The most common cause of chronic heel pain is called Plantar Fasciitis (PF). This is also the most common condition that presents to my office.
The plantar fascia is a very large ligament that attaches to the heel bone and runs all the way up to the ball of the foot. This ligament is the primary supporter of the foot's natural arch. It acts like a rubber band that prevents the foot from over-flattening when your body weight is applied during standing, walking, and running. PF is inflammation of the plantar fascia due to small tears within the fascia.
People that are susceptible to PF include: 1) people with recent and/or rapid weight gain and/or people with a high body mass index; 2) people who run and walk for exercise; 3) people with occupations that require a lot of standing and/or walking; and 4) people who wear unsupportive or worn shoes. If your foot has too much weight/impact applied to it from any of the four reasons mentioned above, small tears will occur.
Most of the time, this condition develops slowly without any history of injury. The condition can also develop suddenly as a result of traumatic injury but that is rare. Many people first experience a dull ache that starts in the mid-arch. It has been described as feeling like a stone is in the shoe. As the condition worsens, it may move toward the heel. Often patients say that it hurts most when walking or standing after periods of rest. In less severe cases, the pain may ease with some walking or running. Over time, this easing of symptoms takes longer and longer to occur and eventually it’s painful all the time.
Most cases of PF can be treated without the need for surgery. When patients initially present to my office with PF, the visit usually focuses on activity modification, shoe wear, and stretching advice. In addition, a medical grade arch support is usually dispensed. If this initial treatment fails, then we may consider a cortico-steroid injection, a night splint, and/or physical therapy. Custom orthotics are also an option. Surgery is a last resort. In my experience, surgery is only needed in about 1 of 50 cases.
Good shoes are a very important part of curing PF. A good shoe is one that combines cushioning and support. Running sneakers are generally the shoes that do this best. A supportive shoe is one that bends only in the toe box. The shoe should also resist an effort to twist from end to end. A cushioned shoe is one that employs some type of shock-absorbing midsole. For more information on shoes, see my previous philly.com article titled "What is the right athletic shoe for you?" Someone with PF should ideally wear a good running shoe for all periods of standing and walking until pain has subsided. There are supportive dress shoes but they are much harder to find. Higher end dress shoes have started making their shoes with a removable insole that comes with the shoe. This allows one to remove the stock insoles (which usually are not very supportive) and replace it with a medical grade arch support if needed. At a minimum, you should make sure that your dress shoes have readily removable insoles rather than glued insoles. Supportive dress shoes for women can be even harder to find because, more often than not, form trumps function in women's shoe wear.
Barefoot walking should be avoided. When at home, if you don't like to wear shoes when in the house I usually suggest my patients get a supportive pair of sandals. Brands that I have endorsed are Birkenstock, Abeo, Spenco, Vionic/Orthaheel, Sole, and Fitflops. A simple pair of slippers, flip flops or crocs will not be supportive enough and they are likely to make the situation worse. An effort should be made to stand and walk less while the heel is still painful.
Arch supports are just as important to treat PF as good shoe wear. The goal of a good arch support should be to reduce the amount that the foot would flatten in its absence. The insert should feel like it slightly props up the arch when standing with a pair installed in your shoes. Therefore, it will reduce the tension on the plantar fascia. If the tension placed on the damaged/torn portion of the plantar fascia is reduced when weight bearing, it is much more likely to mend. There are many pre-made arch supports on the market that can be purchased at running shoe stores for 15-50 dollars. The insert should be semi rigid. This means that when you put the insert on the table and press on it with your thumb, it will flex and partially flatten with a moderate amount of pressure. Heavier people need a more rigid insert. Remember that the insert must reduce the amount that the arch would flatten with your body weight of 100+ lbs being placed on it. Most of the products I have seen being sold in pharmacies are NOT supportive enough.
Stretching exercises should be performed at least 3 times a day: once in the morning BEFORE getting out of bed; once in the evening prior to bedtime, and one other time during the day. Most of the pictures and handouts I have seen on stretching for heel pain depict simple calf stretches. However, a calf stretch does not sufficiently isolate the plantar fascia. In order to fully isolate the plantar fascia, the foot must be pulled up at the ankle AND the toes must be pulled up at the ball of the foot. You should feel the stretch in the arch of the foot as well as the back of the calf. This can be done by stretching your foot against the wall or by stretching your foot with your hands. The painful area can also be massaged with the opposite hand while performing the stretch. The stretch should be held for 10 seconds and relaxed. This should be repeated 5-10 times for each stretching routine.
People with PF should make an effort to reduce the amount of standing, walking, and impact/ weight bearing exercise that they participate in until resolution of pain. Even with good shoes and inserts, there is still some tension being placed on the plantar fascia during any weight bearing. Certain types of exercise are usually okay for PF patients to participate in. Bicycling/spinning is the probably the most practical. Because you are seated and there is no impact, this exercise can be done as much as desired. Exercise will increase your basal metabolic rate and reduce the time it will take for the plantar fascia to mend as long as the damaged tissue is not disrupted during the exercise. Other exercises that are usually acceptable are swimming, yoga, and pilates. Elliptical machine can also be done sometimes. The elliptical machine is a non-impact form of exercise, however, because you are standing during the exercise you are still weight bearing on the foot and possibly disrupting the healing plantar fascia. For PF patients trying to get back into a running routine, elliptical machine exercise is a good way to transition back to the running when your PF is resolved.
If all of the above treatment is followed and pain is still present, I would schedule an appointment to see a foot doctor. There are other much more rare conditions that can cause heel pain. An x-ray can rule out most of those conditions. Cortico-steroid injections are available to take away the inflammation and pain, but it does not mend the damaged/torn portion of the plantar fascia in any way and in some cases it can delay the healing process. For this reason, I usually prefer to make sure that all conservative treatments are performed prior to an injection. Even though I don't believe in the science behind using cortico-steroid injections for PF, I end up giving one or more injections to about 50% of the patients that present to my office with the condition. In my experience, the injections seem to help alleviate the pain, but I always insist the patient has good shoes and supportive inserts prior to getting an injection in order to promote full healing of the condition. A night splint is another treatment that is available. A night splint is a device that is worn on the foot while sleeping that holds the foot and ankle in a position that resembles weight bearing. This helps the ligament heal in that position and helps with the pain when getting out of bed in the morning.
While PF can be a very tricky condition to treat, following the steps discussed in this article and the advice of your doctor can get you up and running again, pain-free.
Dr. Crispell is a foot and ankle specialist at Riddle Hospital in Media, PA. He is a guest contributor to Sports Doc.
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