Plantar Fasciitis – heel pain
April 3, 2018
Plantar Fasciitis – heel pain
Plantar fasciitis is a very painful condition of the foot, and we commonly encounter it in general practice. It is estimated that 1 in 10 of us will get it at some time in our life. Typically, those suffering present with foot pain that is agonising when they take their first steps in the morning. They describe it as a 'stone bruise' under their heel, and it makes them limp and hobble around for a few minutes until it eases off. It will worsen again after a period of rest and may be exacerbated by activity.
The plantar fascia is a ligament like structure that holds together the arch of the foot, running from the heel to the toes. It is a fibrous white band of tissue, that acts as a shock absorber when we walk. In the past we used to think that plantar fasciitis was caused by inflammation of the plantar fascia, however it is now believed that it is caused by recurrent trauma causing multiple micro tears, impeding its structure and function.
This type of foot pain can be found in both athletes and couch potatoes. 10% of those who run regularly or participate in sports that involve running (e.g. soccer) develop it, but 70% of those who have it are overweight. It is a multi-factorial issue, with high arches, tight Achilles tendons, flat feet, standing for prolonged periods all being risk factors. From a mechanical point of view, those whose forefeet pronate (turns out, so during walking the big toe takes the majority of the impact and the little toe takes very little), those with varus knees (knock knees), those with leg length discrepancies and those with a high arch are all more likely to get plantar fasciitis.
Mostly, plantar fasciitis can be diagnosed from the history alone. X-rays and ultra sounds are only done if the pain is atypical or does not respond to the management plan.
Resolving plantar fasciitis can take time and much effort. It is very easy to re trigger (for example, a bare foot walk along the beach), and resolution often requires many approaches.
- Footwear. Walking barefoot or in jandals are common triggers and best avoided (unless you get the specialist orthotic style jandals). Have some good shoes right by your bed, so you put them on first thing in the morning. Get well fitted shoes for walking and running, that are specially designed for what ever biomechanical foot issues you may have. You may need help from a podiatrist or a specialist shoe shop to ensure you have shoes that help rather than exacerbate the problem. Expect to walk on a treadmill to have your gait assessed and take in your old shoes to have the wear marks assessed as part of the process. Rotate your daily footwear, especially if you stand for long periods at work. A small study found those who varied their footwear regularly had less issues. High heels will exacerbate shortening of the Achilles tendon so are best avoided.
- Strengthening exercises. Recent studies have been shown that exercises to strength the plantar fascia are far more effective than stretches we previously advised. These can easily be done at home on alternate days, using just a towel and a step. Watch the YouTube video below for a full illustration. www.youtube.com/watch?v=sqxLXgACht0
- Ice. Freeze a plastic bottle of water and roll your foot over it at least twice a day for 15 minutes a time. Also ice your foot after any vigorous activity.
- Strapping. A podiatrist or physiotherapist can use sports strapping to support the foot and ease the pressure off the plantar fascia. This can be tricky to do yourself because it requires the right degree of tension in the strapping tape.
- Orthotics. Sometimes a simple gel heel raise may be sufficient to ease the discomfort, but often orthotics are required to insert into your shoes to help correct any biomechanical causes of the pain. See a podiatrist with a special interest in biomechanics to either help you choose an off the shelf model, or have custom made ones. Whilst this can be expensive it can be a very helpful way to ensure your choice of footwear does not exacerbate the pain.
- Massage. Really massaging the tight tissue under the foot can be helpful. There are special foot rollers designed for you to do it yourself.
- Stretches. For those with tight Achilles or overdeveloped calf muscles that are pulling excessively on the heel, calf stretches may help. Stand facing a wall with your hands on the wall at eye level. Put the leg you want to stretch about a step behind the other leg. Keep your back heel on the floor and bend your front knee until you feel a good stretch in the back calf. Hold for 30 seconds. Repeat. This should be done twice daily.
- Modify your activity. If running on the pavement is the trigger give it a break for a while then try running on a machine instead. If running continues to be an issue swap to doing your cardio workout on a cross trainer instead or take up cycling or swimming. Box jumps, or other high impact exercises may trigger the problem.
- Lose weight. Get your BMI down to under 25 to help avoid future recurrences. Come and talk to the Medplus team about how to go about this.
- Anti inflammatories. Medications like ibuprofen or diclofenac can be excellent at calming down a painful episode of plantar fasciitis. However, these drugs have many potential side effects and should only be used if advised by your Medplus doctor. Do not use them if you have ever had a gastric ulcer or if you are on a blood thinning medication. They need to be used with a drug like omeprazole to protect your stomach lining. Remember, they are not a long-term solution and need to be used in combination with all of the above suggestions.
- Steroid injections. If despite everything the pain does not improve, come and see Dr Martin Hadler who will consider treatment with a steroid (cortisone) injection into your plantar fascia.
- Night splints. Keeping your foot flexed at the ankle at night by using a special moon boot like splint can help resolve the problem. The problem is that these are often uncomfortable and are often not tolerated. There are also special socks for plantar fasciitis, which can be worn at night. These are tight and compress the foot, so can also be uncomfortable.