Heel Pain! Do you suffer from heel pain and just can not seem to rid yourself of it? Heel pain has many different names. You can call it Plantar Fasciitis, heel spurs, plantar fasciopathy...the list of names for this condition goes on. Google loves to call it heel spurs, GPs and ortho doctors love to call it plantar fasciitis. All of the terms above are in fact incorrect. Lets start with heel spurs, heel spurs are rarely painful, in fact i have never seen a painful heel spur in a patient (thats almost 10 years worth of patients). The number of patients that come in with an xray and tell me they have a painful heel spur and have been using heel cushions for months to try and fix it, numbers in the thousands. A heel spur only shows where you have traction of the intrinsic foot muscles and fascia of the foot into the heel bone (calcaneus). All of these structures attach to a membrane that surrounds the outer surface of the bone (known as the periosteum). Inside this membrane are cells that produce and lay down new bone (osteoblasts). When the soft tissues have tension on them they pull on this periosteum and this pulls the periosteum away from the bone into a triangular shape (a spur shape). This creates a gap between the bone and the periosteum. If this tension continues, the body realises that there is excessive stress in this region and strengthens that region by laying down new bone. This fills in the triangular gap and creates a spur. The spur is always in the direction of tension, in the case of a heel spur, this direction happens to be parallel to the ground. So it never actually pokes into the ground. If for some reason it happened to be vertical (facing towards the ground), then it could be possible for it to cause pain (i have never seen this to date). So unless you have had a freakish accident, its almost impossible for the spur to be vertical in nature. Spurs only show where you have stress/tension on the bone membrane and rarely cause pain. Plantar fasciitis?? this is the most popular term for the injury. The suffix itis in itself means you have an inflammatory condition of the soft tissue structures involved. So if you have plantar fasci-itis, it means you have an inflammatory or systemic condition causing inflammation of the plantar fascia ligament that attaches onto your heel bone. This inflammation of the ligamentous area/periosteal membrane is what is causing your pain. This could be the case if you did suffer from an underlying system inflammatory condition eg rheumatoid arthritis or ankylosing spondylitis. Fortunately, most of us do not have an underlying systemic condition. Rather, we have an overuse injury to the ligaments/muscles that attach into the heel bone. We have degeneration of these soft tissue structures and this is known as an opathy. Which brings me to the next term Plantar fasciopathy. This is the most correct of all the terms and means that you have suffered an overuse injury (an opathy) to the plantar fascia ligament. Unfortunately, for the most part, the plantar fascia is never involved in isolation. If we did some histological studies (tissue samples) of the injured tissues, you would find that not only is the plantar fascia involved, but all of the intrinsic foot muscles that attach onto the plantar/medial aspect of the calcaneus (heel bone) are involved. The muscles and the fascia are degenerated/overused, not just the ligament (plantar fascia). So what do we call it? hmmm i prefer to call it insertional heel pain, as it is all of the plantar intrinsic foot structures that attach into the plantar/medial aspect of the calcaneus that are degenerated. What actually is the Plantar Fascia? The plantar fascia is a thick piece of connective tissue (an aponeurosis) situated beneath the skin on the sole of the foot. If you dorsiflex your toes, you can actually see the medial portion of it running like a thick cord along the length of the arch. It runs from the calcaneal tuberosity (bony bump on the bottom of the heel) forwards to the toes. Towards the front of the foot, at the mid-metatarsal level, it divides into 5 sections, each extending into a toe and straddling the flexor tendons. The plantar fascia is divided into 3 sections. The central portion, the medial and the lateral portions. The plantar fascia contributes to support of the arch of the foot by acting as a tie-rod, where it undergoes tension when the foot bears any loading. During walking this stabilises the arch of the foot and provides shock absorption when the foot hits the ground. Now there are many other conditions that heel pain could also be and often, more than one occurs at the same time eg medial calcaneal neuritis (baxters neuritis), plantar calcaneal bursitis, fibromas of the fascia itself (very painful), an actual partial/full acute tear to the plantar fascia, fat pad syndrome, fracture, referred pain from the lumbar spine, bone bruise...the list goes on. Gradually, we will write more about each condition in the coming months. Especially plantar calcaneal bursitis and heat vs ice. Now, do you wake up in the morning to pain as soon as your heel touches the ground? do