.Have you been stretching, rolling, icing and massaging your heel pain away only to find that the moment you stop doing this, it returns? We are listening to you and would like to help by addressing the reasons why it is so difficult to get rid of your heel pain.
In this blog we are referring to heel pain and plantar fasciitis interchangeably. Although there are other causes of heel pain (eg. Fat pad syndrome, fracture, bursitis etc.), we are focusing only on plantar fasciitis, which causes heel pain.
Plantar fasciitis by definition means “inflammation of the plantar fascia”. The injury, however, is actually an enthesopathy, meaning that the injury occurs by a pulling force from the plantar fascia on its attachment at the heel bone. The pulling force, when repetitive or with high impact, causes such injury to the plantar fascia that it cannot heal itself prior to the next moment of injury. And such begins the chronic cycle of inflammation and non-healing.
What happens on a chemical level in chronic heel pain?
Plantar fasciitis begins with collagen breakdown, similar what we find in chronic tendon injuries. If the injury has been persisting for weeks, it will be accompanied by the presence of fibroblasts, which are not seen in short-term inflammation. These fibroblasts have been shown to provide signals for leukocytes to persistently accumulate in the plantar fascia. Other important cells in chronic plantar fasciitis are macrophages and lymphocytes, which cause cell destruction. Macrophages live far longer than the cells seen in acute inflammation, allowing your heel pain to persist. This means that the longer the heel pain is left untreated, the more likely it is to be trapped in a cycle of non-healing.
What does this have to do with my heel pain?
In one word- everything. If you have been treating your heel pain by rolling your heel on a tennis ball or applying ice, this is often not enough. What we mean is that it often does not do enough to outweigh the forces that are damaging it.
Treatments – the good, the bad and the ugly
There are a host of treatments available to help with plantar fasciitis, but they need to be performed correctly in order to be beneficial.
This is the most common destructive therapy for chronic plantar fasciitis that presents to our clinic. To facilitate healing, we want to move swelling and fluid away from the heel. Ice therapy causes blood and lymphatic vessels to constrict and slow movement of fluid, thereby reducing the movement of this fluid away from the area. It has also been found that ice increases the permeability of lymphatic vessels, meaning that the fluid leaks back into the tissues of the area that you are icing.
Heat is great for increasing circulation meaning it helps to bring blood flow to the injured heel and push those nasty inflammatory cells out. It also provides pain relief and relaxation of the surrounding tissues.
This can promote greater range of movement at the ankle joint and thereby reduce stress on the plantar fascia. If you have tight calves or reduced ankle joint range of movement, massage to release the calves can have a beneficial impact on plantar fasciitis. Massage directly on the plantar fascia should be performed with caution so as not to re-damaging the healing tissues. You can try lightly massaging around the sore spot using a tennis ball with light pressure.
These are used to stretch the calf while sleeping. If tight calves are contributing to the plantar fasciitis not healing, this can be a worthy adjunctive treatment. They are, however, often bulky and an inconvenience to sleep with.
Performance Podiatry follows a treatment protocol for weak foot and leg muscles. These are often contributing to the plantar fascia not healing. Strong foot and leg muscles allow the foot to work in a more ‘normal’ fashion. A ‘normal’ walking style will reducing impact and load on the heel and help reduce heel pain.
Gait and Running Re-training:
As humans we teach ourselves to walk in the easiest possible manner for our bodies. Over time these habits become solidified, even if they are not effective in reducing injury or energy consumption. The same goes for running. A few simple changes such as learning to push through the big toe, reduce stride length or increase cadence can have a huge impact on reducing heel pain by allowing the tissues around it to heal.
Orthotics are customised insoles that you place under your feet and inside your shoes. These can be a great tool for off-loading the heel and sharing the stress across other parts of the leg. They can do so by elevating the heel, contouring the foot arches, reducing shock or reducing unwanted movements from occurring. You will ideally wear these orthotics in most of your shoes until your heel pain resolves. To fit well, your podiatrist will tailor them for smaller fits of shoes like ballet flats and men’s business shoes.
This is where we place a very slim needle into muscle or fascia trigger points to encourage the muscle to relax and facilitate healing. We apply this directly to the heel or to surrounding tissues.
This FDA-approved treatment sends high intensity shockwaves through the tissues on the sole of the foot to reach the plantar fascia. It breaks down targeted tissue and stimulates new blood vessel formation, assisting repair. Click here for more information on Shockwave Therapy at Performance Podiatry.
These should be used with caution as it is proven cortisone weakens the plantar fascia and can predispose to rupture. Cortisone can also cause fat pad atrophy, reducing the cushioning of the heel and predisposes the plantar fascia to even higher loads. In saying this, cortisone injections can be a great last resort treatment after all other conservative therapies have been exhausted.