Heel Pain, Heel Spur, Plantar Fascitis
Heel Pain, Heel Spurs and Plantar fascitis are all often described as “A sharp pain that hits when first standing from lying down or sitting position. A stone bruise type pain or burning arches may also accompany this condition. This pain seems to get better as you warm up or walk it out, but remains as a dull ache when standing for long periods. Pain usually returns in the morning or following rest”.
This is an extremely common problem experienced by a wide variety of people. The most common cause for this problem is excessive rolling in of the feet (over pronation). When the feet roll inwards the arch collapses and the foot elongates. This elongation stretches all of the structures on the bottom of the foot (ligament, muscles and nerves) causing heel and arch pain.
The plantar fascia is the main ligament on the underside of the foot. It runs from the calcaneus (heel) to just behind the toes. The plantar fascia helps to keep the foot from spreading out and rolling in.
When the foot is not properly aligned the bones of the foot unlock causing the foot to roll in. This places excess stretching stress on the plantar fascia. The plantar fascia alone is unable to maintain the arch contour and with overuse becomes painful and inflamed. With every step the foot pronates and elongates. This stretches the plantar fascia causing pain.
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Heel pain, Heel Spur or Plantar fascitis – Common cause of heel pain in adults
Plantar fascitisis the most common cause of chronic heel pain in adults. It has been described with various graphic terms associated with physical activities e.g. tennis heel, joggers heel or policeman’s heel.
What happens to the foot with heel pain, heel spurs and plantar fascitis?
Within the foot there is a tough sheath of tendons that maintains the normal arch of the foot from underneath known as the plantar fascia. The plantar fascia normally has a narrow end that is attached below the calcaneus (heel bone). The wider end fans out to be attached to the underside of the toe bones. When intact, it maintains the arch of the foot and also acts as a shock absorber for the foot. This fascia acts like a hammock, bearing the weight of the foot. The fascia normally has elastic and flexible properties that permit free movement of the foot and allow it to perform its shock absorbing function.
Plantar fascitis occurs when there are repeated small injuries to the fascia, this is usually due to physical exercise, over pronatoin or poor footwear. These injuries are too tiny to be repaired and occur as a part of daily stress and strain on the fot. When there are repeated injuries to the fascia, a new tougher scar tissue forms. The new tissue that is formed is often not as supple or elastic as the original one. This scar tissue gives rise to the condition where the ability of the fascia to maintain the arch is slowly lost, as the plantar fascia is not as flexible as it needs to be.
When the plantar fascia is damaged it effectively shortens due to the scarring from injury. When the plantar fascia cools down when at arrest the length of the plantar fascia is further shortened. This occurs when the foot is not bearing weight when at rest, as happens at night when the person is in bed. As soon as the first steps are taken in the morning, the foot needs to bear weight. This causes the arch of the foot to flex and the fascia to stretch to bear the weight, like a hammock. It is this stretching that leads to the pain, as the plantar fascia is stressed. The pull at the heel bone, where it is attached, can eventually give rise to the formation of small bone extensions at the heel bone, where the fascia is attached. These are called heel spurs and these aggravate the condition. After bearing weight or walking, the fascia warms up and becomes more flexible. This relieves the stabbing heel pain however this is only temporary. The inflammation from repetitive small injuries within the plantar fascia remains and the pain also persists as a dull ache. At the end of the day, the pain regains its earlier intensity, although it is not a stabbing pain.
Causes of heel pain, heel spurs and plantar fascitis
Repeated stress and strain on the fascia is the common reason for the development of this condition.over pronation is the number 1 cause of excessive strain on the plantar fascia. Excessive weight or obesity is also a common cause, this results in extra load being placed on the foot and this causes further over pronation. People who need to stand for long hours are also common victims. Walking or standing bare foot or on hard ground or wearing shoes with hard heels can also lead to this condition or aggravate an existing one. Aging that leads to loss of the flexibility of the fascia is also commonly associated with plantar fascitis. Most patients are between 40 and 70 years of age. People with problems in the arch of the foot, like those with flat foot or very high arch, are susceptible to plantar fascitis. Sports people or people who are active can suffer from plantar fasciitis if they have faulty foot mechanics that can result in over pronation.
