Heel pain is a common condition in many people that can cause symptoms ranging from mild discomfort to debilitating pain. The most common cause of heel pain is plantar fasciitis. Heel pain may also be due to other causes, such as a stress fracture, tendonitis, arthritis, nerve irritation, or a cyst. It is therefore important to have heel pain properly diagnosed and distinguished from all other possibilities in order to determine the underlying source of heel pain.
Plantar fascia: the anatomy
A long thin filament that connects the heel of a person to the front of his/her foot and supports the arch of the foot is termed as the plantar fascia. It lies directly beneath the skin on the bottom of the person’s foot. The plantar fascia ligament is like a rubber band and loosens and contracts with movements of the foot. Too much pressure on the foot can damage or tear the tissues. Under normal circumstances, this is avoided by the plantar fascia that is designed to help absorb the high stresses and strains placed on a person’s feet. If the plantar fascia is short, a person is said to have a high arch, and if it is long he/she is said to have a low arch/flatfeet.
Plantar fasciitis: the condition
Plantar fasciitis was traditionally thought to be an inflammatory condition. However, the condition is now suggested to be due to degeneration of the collagen fibers close to the attachment to the calcaneus/heel bone. With advancing age there is loss of elasticity in the plantar fascia, and it becomes more like a rope that doesn’t stretch very well. Also, there is thinning of the fat pad on the heel and it cannot absorb as much of the shock that is caused by walking. The extra shock is responsible for the damage of the plantar fascia and causes it to swell, tear, or bruise. The most common cause of the condition is an overload of physical activity and exercise. Continuous pulling of the fascia at the heel bone, eventually may lead to the development of a bony growth on the heel called as the heel spur. It is seen in about 70% of patients with plantar fasciitis and can be detected on X-Ray.
The condition is common in middle aged persons. It can also occur in younger people who are on their feet for most of the time as in athletes and soldiers. In recreational athletes/runners, and in persons involved in activities such as jumping the repetitive or excessive stress on the tissue leads to tears and inflammation. Persons with arthritis can develop plantar fasciitis due to inflammation in the tendons. Among the elderly, diabetes is also a factor that can contribute to heel pain and damage. Plantar fasciitis can be caused in persons in whom there is a tendency of the foot to roll inwards upon walking. Wearing incorrect shoes, shoes that do not fit properly, or provide inadequate support or cushioning can cause fasciitis. Other factors known to increase a person’s risk of developing plantar fasciitis are tighter calf muscles that make it difficult for the person to flex his/her foot and bring the toes up towards the shin, obesity, a very high arch, flat footedness, and spending most of the day on his/her feet.
Symptoms
A person suffering from plantar fasciitis may experience symptoms such as pain on the bottom of the foot near the heel, pain with the first few steps after getting out of bed in the morning or after a long period of rest (e.g. a car ride), and increase in pain intensity after exercise or certain activity. However, pain is not experienced during exercise or any activity. Pain is also seen to subside after a few minutes of walking. Heel spurs are not responsible for the heel pain in persons suffering from the condition. Heel pain in plantar fasciitis is seen due to irritation and inflammation of the plantar fascia.
Diagnosis
The doctor will take a detailed medical history including illness or injuries in the past, symptoms of pain (location and factors worsening it), the person’s level of activity and types of physical activity in daily routine. Physical examination by the doctor in a person suffering from plantar fasciitis will reveal signs of a high arch with an area of tenderness on the bottom of the foot just in front of the heel bone. Flexion of the foot may cause an increase in pain and there would be limited up motion of the ankle. The doctor will order for imaging tests to confirm if the heel pain is caused by plantar fasciitis. X –ray imaging will help in ruling out fractures or arthritis as the cause for heel pain. It can also detect the presence of heel spurs. Other imaging tests such as MRI and ultrasound are rarely ordered for in diagnosing the condition. They may be done if the heel pain is not relieved by initial treatment methods.
Self help measures
There is no single treatment that can help a person with plantar fasciitis. But there are many things that a person can do to help his/her feet get better. If a person runs or walks a lot he/she may benefit from cutting back on those activities to some extent. Placing pads in the shoe can soften the impact of walking. Strapping may help to support the foot and reduce strain on the fascia. Persons with flatfeet or a high arch may use inserts (orthotics – arch supports) into the shoes. Losing weight may help overweight persons in getting some relief from the pain. If a person’s job involves standing on a hard floor or standing in one spot for long periods placing some type of padding on the floor where he/she needs to stand may help. Few other measures include avoiding walking barefoot (prevent undue strain and stress on the fascia), putting an ice pack for 20 minutes every day (place a towel between the ice pack and the heel), and wearing supportive shoes that support the arch. Medicines such as aspirin, acetaminophen, naproxen and ibuprofen may help in easing heel pain.
Do exercises help?
Exercises that stretch the calf muscle can help ease pain and assist in recovery. One of the stretches that can help is the plantar fascia stretch. In this the person has to stand straight with his/her hands against a wall and the injured leg slightly behind the other leg. With both heels flat on the floor the person needs to bend both knees. The stretch should be felt in the lower part of the leg. In the calf stretch the person needs to stand with his/her hands against a wall and the injured leg behind the other leg. Keeping the injured leg straight, heel flat on the floor, and the foot pointing straight ahead the person needs to lean forward slowly bending the other leg. The stretch should be felt in the middle of the calf. In both the methods the stretch should be held for 10 to 15 seconds and should be repeated for 6 to 8 times in a day. Other exercises that may help strengthen the leg muscles include standing on the ball of the foot at the edge of a step and raising up as high as possible on the toes and relaxing between toe raises and letting the heel fall a little lower than the edge of the step or grabbing a towel with the toes as if trying to pick it up with the foot.
Persistent pain
In some patients with plantar fasciitis stretching, arch supports, medicine and exercises may not seem to help with the pain. Such persons may need to wear splints on the foot at night that allows maintaining an extended stretch of the plantar fascia while sleeping. This may help reduce the morning pain experienced by some patients. A removable walking cast may be used to immobilize the foot for a few weeks to allow it to rest and heal. Short wave therapy or corticosteroid injections into the tender area may provide relief in severe cases. Some persons may need surgical intervention to release the plantar fascia from its attachment to relieve the pain.
Outlook
Plantar fasciitis is a painful condition that results from overuse of the plantar fascia or arch tendon of the foot. Most of the patients respond to conservative methods of treatment and do not require surgery or invasive procedures to stop pain and reverse damage. No matter what kind of treatment a person undergoes for plantar fasciitis, the underlying causes that lead to this condition may remain. Therefore preventive measures such as wearing of supportive shoes, stretching, and using custom orthotic devices are the mainstay of long-term treatment for plantar fasciitis. However, every person’s body may respond to plantar fasciitis treatment differently and recovery times may vary.
