to work much. It would be really much like taking a small child and never allowing them to use her hands without any snug pair of mittens on. By the time that child was an adult, the muscles in their hands may be a capable of grasping and doing fine manipulation of objects. That child’s hand would most likely be permanently impaired from this development. Why would we expect our feet to develop differently?
Finally, our sedentary lifestyle contributes by allowing us to be heavier and in worse condition. In many ways, plantar fasciitis can be a sign of overall poor body conditioning. Other contributing factors include the fact that we as a Society are getting older.
In some cases, changes in activity and stress to these for structures can precipitate an episode of plantar fasciitis. This is a factor in many forms of tendinitis and stress injury. There was a great man, named Julius Wolff, who came up with a very simple principal that underlies this. Dr. Wolff was one of the first professors of orthopedics in Berlin. He was examining heel bones and noted that this small bony spicules within the bones lined up with the force within the bone. He correctly guessed that the loading of a bone causes it to become stronger over time. However, this remodeling requires time. If the stress overload to the bone, then it can go on to injury before it strengthens. Therefore, training errors during athletics in which a person “overdoes it”, can lead to injury.
Other general medical problems can also contribute such as diabetes, atherosclerosis, and inflammatory conditions such as rheumatoid arthritis.
So, how do we treat it? Whatever we do, this seems to work 85-90% of the time. Many of the treatments that have been suggested include heat, cold, wrapping with an Ace wrap, taping, therapeutic ultrasound, phonophoresis, deep tissue massage such as using the Graston technique, and soaking in Epsom salts. These methods have many things in common. The first is that they don’t do a darned thing to help cure plantar fasciitis, but they do make it feel better for a while. This may be of some benefit. They also all work the same way.
The Gate Theory Of Pain was developed by Melzack and Casey in 1968. It suggests that pain is modified in several areas from the source of the pain, in this case in the foot, to where it is perceived in the brain. The pain nerves are stimulated and conduct their impulses to the spinal cord. If enough impulses stimulate the nerve or gate in the spinal cord, this impulse is relayed to the brain, where we would identify and understand that something painful was occurring. If other nerves such as the nerves that sense cold, heat, pressure, vibration, or light touch are stimulated at the same time, these impulses interfere with the gate in the spinal cord, making it less likely that the pain will be noticed by relaying it to the brain. Placing ice on an injury or rubbing it stimulates these nerves and makes it harder to proceed pain.
Another way of treating plantar fasciitis is to reduce the stress on the plantar fascia. Wearing a rigid shoe reduces the motion in the front and middle portions of the foot, reducing stress and hopefully allowing the body to catch up with the injury. Similarly, arch supports can eliminate or reduce motion within the arch, reducing pressure and stress from the plantar fascia. But didn’t you that these were bad for feet? Well, I did say that they were bad for healthy feet.
Let’s talk about the stages of healing.
Nearly every injury occurs and resolves in a pattern. I use this pattern to help guide my treatment and the degree of activity that is appropriate. Stage I is the acute stage. In this stage, pain is present to the point that it interferes with daily function. During this stage, the injured area should be protected and arrested. Palliation or doing things to simply help with pain is really reasonable. Stretching may be helpful at this stage. Strengthening and conditioning however does not make sense when you can barely make it through the day. To some extent a period of time needs to be allowed to get out of this stage. Hopefully, it will be brief.
Stage II is the subacute stage. In this stage, the pain is not functionally limiting. Usually, it is primarily morning pain or pain at the onset of activity. The pain can temporarily increases with activity, but the activity should not aggravate it for any prolonged period of time. It is likely that athletics of any significant intensity may be difficult during this stage. The protection that was begun during the first stage should be gradually removed during this stage. This includes such things as supportive shoes and arch supports. The rehabilitative goals are not only improving flexibility but also beginning strengthening on a gradual basis and conditioning.
Stage III is the final stage. The pain has resolved. During this stage, the foot should be gradually exposed to increasing stress to allow it to strengthen. Hopefully, with weight loss, and conditioning, the foot can be strengthened above its preinjury level.
At a minimum, rehabilitative exercises should focus on flexibility. As it has been documented scientifically, that tight Achilles tendons and muscles and tight hamstring muscles are associated with the development of plantar fasciitis, improving flexibility of these muscles is a key part of rehabilitation. The stretches focused on the Achilles/gastrocnemius complex, the hamstrings, and the plantar fascia.
Strengthening and conditioning exercises focus on the intrinsic muscles. I encourage my patients to do these exercises without shoes. One good exercise is to place the front of the foot on a 2 x 4” and to slowly rotate the heel in a circle, shifting the weight on the forefoot from the inside to the outside during the rotation. Begin by doing this for 30 seconds, 3 repetitions, once a day. Gradually, increase the duration to 5 minutes or more, 3 times a day. Other exercises include balance exercises, such as one leg squats or yoga positioning maneuvers. The intrinsic exercises that I think due to most good involve weight bearing (no towel scrunching or picking up marbles with her toes). As resilience increases, hopping or leaping maneuvers are very helpful and may help you get back to sports.
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