Plantar Fasciitis

Plantar fasciitis is a painful inflammatory condition of the foot caused by excessive wear to the plantar fascia that supports the arches of the foot or by biomechanical faults that cause abnormal pronation. The pain usually is felt on the underside of the heel, and is often most intense with the first steps of the day. It is commonly associated with long periods of weight bearing or sudden changes in weight bearing or activity. Obesity, weight gain, jobs that require a lot of walking on hard surfaces, shoes with little or no arch support, and inactivity are also associated with the condition.

Plantar fasciitis was formerly called “a dog’s heel” in the United Kingdom. It is sometimes known as “flip-flop disease” among US podiatrists. The condition often results in a heel spur on the calcaneus, in which case it is the underlying condition, and not the spur itself, which produces the pain.

Plantar fasciitis usually develops gradually, but it can come on suddenly and be severe. And although it can affect both feet, it more often occurs in only one foot at a time. Watch for:

• Sharp pain in the inside part of the bottom of your heel, which may feel like a knife sticking in the bottom of your foot
• Heel pain that tends to be worse with the first few steps after awakening, when climbing stairs or when standing on tiptoe
• Heel pain after long periods of standing or after getting up from a seated position
• Heel pain after, but not usually during, exercise
• Mild swelling in your heel

Under normal circumstances, your plantar fascia acts like a shock-absorbing bowstring, supporting the arch in your foot. But, if tension on that bowstring becomes too great, it can create small tears in the fascia. Repetitive stretching and tearing can cause the fascia to become irritated or inflamed. The causes of plantar fasciitis can be:

• Physical activity overload. Plantar fasciitis is common in long-distance runners. Jogging, walking or stair climbing also can place too much stress on your heel bone and the soft tissue attached to it, especially as part of an aggressive new training regimen. Even household exertion, such as moving furniture or large appliances, can trigger the pain.
• Arthritis. Some types of arthritis can cause inflammation in the tendons in the bottom of your foot, which may lead to plantar fasciitis.
• Diabetes. Although doctors don’t know why, plantar fasciitis occurs more often in people with diabetes.
• Faulty foot mechanics. Being flat-footed, having a high arch or even having an abnormal pattern of walking can adversely affect the way weight is distributed when you’re on your feet, putting added stress on the plantar fascia.
• Improper shoes. Shoes that are thin-soled, loose, or lack arch support or the ability to absorb shock don’t protect your feet. If you regularly wear shoes with high heels, your Achilles tendon which is attached to your heel can contract and shorten, causing strain on the tissue around your heel.

Foot Arch Pain

Foot Arch Pain

Foot Arch Pain Overview

Each foot contains 24 bones, which form two arches. The longitudinal arch runs the length of the foot, and the transverse arch runs the width. The bones of the arch are primarily held together by the shape with which they fit with each other and by fibrous tissues known as ligaments that serve to hold the bones to each other. The muscles of the foot, along with a tough, sinewy tissue known as the plantar fascia, provide secondary support to the foot. There are also fat pads in the foot to help with weight-bearing and absorbing impact. Arch pain can occur whenever something goes wrong with the function or interaction of any of these structures.

Foot Arch Pain Causes

The arches are the primary structures of the body that absorb and return force to and from the body to the outside world when we are on our feet. When something happens to these structures, pain and injury may result. Foot arch pain is a common problem that many suffer from.

There can be many causes of foot arch pain. Direct force trauma, ligament sprains, muscle strains, poor biomechanical alignment, stress fractures, overuse, or the tightness or lack of tightness of the joints in the foot may all cause pain in the arch.

Injury to the plantar fascia is a common cause of foot arch pain. The plantar fascia is a tough fibrous sheath that extends the length of the bottom of the foot and lends support to the arch. When the plantar fascia is damaged, the resulting inflammatory response may become a source of foot arch pain.

Sprains, strains, bruises, and fractures may be the result of a single stress or a combination of stresses to the foot. A blunt-force injury such as someone stepping on your foot may result not only in a bruise (contusion), but also in damage to the primary and secondary structures of the foot. Many of the muscles of the lower leg and foot attach on or near the arch. Injured or tight muscles may lead to incorrect biomechanics and in turn cause foot arch pain.

Injury to the bones of the foot can be caused by a single blow or twist to the arch or also by repetitive trauma, which can result in a stress fracture. A sprain of the arch occurs when the ligaments which hold the bones together are overstretched and the fibers tear. The muscles of the foot may be strained by overstretching, overuse, overloading, bruising, or being cut by stepping on a sharp object. Arthritis of the arch joints may also occur if the foot is subjected to repetitive movements that stress the arch.

