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 have been listening to you and would like to use this blog to address the reasons why it is so difficult to get rid of that painful heel.
In this blog we will be referring to heel pain and plantar fasciitis interchangeably. Although there are other causes of heel pain (eg. Fat pad syndrome, fracture, bursitis etc.), we will focus only on plantar fasciitis that affects the heel.
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 to the degeneration found in chronic tendon injuries. If the injury has been persisting for weeks, the collagen breakdown will be accompanied by the presence of fibroblasts, which are not seen in acute (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 them and thereby the plantar fasciitis, to persist. This means that the longer the heel pain is left untreated, the more likely it is to be trapped in this 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 does not improve your plantar fascia 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 the calves are tight or ankle joint range of movement is restricted, massage to release the calves can have a beneficial impact on plantar fasciitis. Massage directly on the plantar fascia needs to be performed with caution so as not to assist in re-damaging the tissues. A light massage directly to the site of inflammation can be performed using a tennis ball with light pressure.
These are used to stretch the calf while sleeping, meaning that the heel is placed under less stress during daily activities. 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.
Our clinic follows a treatment protocol for weakened foot and leg muscles that may be contributing to the plantar fascia not healing. This allows the feet and legs to work in a more ‘normal’ fashion, reducing impact and load on certain areas in the feet.
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 injury and thereby healing tissues such as the plantar fascia.
Orthotics are customised insoles that are made to be placed 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 foot and leg. They can do so by elevating the heel, contouring the foot arches, reducing shock or stopping unwanted movements from occurring. These orthotics need to be able to be worn in most of your shoes and so may be tailored by your podiatrist for smaller fits of shoes such as ladies ballet flats or gentleman’s business shoes.
This is where an extremely thin needle is guided into muscular or fascial trigger points, to encourage a muscle to relax or facilitate healing. The aim of dry needling is provide a small but focussed stimulus to the muscle to produce neurochemicals that bring an inflammatory response to the area. This can be performed directly to the heel, or to surrounding tissues that are affected.
This FDA-approved treatment works by sending 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.
These should be used with extreme caution as it has been shown that cortisone weakens the plantar fascia in the first two weeks and can predispose to rupture. Cortisone can also cause fat pad atrophy, which reduces 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.