Well Heeled

It”s a beautiful morning. You bound out of bed–only to drop to your knees in pain. A vindictive spouse, an angry roommate, or an evil spirit has surely placed broken glass or nails on the floor beside your bed; the intense pain in your heels as your feet touch the floor is incredible! However, a quick visual survey reveals no maliciously planted items of torture. You, my patient and friend, have developed plantar fasciitis. The problem is common and quite painful. And, most distressingly, it does not resolve either quickly or easily.

Heel pain syndrome is a chronic degenerative/reparative process secondary to stress overload. Patients usually describe a gradual increase in heel pain over weeks to months, though the problem may occur rather acutely as the above example illustrates especially in distance runners who most likely have developed partial or complete tears of the plantar fascia. The pain is characteristically associated with weight-bearing, especially in the morning or when rising from a chair. The pain may be described as burning, aching, or shooting and often actually wanes during the course of a day as the plantar fascia stretches. Examination typically reveals localized tenderness over the medial aspect of the heel and variable localized swelling. Because an inflammatory/stress reaction is felt to be the primary etiology of this condition, it is a painful condition that is common in both active and relatively sedentary but overweight individuals.

One typical patient with plantar fasciitis is middle-aged, overweight, and engaged in an occupation that requires prolonged standing on hard, unyielding surfaces (e.g. concrete flooring). Another typical patient is the long-distance runner, usually reporting an escalation in mileage, the addition of steep hill-running to the workout, or wearing running shoes well beyond the recommended 6months/400 miles of use. Additionally, people with congenitally flat-feet or feet with arches that curve inward may be more likely to develop this problem. . . especially if they are addicted runners. Unfortunately, I see a fair number of patients who develop plantar fasciitis when they begin exercise programs too rigorously after months of inactivity–especially when they fail to stretch well before and after the exercise. What an ironic result of good intentions!

Ninety percent of patients with plantar fasciitis will respond to nonoperative treatment, though complete resolution of symptoms is a prolonged process which combines activity modification with a stretching program. The stretches include a traditional wall-leaning exercise as well as heel-lowering exercises on stairs, and passive dorsiflexion of the foot; the latter stretch is particularly helpful before weight-bearing. Activity modification might substitute biking or swimming for walking or running, and of course decrease in mileage, velocity, and hill work for distance runners. Additional therapies include use of nonsteroidal antiinflammatory drugs, visco-elastic heel cups, and sometimes the use of plantar fascia night splints. These night splints support the ankle at approximately five degrees of dorsiflexion while the patient is recumbent at night and serve to break the cycle of repetitive tearing of soft tissues by keeping the plantar fascia lengthened at night.

For recalcitrant cases, taping, corticosteroid injections into the heel, or casting of the foot may be necessary. Surgery is reserved for the intractable cases that fail to resolve over 6 to 12 months despite maximal conservative treatment . Having had significant plantar fasciitis in both of my heels as a result of intensive long distance running, I can tell you that it took me about 9 months to recover completely. Stretching and massage were critical components in my recovery; and I had to substitute swimming for my running routine for about 4 full months.

In summary, plantar fasciitis is a common cause of heel pain that is caused by inflammation and tearing of the soft tissues in the heel and base of the foot. For most patients, curing this nagging, painful condition will include stretching of the calf muscles on a regular basis, massage of the calf, achilles tendon and heel, some form ofarch support, a long term rest break for the feet (which might include switching to a nonweight-bearing exercise), and/or losing weight. Topical or oral anti-inflammatory agents can help, and, taping, splinting and casting might be considered for more severe cases. Surgery should be considered only after diligent long term compliance with the above measures has failed. If you make a habit of stretching well before and after any form of weight-bearing exercise, and you moderate activity levels at the first indication of foot discomfort, you may actually be able to avoid progression to frank plantar fasciitis. These very basic habits may keep you well-heeled.

Stephen L. Hines, M.D.
April 2000