Monday, December 15, 2008

Plantar Fasciitis or My Heel Hurts! Now What?

Plantar Fasciitis or My Heel Hurts! Now What?
By Dr. Christiane Gardner


Perhaps the most common and most frustrating overuse injury in runners is chronic heel pain that just won't go away! (Achilles tendonitis is a close second!) It seems all of us have either experienced this nagging injury or knows someone who suffers from it. This article will give you the nitty-gritty on plantar fasciitis:

  • what it is,
  • what it isn't,
  • how to cure it, and
  • how to avoid it recurring.

Just remember: nothing can take the place of a good sports physician or podiatrist.

Let’s start with the basics.




What plantar fasciitis is…
The plantar fascia is a strong ligament which lies just beneath the skin on the plantar surface of the foot. It extends from its attachment at the heel distally to the toes. Its purpose is to provide integrity to the bottom of the foot and allow some "spring" action in the push off phase of gait.

The plantar fascia works very closely with the calf muscles and Achilles tendon. The tighter your calf muscle, the more strain is placed on the Achilles tendon and plantar fasciia. The reason your heel hurts worse in the morning is that when you sleep, your foot is plantarflexed (toes point down) a bit. This causes the calf muscle to tighten which in turn causes the Achilles tendon and plantar fascia to tighten. When you first step on the floor in the morning, the tight plantar fascia is suddenly stretched causing pain. The patient with plantar fasciitis typically complains of pain first thing in the morning. This pain usually goes away after a few steps, only to return after a period of inactivity such as driving to work. We runners have a tendency to ignore small aches and pains. However, if you ignore heel pain, it will likely become worse and therefore much more difficult to heal.

What plantar fasciitis isn't…
If your heel is always painful especially with weight-bearing, and there is pain when you cup your heel with your hand and squeeze, then you may be suffering from a stress fracture of the calcaneus (heel bone). Time to get an X-ray or bone scan.

If you experience a tingling sensation like a mini electrical shock in your arch and heel, then a condition called tarsal tunnel syndrome may be the cause of your pain. This is the foot version of carpal tunnel syndrome where a ligament becomes very tight across a nerve causing the tingling. This is usually caused by excessive pronation and is often cured with an orthotic.

Pain in the medial arch is often confused with plantar fasciitis, but is usually an inflammation of the posterior tibial tendon. Lastly, chronic back pain due to arthritis of the lower back can cause referred pain in the heel. A sports medicine physician or podiatrist should be able to diagnose your condition and get you back running again.



How to cure plantar fasciitis.
Plantar fasciitis by definition is caused by inflammation of the ligament. Initial treatment consists of early recognition of the problem and reducing the inflammation. Ice, stretching and anti-inflammatory medications can help in the early stages of plantar fasciitis. Try and look back over your training log to see if your training changed which may have caused this overuse injury:


  • Have you increased your mileage too much too soon?
  • Are your running shoes past their expiration date?
  • Have you added speed work or hill repeats?

If ice, stretching, ibuprofen, and change in running shoes do not resolve your symptoms, an orthotic may be necessary to reduce the pronation or flattening of your foot. These do not have to be expensive. While some patients will require a custom orthotic made from an impression of their feet, most patients do quite well with off the shelf orthotics such as the "Sole Orthotic". These are heat- moldable inserts which run about $50. They can be found in most running stores or at Zombie Runner (I have no financial interest in anything!).

A night splint may also be beneficial. This is a brace which holds your foot at 90 degrees thus gently stretching your achilles tendon and plantar fascia. Patients find the splint is very easy to wear especially when reading, watching TV or sleeping. I find the dorsal night splint to be the most comfortable. Google "night splint for plantar fasciitis" for a listing of suppliers.

Massage therapy and physical therapy are also beneficial in reducing the inflammation and relieving the tight plantar fascia. Injection therapy is an option if the above does not relieve your symptoms. While I am against injecting a steroid directly into a tendon, I do often inject the plantar fascia. The injection will usually reduce the inflammation to a point where conservative measures can now work more effectively. Again, the key is reducing the inflammation.

Surgery is sometimes necessary to resolve plantar fasciitis which is not improving with any of the above treatment measures. Only about 5% of patients require surgery. In general there are two types of surgical procedures:

The first is aimed at cutting part of the plantar fascia thus elongating the ligament (picture cutting through one half of a large rubber band).

The other surgery involves no incision, but rather a series of shock waves is applied to the heel. The body does not respond to chronic inflammation very well, however it does respond quite well to acute inflammation. The shock wave therapy is aimed at changing the chronic inflammation into acute inflammation so the body can begin to heal.

How to avoid a recurrence
OK, so now you have finally gotten rid of the dreaded plantar fasciitis, how can you stop it from recurring? As always, watch your training, stretch gently and replace your shoes when needed. Having said all that, I have become a big advocate of running barefoot for short periods of time each week. When a foot is encased in a supportive shoe with a heel, the muscles of the foot do not have a chance to strengthen. Try standing on one foot without shoes. Do you wobble a lot? This may be due to weak muscles in the foot. Running shoes with a high heel can predispose a runner to achilles tendonitis and plantar fasciitis by shortening these tendons and ligaments. I am not saying get rid of your favorite shoes! I am suggesting gently running a half mile or so barefoot on a soft surface once or twice a week. This will strengthen muscles you never knew you had as well as teach you to run gently thus allowing your foot and leg to absorb shock rather than relying on the shoe.

Remember: early recognition of the symptoms is key to healing quickly!