you get up after sitting down for lunch to pain in the heel as soon as you start walking? Has this been happening for months and months? Have you tried stretching your calf/hamstrings/intrinsic foot muscles/loosening the gluts to no avail and still have the pain? treated your lower back and SIJs to treat the foot pain? been to physios/osteos/chiros already? you have tried rolling the plantar aspect of the foot on a golf/tennis ball? you have been flossing the crap through your ankle to improve the mobility and been doing flossing and tacking on your calf and still have the pain? Chances are you need more than just mobility work. Most people write about wearing minimus type shoes to strengthen your feet, going barefoot on sand or grass, performing strengthening exercises of the intrinsic and extrinsic foot muscles, improving your mobility, shock wave therapy, dry needling, acupuncture, corticosteroid injections, platelet therapy...this list goes on. If you have had your heel pain for months/years, chances are also that you have tried all of the above. If you have tried all of the above and still have the pain...you need rest! You need to splint the injured/degenerated structures and allow them to heal. Give them time to heal. In fact, if you have already been working with the physio for months and months and working on your mobility, chances are you are most likely extremely mobile already (hypermobile, ligamentous laxity). Your ankle range of motion and foot range of motion is excessively large, but in response to this, your tissues are stiffening up in an attempt to stabilise you. If this is the case and you have heel pain you need to reduce this motion and splint these tissues and joints. A lot of patients come into me who are hypermobile and tell me they are stiff and tight and they have no ankle mobility. Muscles are pretty dumb, they tighten up only when neurologically activated to do so. Pain, protection and overuse being some of those that trigger the muscle to tighten. Overuse in particular means the muscle has been working excessively hard for a long period of time to stabilise something. That something is a joint. When your joints are unstable, the muscles tighten up as a neurological response to protect and stabilise the joint/s. When a muscle tightens, it increases loading and tension on the soft tissue structures that are directly (tendon) or indirectly attached to it (fascia/periosteum). This over time increases the soft tissues stresses on this chain of tissue and causes degeneration/wear and tear. Just like a car engine wears out over time. so do our joints and soft tissues. Now, if you broke a bone, lets say a bone in your forearm and it was in a cast. You would not take the cast off and start stressing the broken bone until it had fully healed. You would give it time to heal (roughly 6 to 8 weeks). This is the same for the soft tissue structures eg ligamentous/tendinous/muscular structures that have degenerated. The unfortunate part is, that unlike bone, which heals relatively quickly, soft tissues like tendon/ligaments are very avascular (lack a good supply of blood vessels and hence blood flow) and can take months to regenerate and remodel. We are talking longer than 3 months minimum. Chronic heel pain can take longer than 6 months. So if you fall into the above category, I have attached a video of a strapping method. This strapping method is known as low dye strapping and it helps to reduce the joint range of motion of all the intrinsic foot muscles and shortens the range of motion they move through. This as a result reduces tension to the injured structures. Like a rock climbing rope, if the rope had tears in it, you would not keep adding weight to the end of the rope or start climbing it. You would unload the rope and let the fibres approximate one another so they could potentially regenerate (in the case of soft tissues that is, the rope obviously will not regenerate). Head down to your local pharmacy, buy some strapping tape. I prefer Leukoplast, its the stickiest of them all. Follow the video below. This strapping method should pretty much reduce the pain from anywhere between 50% to 100%. I can usually achieve almost 100% pain relief when applying this taping method to patients I see. (this does not mean the structures have miraculously healed, it just means we have reduced the loading through them). Leave the tape on for 2 to 3 days at a time. Take it off on the 2nd/3rd night and reapply the next morning. If this works and you have greatly reduced pain, chances are you most likely need orthotics. These will be left in your footwear to provide that long term splinting your tissues need to heal and recover and prevent that excessive joint motion. By preventing the excessive joint motion, you will also find that the stabilising muscles will relax and not tighten up. As for Orthotics and footwear, especially amongst the crossfit world and barefoot running enthusiasts...i will leave these as a topic i will write about in the coming months for now.
Posted on: Fri, 11 Jul 2014 08:20:39 +0000
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