Stress fractures, plantar fasciitis, and acute and chronic arthritis are most commonly the result of repetitive micro-trauma injuries. Micro-trauma injuries are caused when the structures of the body are stressed and re-stressed to the point that damage occurs in the tissues. Factors that commonly contribute to this injury can be running on uneven surfaces or surfaces that are too hard or too soft, shoes that have poor force-absorption qualities, or going too hard or too long during repeated exercise bouts.

Foot Arch Pain Symptoms

Foot arch pain and tenderness associated with plantar fascia strains are usually felt on the bottom of the foot and may manifest either as a specific or general area of tenderness. Plantar fascia pain may be increased or decreased by stretching of the arch. Generally, in mild cases of plantar fasciitis, the pain will decrease as the soft tissues of the foot “warm up”; however, pain may increase as use of the foot increases. In more severe cases of plantar fasciitis, pain may increase when the arch is stressed.

A more specific pain (point tenderness) is an indicator that something is wrong in that specific area. Pain with movement of the affected area is also an indicator of the particular body part affected.

Bones and ligaments work together to form joints, and bones are joined together by ligaments. Strains occur in ligaments. In the arch, there are ligaments that are located at the ends of each bone. These ligaments connect the bones to other bones on both ends and on the sides. Point tenderness and looseness of a joint are indicators of a sprain.

Fractures are indicated by point tenderness that may be severe over the area of bone that is affected. There may be a distinguishable lump or gap at the site of the fracture. A rotated toe or forefoot may also be a sign of a fracture.

The groups of muscles that support the arch can be divided into two groups. The muscles on the top of the arch start on the front lower leg and help to lift the arch, and the muscles that help pull the arch on the bottom of the foot are located the on back of the lower leg. Muscle injury may be indicated when pain is felt when the foot is fully extended, flexed, or turned in or out. Foot arch pain may also be felt when working the foot against resistance.

Bruises are the result of a direct-force injury to the body. A bruise can occur to the foot by a variety of causes, such as having your foot stepped on or by stepping on a rock. The tissues that compose the arch do not provide that area of the body much protection. Blows to the foot that result in pain, discoloration, swelling, and changes in how you walk may indicate more serious damage.

Foot Arch pain may have a variety of different causes. Proper evaluation and diagnosis of arch pain is essential in planning treatment. A good general guideline is to compare the injured side to the uninjured side. Injury may present itself as a distinguishable lump, a gap felt at that location, or a “crunchy” feeling on that spot caused by inflammation. The type, causes, and severity of pain are also good indicators of the severity of the injury.

Four grades can be used to describe foot arch pain:

• Pain during activity only
  

• Pain before and after activity, and not affecting performance
  

• Pain before, during, and after athletic activity affecting performance
  

• Pain so severe that performance is impossible

Exams and Tests

The doctor will take a brief history to determine how the injury occurred. If necessary, a thorough physical exam may be conducted to evaluate for any other injuries. Taking your workout shoes to the exam may also provide valuable information to the medical practitioner.

• Both feet will be physically and visually examined by the medical practitioner. The foot and arch will be touched and manipulated possibly with a lot of pressure and inspected to identify obvious deformities, tender spots, or any differences in the bones of the foot and arch.
  

• The medical practitioner will examine how the muscles of your foot function. These tests may involve holding or moving your foot and ankle against resistance; you may also asked to stand, walk, or even run. Pain caused by movements may indicate the cause of the pain.
  

• The nerves in the foot will be tested to make sure no injury has occurred there.
  

• An x-ray, MRI, or bone scan of the foot and arch may be taken to determine if there are changes in the makeup of the bone.

Foot Arch Pain Treatment

Self-Care at Home

When you first begin to notice discomfort or pain in the area, you can treat yourself with rest, ice, compression, and elevation (RICE). Over-the-counter medications may also be used to reduce discomfort and pain.

Rest will allow the tissues to heal themselves by preventing any further stress to the affected area.

Ice should be applied no longer than 20 minutes. The ice may be put in a plastic bag or wrapped in a towel. Commercial ice packs are not recommended because they are usually too cold.

Compression and elevation will help prevent any swelling of the affected tissues.

There are two types of over-the-counter medication that may help with the pain and swelling of arch pain. Acetaminophen (Tylenol) will help with the pain, and a nonsteroidal anti-inflammatory such as aspirin, ibuprofen, or naproxen will help with the pain and battle the inflammatory response. Caution should be taken when using these drugs, and dosage should not exceed the labeled directions. Those who have chronic medical conditions or who are taking other medications should consult with their doctor regarding the most appropriate type of pain and/or anti-inflammatory medications. Arch supports or foot orthotics may also help to ease arch pain.

Medical Treatment

Once the severity and cause of arch and foot pain is determined, a course of corrective and rehabilitative actions can be started.

• Therapists may use machines and/or manual therapies to reduce pain and increase circulation to the area to promote healing.
  