Previous articles from Dr Chris:
Chronic Achilles Tendonitis

16 comments:

Anonymous said...

Lisa

This is a great post full of just the information I needed to learn and the right information to put to good use. This injury is not fun but after reading this I feel hope.

Sam

Anonymous said...

Interesting timing! I have a question and an observation. First, the question: My pain is on the OUTSIDE of the midfoot and back toward the heel . . . the article and picture seem to suggest that this applies to the big toe side of the foot. Is this applicable to me? One thing that I noticed in there is that it said, "if you have constant pain, it is probably not plantar fasciitis." I am having constant pain since completing my run yesterday. The cup-and-squeeze of my heel doesn't intensify the pain, which is good. But, my pain doesn't seem entirely in line with the description. Perhaps it is, but I wonder if I've just bruised it.

Finally, I'm doing what it recommends--lots of stretching, shoes with only 120 miles on them, and ice.
T

Anonymous said...

Hi T,

It sounds as if you are suffering from an inflammation of the peroneus brevis tendon. This tendon starts off on the lateral aspect of the leg, courses around the outside of the ankle and attaches to the base of the 5th metatarsal (that nobby thing on the outside of your midfoot). This tendon is the prime evertor of the foot. As such, it can easily become strained and inflammed. Rest, ice, massage should help. If you recall any trauma to the foot such as twisting your foot, it is possible that you may have suffered an avulsion fracture of the 5th metatarsal. If this is the case, time for an XRay. Heal quickly!
Dr Chris

Anonymous said...

Great piece! Dr Chris has given the best online analysis I seen. My wife did suffer a fracture, did not seek medical advice and continued running on her fractured foot for over a year constantly in pain until she decided to see a doctor. Don't be brave, get an xray and get to the source. If it is an inflamed tendon, I use a Strasburg sock to stretch out the tendon. Hope this helps!

Marc Bremner

Anonymous said...

Thank you Dr. Chris. I agree this is such good information. It is always difficult to take the right path when you do not want to stop running. Very helpful.

Merry Christmas.

Julie in Texas

BareFootGBG said...

I personally would suggest adding barefoot or vibram fivefinger minimalist shoed running to your regime.
What is described here is the really the result of weaknesses in the feet and legs showing up in the ligaments of the feet because of recruitment of anatomical parts into over use when other parts are not able to do their job.

Chronic shoe wearing can cause this. I run up to 125 miles per week for months on end and have never come close to a biomechanical injury.

Worth considering...

Erskien Lenier
www.BarefootGBG.com

Anonymous said...

Dr. Chris,

Thanks for the thorough explaination of heel pain. I may have a stress fracture - while squeezing my heel, there is slight pain. There is alway slight pain with weight bearing. Of course, first thing in the morning the pain is more moderate and quickly lessens. I do have a strauss sock, it seems to increase the pain after a few days of use for 1/2 hour a day, so i stopped using it. Here's my question, should i get an xray? Money is tight.

Thanks,
K

Anonymous said...

K,

An XR may be necessary to determine if there is a stress fracture. If you choose this route, make sure to get a Lateral view and a Calcaneal Axial view. Also, I have not found the straus sock to be as beneficial as a dorsal nite splint and I have tried them all!!!! :( If you aren't able to get an XR, perhaps water running, etc to allow the heel to heal (I love that!). Make sure you take your calcium and Vit D and listen to your body.
Merry Christmas and heal quickly!
Chris

Ben said...

This is a great post.. thanks for the information... I have had this problem for a while, but not wanted to stop my running and training, so I will try what you have stated... thanks for the great info!

Joseph said...

Dr. Gardner,

Thank you for the post. This is providing some insight. I recently switched to vibrams but they continue to strain my feet, even after a few weeks. My heels will be ok and then after a couple of days they just plain hurt so I have to switch back to a regular sneaker. The vibrams certainly provide relief from other leg injuries/soreness but they are killing my feet, which I didn't have a problem before. Thanks Joe

mitch said...

Thanks for the information. Almost forty and started to play some soccer. Mind wants to play like a twenty year old, body acts older. Will definitely do the stretching ....Thanks to all.

Ron said...
This comment has been removed by the author.
Anonymous said...

Could you please elaborate with the pain being directly on the back of the heel. I'm a strict trail runner. A simple 3 mile run on a treadmill 2 weeks ago did me in. The tightness lessens but has not gone away. This is my first search for hope.

Compa said...

Thanx for the info :D A few months ago, I was running during a Soccer match with some friends and after that match, I started to experience pain under my heel each morning and after playing videogames (since I cross my legsand sit in my bed).
The only way I could bear the pain was by using a pair of skechers designed for running (with a very soft sole). The ones I used for my socker match had a very thin sole by design (Now I think that it is a very poor design and made just for looks)

Yesterday I decided to crawl the internet and found your article and well, I wanted to say thanx because now I think I know what I have hehe.

Anyways, thank you for the article! (Yeah, I know I'm posting 5 years after you posted it but THANX! :D )

Herman Garcia said...

your description describes everything that is wrong with my heel!.lol i had to stop running for like two weeks, i could only do bycicle, the pain was gone, i could even play basketball again! but yesterday i went to do a 4mile run with my lil bro, right when i was hitting my third mile, my heel started feeling weird, but no pain.. 30 min after we were done the pain kicked in! i couldn't.even walk!, today i feel better, i will do no running for a month an, wait for the inflammation to go away i guess it does take time for tendons to heel

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