Recently, I was involved on a wine country expedition on a close high school friend’s birthday. Among the six of our close knit friends, I have one friend in particular who dominated us on our pickup basketball. On game day, he complained to me about his heel pain. Like many people, this pain is a big annoyance that isn’t necessarily disabling.
He had pain and palpable tenderness in the area just under his heel bone on the inside portion of the sole of his foot, also known as the medial tubercle of the calcaneus. Like others with his condition, his pain increased when taking the first few steps in the morning and the pain worsened with continued weight bearing. There is no associated tingling or numbness. Though it seemed to lessen with activity, it was worse by the end of the day. I told Mike, this is a very common problem that is responsible for heel pain 80% of the time. This usually occurs in athletes, runners, and those who stand for a prolonged period of time as part of their occupation.
It is called plantar fasciitis. I explained to him that it occurs due to repetitive microtrauma at the origin of the plantar fascia, a thick ligament on the sole of the foot connecting the heel bone to the toes and flexor tendons. The plantar fascia functions as a cable that tightens as a windlass does, when the toes are extended upward or dorsiflexed. This elevates and maintains the arch of the inside (medial) part of the foot during ambulation. It sustains the stresses of the gait cycle to allow for a rigid lever arm to help propel the body forward. Having tight calf muscles or an inflexible foot can cause overstretching of the plantar fascia at its origin causing the microtrauma and sometimes pulling of the bone which can create a spur that can be seen on x-ray.
Most importantly, the condition is successfully treated 90% of the time without surgery. This typically involves a period of rest, stretching the tight structures, icing the area, and non-steroidal anti inflammatory medication such as ibuprofen or naproxen. More refractory pain can be aided with a guided physical therapy program. In his case, I advised him to get night splints that would keep his foot up and his ligament stretched. When most people sleep, this fascia tightens and shortens in length because naturally the foot goes down towards the floor during the resting phase. The night splint prevents that from happening.
In addition, I demonstrated a simple stretching exercise with a sheet placed at the base of his toes and pulling tension to stretch his heel cord and calf muscles. A more specific variation involves grabbing the toes and pulling up towards one’s self to stretch the plantar fascia. Stretching helps mobilize the foot and loosen the structures around the fascia so that it may function effectively as a windlass mechanism.
Other options such as foot orthoses can help optimize loading of the foot to off-load the plantar fascia at its origin. This is usually obtained with heel cups or arch support inserts. Cortisone injections can provide short term relief though caution should be advised given the risk of fat atrophy in that area following an injection. Some treatments such as casting, shock wave therapy, and radiofrequency stimulation may provide some benefit, though this remains an area of controversy. Finally, surgical treatment with a limited release of the fascia has been advocated after 6 months of failed conservative management.
I spoke to him a couple of weeks later, and his pain seemed to have improved greatly with the stretching and medications alone. He agreed that he could keep coming to me for his sports injuries as long as he doesn’t block my layups and miss some more shots when I guard him at our next pickup game.
For more information on heel pain, visit OrthoInfo.org.
San Francisco Orthopaedic Residency Program, St. Mary’s Medical Center
San Francisco, CA