• Maintenance of fitness levels via modification of activity may be prescribed.
  

  • Substitute activities that may aggravate the pain and soreness with other activities; for instance, running causes the body to have multiple impacts with the ground, but the use of bicycling, elliptical trainers, step machines, swimming, or ski machines eliminates impact and allows you to continue to maintain and improve your fitness levels.
    

• Use corrective prophylactic measures.
  

  • Purchase new shoes or replace the insoles of your current shoes.
    

  • Athletic shoes lose the elastic properties of the soles through usage and age. A good rule of thumb is to replace your shoes every six months, more often if there is heavier usage. The use of insoles can increase energy absorption and add support to the foot.
    

  • Corrective foot orthotics may also improve the biomechanics of the foot.
    

• Focus on muscle strengthening and flexibility.
  

  • You may be given exercises to increase the strength and stability of the affected area and to correct muscles that may not be balanced.
    

  • Exercises to increase flexibility will maintain or improve the length of a muscle. Flexibility helps to make a stronger muscle that is less likely to be injured.
    

• Take medications to help reduce foot arch pain and inflammation as prescribed by your doctor.
  

• Follow up with your doctor until you are better.

Heel Pain? Arch Pain?

Heel spurs are one of more common problems faced by Podiatric Physicians.  A heel spur is a point of excess bone growth on the bottom of the heel.  Heel spurs are visible by x-rays.  The spur formation usually starts at the heel bone and extends towards the toes.

An even more common problem that is faced by Podiatric Physicians is Plantar Fasciitis.  This common heel problem is caused by a partial tearing of the plantar fascia (a dense fibrous connective tissue that connects the heel to the toes) usually at the attachment of the fascia to the heel bone.  This partial tear can result in a heel spur, fasciitis, or both.

The most frequent cause of heel pain is an abnormal motion of the foot called pronation.  Normally while walking your foot will strike the ground on the heel, then roll forward toward your toes and inward to the arch.  Your arch should only dip slightly during this motion.  If your heel is rotating outwards too much and your arch is lowering too much then you have excessive pronation.  The excess pronation leads to the arch of your foot stretching excessively.  It is this extra stretch in the arch that causes the partial tearing of the plantar fascia and the possibility of spur formation.

Other factors that may contribute to plantar fasciitis and heel spurs include a sudden increase in daily activity, increase in weight, or a change in shoes.  Dramatic increases in training intensity or duration may cause plantar fasciitis.  Shoes that are too flexible in the middle of the arch or shoes that do not bend in the correct location will also increase the amount of tension on the plantar fascia, as will an increase in weight.  And it is this increase in tension that leads to the partial tearing of the plantar fascia.

Plantar fasciitis is usually controlled with conservative treatments.  About 90% or more of the patients with plantar fasciitis will be controlled with conservative treatments.  Conservative treatments consist of: strapping of the feet, combined with a physical therapy program, and anti-inflammatory.  One of the main things a patient can do is stretching of the calf muscles and icing to the painful areas on the heels.  If the patient improves with the temporary strapping, then the patient would most likely also benefit from an arch support.  There are many types of arch supports on the market today.  The best arch support is a custom made orthotic which will control the excessive pronation and also support the arch taking the tension off the plantar fascia.The orthotics can then worn in a variety of shoes.

If the patients continue to have pain a physician could choose to do injection therapy, which consist of injecting a small amount of cortisone into the painful area trying to decrease the amount of inflammation present.  The patient could receive several injections while still performing the conservative treatment also over a period of several weeks or months.

If the pain still continues for a time period of 6 months or more, despite treatment, the patient may be choose to have a new treatment which uses shock waves.  This new treatment is called, Extracorporeal Shock Wave Therapy (ESWT).   This innovative, non-surgical treatment involves the delivery of sound energy or shock waves to affected areas of the body triggering the body’s own natural repair mechanisms and stimulating healing.  ESWT can be done in the office (low energy) and without the need for anesthetic.

ESWT is a safe and effective treatment option for many kinds of chronic pain associated with tendonitis.  The recovery period is shorter than traditional invasive surgery and the procedure eliminates many of the risks associated with traditional surgery.   Insurance may cover these treatments; however, it would be best to check with your specialist.

For the remaining small percentage of patients who fail to be relieved of the pain, the patient may choose to have surgical correction.  Surgical corrections consist of releasing the part of the plantar fascia from the attachment to the heel bone.  This is done to stop the pull of the fascia on the heel bone, thus stopping the pain.  The physician may also choose to remove the heel spur at this time also. Following surgical correction it will require the patient to be immobilized for a period of time.  The patient will then have the need for rehabilitation later.

In summary heel pain, heel spurs, and plantar fasciitis are common problems that are faced by many patients.  It is a problem that can be controlled and managed without surgery for the majority of the patients suffering from heel pain.