Plantar Fasciitis
ASK THE PODIATRIST
Heel and Arch Pain!
--Dr. Jay C. Goldstein
Q: I was diagnosed with plantar fasciitis almost a year ago. My doctor recommended surgery. Are there any other options?
A: Plantar fasciitis is easily one of the most common problems treated by podiatrists. I do not think I can remember the last time I went through an entire day (in the office!) without treating at least one case of plantar fasciitis. I sometimes think the world is divided into those who have had plantar fasciitis, those who have plantar fasciitis, and those who will have plantar fasciitis.
SYMPTOMS
Most people with plantar fasciitis have pain at the bottom of their heel and/or arch when they first get out of bed in the morning. After a few minutes of walking the pain improves. If one walks too much the pain gets worse. The pain improves by sitting and eliminating weight-bearing. If one rests too long, he or she is likely to have pain when they first get up. If lucky, the pain will again improve after a few minutes of walking. If not so lucky, the pain (possibly accompanied by a limp) will persist for the remainder of the day. Nighttime finally brings relief, unless the poor soul’s bladder is a member of AARP, in which case you may again find yourself limping at 4 a.m. (give or take a few minutes).
The pain at the bottom of the heel usually feels like a bruise. The pain in the arch is often described as sharp, tearing, and/or burning. Symptoms are exacerbated by:
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running
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jumping
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pivoting or twisting
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lifting or carrying weight (more than 15 pounds)
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gaining weight
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walking on uneven terrain
Some inflammatory diseases (e.g., arthritis, fibromyalgia) cause and/or exacerbate heel pain. Such cases represent a minority of heel pain, and are outside the scope of this article.
ANATOMY
The plantar fasciitis is a trapezoidal shaped band of connective tissue that extends from the heel to the ball of the foot. Think of it like a guy wire (see the diagram).
Plantar Fascia
The foot is comprised of 28 bones and 33 joints, which means that there is lots of opportunity for movement. Pronation is a three dimensional motion that causes the foot to become more flexible, allowing some of those bones to shift, and causing the foot to flatten. Therefore, less stable foot structures, and activities that increase pronation, cause the foot to lengthen, increasing the tension upon the plantar fascia.
Activities like running, jumping, and lifting heavy objects (or gaining weight) also cause the bones to shift and the foot to lengthen. This lengthening tendency is resisted by the plantar fascia, placing significant tension upon the guy wire (the plantar fascia). If the tension is too great, the fibers of the plantar fascia become inflamed, and may tear. Since the plantar fascia attaches to the heel, the “pull” of the plantar fascia upon the outer sheath of the heel bone causes inflammation and pain.
If the tension upon the outer sheath of the heel bone persists, a heel spur is created. Most patients assume the heel spur causes their pain. However, many people with extreme pain have no spur. The spur is probably not the cause of the pain unless it becomes large or points downward, rather than horizontally. Rather, the presence of the spur is a manifestation of the long-term traction applied by the plantar fascia upon its attachment to the heel. The pain is caused by the accompanying inflammation.
TREATMENT
Treatment should be directed at reducing the tension upon the plantar fascia. Therefore, one needs to begin by determining the most likely cause of the increased tension, and countering the cause. Treatment may also be directed at reducing the inflammation and allowing the fibers of the plantar fascia to heal.
Dr. Goldstein is Board Certified in Podiatric Surgery, Podiatric Orthopedics, and in Podiatric Medicine. He has been running for many years, although sometimes he rests.