Typical clinical presentation of heel pain, heel spurs and plantar fascitis
The most common complaint related to plantar fascitis is heel pain after long periods of non bearing weight. The patient usually complains of stabbing pain in the heels, while taking the first few steps in the morning. The pain often dulls with more walking or bearing of the body weight, only to intensify during the day or while walking bare foot on hard surfaces. After long periods of sitting or non-weight bearing, the pain may come back with great intensity. The patient may limp due to the pain, often avoiding putting weight on the heels and literally tiptoeing. Walking on the toes can further aggravate the pain.
How this is heel pain, heel spurs and plantar fascitis diagnosed
Palpation (touching) the underside and sides of the heel the patient may complain of pain. There may be mild swelling and redness over the heels. Standing on the tip of the toes may aggravate the pain in the heels. Similarly, an attempt to bend the foot so as to bring the toes towards the shins (dorsiflexion) can also be painful.
X-rays of the foot to check for heel spurs are sometimes helpful but not always necessary. MRI images may be recommended, to detect the actual thickening of the inflamed fascia and the swelling around the fascia.
Podiatrists might want to exclude other causes of heel pain like injury or contusions, fractures, tearing of tendons, inflammation of fluid-filled sack inside the foot (called bursitis), nerve pain, infections of the small joints, tumors, etc.
Prevention of heel pain, heel spurs and plantar fascitis
Avoidance of high impact sports like running, jumping, volley ball, basket ball etc. can help the fascia to heal and prevent onset of pain. Walking bare foot, especially on hard surfaces, can also prevent aggravation of the condition. Other exercises, where the feet will not have to take the body weight, such as swimming or cycling, can be done.
Well-fitting and supportive shoes with soft supportive innersoles can do wonders for the aching heels of plantar fascitis. At times, an ice pack and some anti inflammatory medication can also help relieve the pain. Night splints that hold the foot in position while sleeping can prevent early morning pain. Regular stretching of the calf muscles will ease muscle tightness and may bring in relief.
Innersoles help to limit over pronation and prevent pain. These provide adequate support to the arch of the foot and ease the tension of the fascia, allowing it to heal as well as function more efficiently.
Long term consequences heel pain, heel spurs and plantar fascitis
With treatment most cases can be resolved however the treatment time usually depands on the amount of time the condition has been untreated for. Some patients may need to undergo surgery to correct the problem.
Treatment of Heel pain, Heel Spur, Plantar Fascitis
Rest – activity should be limited to those, which are unlikely to aggravate the injured site such as swimming and cycling.
Ice – ice will help reduce pain and swelling in to the area and will also help to reduce pain involved with the injury. Ice should be applied for 10 minutes 3 times per day for the first 72hrs. Ice should also be applied following activity.
Anti-inflammatory medication – will also reduce the pain and inflammation associated with the injury and will speed up recovery. Anti-inflammatory medication can be purchased over the counter from your chemist (Neurofen).
Strapping – helps to rest the injured site without limiting your activity. Strapping is also used to temporarily correct any mechanical abnormality in foot function. If strapping has reduced the amount of heel pain then an insole can be used as permanent measure. Strapping is best applied by an experienced podiatrist.
Stretching & Strengthening – stretching of the calf muscle group helps to relieve the tension on the plantar fascia in walking and at rest by allowing the foot to function properly.
Innersoles – used when there is a mechanical deformity in the bony structure of the foot (usually rolling in). Innersoles balance the foot which allows it to function more efficiently which relieves the strain on the plantar fascia.
Shoes – Good supportive shoes are essential control foot mechanics and unload the plantar fascia.
Cortisone Injection – usually used in long standing cases of heel pain that have responded poorly to the above treatments
Surgery – is used when all of the above treatments have failed to relieve pain in the heel. This usually involves removing the plantar fascia from the heel bone.
In a small number of cases conservative treatment of plantar fasciitis is unsuccessful and cortisone injections followed by surgery may be necessary.