What Is Pain At The Heel And The Best Ways To End It

Painful Heel


Overview


Plantar fasciitis is the most common cause of heel pain. Pain from plantar fasciitis is often most noticeable during the first few steps after getting out of bed in the morning. The plantar fascia is a thick band of tissue in the sole of the foot. Microtearing at the origin of the plantar fascia on the heel bone (calcaneus) can occur with repetitive loading. This microtearing leads to an inflammatory response (healing response) which produces the pain. Risk factors for plantar fasciitis include excessive standing, increased body weight, increasing age, a change in activity level, and a stiff calf muscle. Plantar fasciitis can be managed non-operatively in the vast majority of patients. The main components of an effective non-operative treatment program are: calf stretching with the knee straight, plantar fascia stretching, activity modification (to avoid precipitating activities), and comfort shoe wear.






Causes


There are several possible causes of plantar fasciitis, including wearing high heels, gaining weight, increased walking, standing, or stair-climbing. If you wear high-heeled shoes, including western-style boots, for long periods of time, the tough, tendonlike tissue of the bottom of your foot can become shorter. This layer of tissue is called fascia. Pain occurs when you stretch fascia that has shortened. This painful stretching might happen, for example, when you walk barefoot after getting out of bed in the morning. If you gain weight, you might be more likely to have plantar fasciitis, especially if you walk a lot or stand in shoes with poor heel cushioning. Normally there is a pad of fatty tissue under your heel bone. Weight gain might break down this fat pad and cause heel pain. Runners may get plantar fasciitis when they change their workout and increase their mileage or frequency of workouts. It can also occur with a change in exercise surface or terrain, or if your shoes are worn out and don't provide enough cushion for your heels. If the arches of your foot are abnormally high or low, you are more likely to develop plantar fasciitis than if your arches are normal.






Symptoms


Plantar fasciitis is usually found in one foot. While bilateral plantar fasciitis is not unheard of, this condition is more the result of a systemic arthritic condition that is extremely rare in an athletic population. There is a greater incidence of plantar fasciitis in males than females (Ambrosius 1992). While no direct cause could be found it could be argued that males are generally heavier which, when combined with the greater speeds, increased ground contact forces, and less flexibility, may explain the greater injury predisposition. The most notable characteristic of plantar fasciitis is pain upon rising, particularly the first step out of bed. This morning pain can be located with pinpoint accuracy at the bony landmark on the anterior medial tubercle of the calcaneus. The pain may be severe enough to prevent the athlete from walking barefooted in a normal heel-toe gait. Other less common presentations include referred pain to the subtalar joint, the forefoot, the arch of the foot or the achilles tendon (Brantingham 1992). After several minutes of walking the pain usually subsides only to re turn with the vigorous activity of the day's training session. The problem should be obvious to the coach as the athlete will exhibit altered gait and/ or an abnormal stride pattern, and may complain of foot pain during running/jumping activities. Consistent with plantar fascia problems the athlete will have a shortened gastroc complex. This can be evidenced by poor dorsiflexion (lifting the forefoot off the ground) or inability to perform the "flying frog" position. In the flying frog the athlete goes into a full squat position and maintains balance and full ground contact with the sole of the foot. Elevation of the heel signifies a tight gastroc complex. This test can be done with the training shoes on.






Diagnosis


The health care provider will perform a physical exam. This may show tenderness on the bottom of your foot, flat feet or high arches, mild foot swelling or redness, stiffness or tightness of the arch in the bottom of your foot. X-rays may be taken to rule out other problems.






Non Surgical Treatment


Plantar fasciitis treatment can be conservative (non-surgical) or invasive (surgical). Among the non-surgical ways to manage plantar fasciitis involves stretching and icing exercises. A night splint which help stretch the Achilles tendon and plantar fascia overnight, so that they can be more easily stretched during the morning. Orthotics that can be custom-made for the feet can also distribute tension on the feet more consistently. Corticosteroid is injected into the affected area to relieve pain and decrease inflammation. Doctors may also use extracorporeal shockwave therapy before considering plantar fasciitis surgery. During the therapy, sound waves are used to stimulate the affected area and eventually heal it. Physical therapy incorporation, deep massage stretching, and other modalities can at times be a helpful adjunct treatment. Surgery for plantar fasciitis is only considered when all other conservative treatments have failed.


Plantar Fascia






Surgical Treatment


In very rare cases plantar fascia surgery is suggested, as a last resort. In this case the surgeon makes an incision into the ligament, partially cutting the plantar fascia to release it. If a heel spur is present, the surgeon will remove it. Plantar Fasciitis surgery should always be considered the last resort when all the conventional treatment methods have failed to succeed. Endoscopic plantar fasciotomy (EPF) is a form of surgery whereby two incisions are made around the heel and the ligament is being detached from the heel bone allowing the new ligament to develop in the same place. In some cases the surgeon may decide to remove the heel spur itself, if present. Just like any type of surgery, Plantar Fascia surgery comes with certain risks and side effects. For example, the arch of the foot may drop and become weak. Wearing an arch support after surgery is therefore recommended. Heel spur surgeries may also do some damage to veins and arteries of your foot that allow blood supply in the area. This will increase the time of recovery.






Stretching Exercises


Exercises designed to stretch both your calf muscles and your plantar fascia (the band of tissue that runs under the sole of your foot) should help relieve pain and improve flexibility in the affected foot. A number of stretching exercises are described below. It's usually recommended that you do the exercises on both legs, even if only one of your heels is affected by pain. This will improve your balance and stability, and help relieve heel pain. Towel stretches. Keep a long towel beside your bed. Before you get out of bed in the morning, loop the towel around your foot and use it to pull your toes towards your body, while keeping your knee straight. Repeat three times on each foot. Wall stretches. Place both hands on a wall at shoulder height, with one of your feet in front of the other. The front foot should be about 30cm (12 inches) away from the wall. With your front knee bent and your back leg straight, lean towards the wall until you feel a tightening in the calf muscles of your back leg. Then relax. Repeat this exercise 10 times before switching legs and repeating the cycle. You should practise wall stretches twice a day. Stair stretches. Stand on a step of your stairs facing upstairs, using your banister for support. Your feet should be slightly apart, with your heels hanging off the back of the step. Lower your heels until you feel a tightening in your calves. Hold this position for about 40 seconds, before raising your heels back to the starting position. Repeat this procedure six times, at least twice a day. Chair stretches. Sit on a chair, with your knees bent at right angles. Turn your feet sideways so your heels are touching and your toes are pointing in opposite directions. Lift the toes of the affected foot upwards, while keeping the heel firmly on the floor. You should feel your calf muscles and Achilles tendon (the band of tissue that connects your heel bone to your calf muscle) tighten. Hold this position for several seconds and then relax. Repeat this procedure 10 times, five to six times a day. Dynamic stretches. While seated, roll the arch of your foot (the curved bottom part of the foot between your toes and heel) over a round object, such as a rolling pin, tennis ball or drinks can. Some people find that using a chilled can from their fridge has the added benefit of helping to relieve pain. Move your foot and ankle in all directions over the object for several minutes. Repeat the exercise twice a day.

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