Time Heals All Wounds

As with many running injuries overuse is the underlying cause and many long distance runners have suffered pain under the heel along the thick fibrous band called the plantar fascia. The plantar fascia is a thick fibrous band between the heel and ball of the foot that stretches with weight bearing storing energy which is then released at push off rather like a spring. Repetitive use trauma causes small tears. When injury exceeds repair there is necrosis (death) of the tissue near the heel attachment leading to a very painful condition especially severe when getting out of bed after sleeping. It is sometimes called "heel spur syndrome" but the pain rarely has anything to do with a bone spur which may or may not be present.

Predisposing anatomical factors include both very high arches and flat feet as well as rotation deformities of the leg and hip that turn either in or out increasing the load on the fascia. Our bodies heal tears but as we age the healing is slower so the problem increases. Tight fascia is more likely to tear.

As with many injuries it is a lot easier to prevent then to cure.

Number one in prevention is preventing tightness with a stretching program of the calf and plantar fascia. Women who "live" in high heels really need to stretch as they are prone to tightness. Wall and curb/stair stretches do the job although if you have chronic problems it is worth while building a slant board.

Second is proper shoe wear with adequate support under the medial arch for all and for the pronated foot a stable shoe to limit pronation. Shoes lose absorption properties with time and use so bury that dead shoe at 500 miles or one year.

Third is running surface, the softer the better but especially avoiding concrete.

Once symptoms begin, starting treatment immediately is important. Early on treatment is pretty easy but later this becomes a really resistant and difficult problem to cure. As a general rule healing time equals symptom duration time. Long term denial with no or inadequate treatment leads to a typical resolution time of 6 to 18 months.

There are many forms of treatment out there which tells you something. If this were simple and easy there would only be one method!

Sometimes people respond to different treatments because there is a different disorder. For example people with a bone bruise or inflamed heel fat pad often do well with heel cups but that is the least effective treatment for plantar fasciitis.

So what works?

The most effective program for fairly short term problems involves a short period of rest from weight bearing exercise (two weeks minimum) followed by a combination of foot and calf stretching and intrinsic foot strengthening exercises. Stretching is both static(wall, step, slant board) and dynamic(rolling on a can or tennis ball). Stretching with a towel while still in bed gets rid of those excruciatingly painful first steps. Strengthening of the intrinsic foot muscles is done by curling the toes against resistance (pulling a towel on a smooth floor, picking up marbles, toe flares and taps). Acute secondary aids are ice massage(styrofoam cup cones or frozen peas), a short course of anti inflammatory medication and new, better shoes.

If the problem is long standing or resistant what can be added?

During sleep your foot relaxes downward and the fascia really tightens up. Night splints can be worn to keep the ankle cocked up slightly which cures many resistant cases (80%). Over the counter arch supports are helpful for mild pronation but go for the firmest you can find and tolerate. They need to be replaced yearly. If your pronation is more severe a custom orthosis may help although they are quite expensive and there may be aggravation by a too rigid, overcorrecting orthosis.

A treatment called iontophoresis uses a low voltage galvanic current to drive topical corticosterods to the involved area giving help short term symptom relief but must be done 2 or 3 times a week, is expensive and long term offers no real advantage over other methods.

Corticosteroid injections help 70% of cases but require some technical skill so as not to cause fat pad damage. Rare cases of plantar fascia rupture after injection have occurred which cure the symptoms but may lead to loss of arch support.

What about surgery?

95% get better in one year without surgery so it is rarely needed but in properly selected cases surgery is very effective (close to 90%). The medial part of the fascia is released from the heel bone and the damaged plantar fascia is removed. Removal of a heel spur is VERY rarely indicated as it is not the problem and removal causes a much longer healing process. The lateral plantar nerve branch should be carefully protected and decompressed as often the inflammatory reaction has caused scar around it.

Treatment failure results most commonly from lack of compliance in the exercise and strengthening while continuing to run. If compliance is good but problems persist it is time to look for the less common causes of heel pain ie tumor, stress fracture and nerve compression syndromes. Nerve compression problems present with somewhat different types and distributions of pain which can usually be identified with a careful history and exam but may be confirmed with electrical nerve conduction tests(not much fun). Tumors and fractures are diagnosed by x-rays, bone scans and MRIs

So you suffered with it, worked hard to get rid of it and now you want to keep it from coming back. Your two best friends in this are your stretching program (forever) and your running shoes whenever possible to wear them or an arch support in dress shoes when you have to wear them.

Remember!!! The most common reason for an injury is that you had it before.