Oh! My Aching Feet...

Summer is almost here and Autumn and Winter are not far behind. Most of us have been active with work and activities that have placed the feet under a lot of stress which can result in soreness or pain to one or both of our feet. One of the most common ailments we encounter in our office is pain to the heel(s). Most Heel Pain is associated with Plantar Fasciitis.

Pain associated with plantar fasciitis is derived from the excess repetitive strain on the plantar fascia. The pain has little to do with the heel striking the ground. In fact, placing something too soft under the heel will often aggravate the condition by letting the arch sink down lower thereby adding strain to the plantar fascia. Each time the foot strikes the ground, the heel hits first, followed by the ball, followed by the arch coming down. The plantar fascia bowstrings across the arch decelerating the speed at which the arch comes down. It is a shock absorbing mechanism for the body. A foot that flattens too rapidly or too much overstretches the plantar fascia and it is the repetitive overstretching that leads to painful heels. Heels that display pain in this area is due to where the fascia attaches to them. That flattening of the arch actually occurs with the foot rolling in too much, often called overpronation.  
Overpronation is often associated with heel pain.
There is no “cure all” to plantar fasciitis despite the various “gadgets” being sold on the internet. The key to helping plantar fasciitis often is related to the ability to decrease the tension or strain on the fascia. An arch support which “props up” the arch can help, but an orthotic which works by relieving tension from the heel and ball (the areas where the fascia attaches) can be much more effective. Basically, if one turns the heel inward and the ball of the foot the opposite way, tension is relieved from the plantar fascia. The goal of an orthotic is just to minimize that tension. If one can use the orthotic long enough to allow tension to be taken off the fascia, the fascia is no longer being overstretched and can heal itself.
Plantar fasciitis which has been around for a long time can lead to a deposit of calcium at the heel bone along the area where the fascia attaches. When that deposit of calcium is viewed from the side, considering the fact that x-rays are two dimensional, one sees a pointy area of calcium referred to as a heel spur. The heel spur is really a “shelf” of bone or calcium deposited along the origin of the ligament and points in the direction of the toes. The so-called “heel spur” thus has little or nothing to do with the pain experienced but is a two dimensional manifestation of a three dimensional shelf of calcified fascia. The spur itself is not the cause of the heel pain but rather a manifestation of it. It is just an “island” of calcification or ossification (bone formation) that forms in the area of fascia that is chronically inflamed.

Diagnosis of Plantar Fasciitis

Plantar fasciitis is often diagnosed by history of the disease process. Most patients note heel pain or arch pain upon arising in the morning or after rest. Often, the harder they have used their feet the day before, the more tender the heel will be upon arising the next day.
When I examine a patient, I look at the “mechanics” of the foot by watching the patient walk. Individuals with plantar fasciitis often have feet that roll in (pronate) too much. Such feet often flatten too much with weight bearing pressure, placing tension on the plantar fascia. That can happen to an individual with a high arch, low arch or a medium arch. One does not have to be flat footed to have heel pain.
Sonography involves the use of diagnostic ultrasound to look at the fascia itself. Remember that the fascia is a ligament, so it does not show up on x-rays. X-rays can be helpful to rule out things like stress fractures, arthritis, tumors but does not show the fascia. Sometimes calcium will deposit itself along the origin of the fascia, especially when the fascia has been inflamed for a long time. Since x-rays are two dimensional representations of a three dimensional object, one can see, from the side, a shelf of calcified ligament which is termed, somewhat mistakenly as a heel spur. Heel spurs, in actuality, do not exist but are simply a side view of the plantar fascia, showing a shelf of calcified ligament. The so-called spur always points forward in the direction of the ligament and is not the source of the pain.
MRI’s or ultrasound machines (Sonography) actually allows one to look at the plantar fascia itself studying the orientation of the fibers in the fascia and how thick they are. Sonography can be done, usually in the doctors’ office on the initial visit and costs about 1/20 the price of an MRI. The average thickness of the fascia as measured by ultrasound is about 3.5 mm. a thicker fascia can be indicative of a diseased, overstressed fascia. The sonographer also looks at the orientation of the fibers which should be parallel and neat. If the fibers are running in various directions or if one sees swelling (dark areas) in the fascia, that can indicate a bad or diseased plantar fascia.
Role of weight, occupation, time on feet. The more weight one has on their feet, the more tension is placed on the plantar fascia. That is true whether one is overweight or has an occupation which involves standing for long hours on hard surfaces.
People’s occupation often cannot be readily modified but your doctor can order light or modified duty. Additionally, a doctor can do something as simple as writing a note to an employer requesting use of preferred shoe gear. Preferred shoe gear may include shoes with a lot of cushioning and support, running shoes like the New Balance 1123, New Balance 925 (the all black or all white version of the 1123), the Brooks Beast or the Brooks Addiction 6 (the all black or white leather version AKA the Addiction Leather). Use of the right prescription orthotic in the shoe can render a shoe to become therapeutic in the standing process.
Body weight is a tougher subject. Nevertheless, if you have heels that are sore enough to make it tough to get through the day, then it may be hard to do certain exercise as walking. Keep in mind that almost all exercises can be done in an aerobic (fat burning) fashion when using lighter reps but higher frequency.
…Coming Up Next – Treatment of Plantar Fasciitis