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PLANTAR FASCIITIS
Foot and heel pain are two of the most common problems for which people consult us at
the Center for Sports and Osteopathic Medicine. This is of special concern in the
athletically active 20 to 55 age group.
Characteristically, the classic complaint is of
pain, localized to the inner aspect of the heel, worse in the morning on getting out of
bed. Arising to one’s feet after prolonged sitting can be an epic pain experience, so
can a nice long walk on cement sidewalks, or a run on the cinders around the reservoir.
Commonly the pain comes on after an increase in training time and/or intensity. It usually
subsides after several steps, but then recurs with increasing frequency and severity with
progressively less provocation. Often the pain extends forward to involve the arch.
WHAT’S HAPPENING?
A thick band of tissue extends from the heel to the ball of the foot. It is called the
plantar fascia and is an essential part of the support mechanism of the sole of the foot.
It is actually continuous with the Achilles tendon, and through it, with the calf muscles:
the gastrocnemius and the soleus. Muscles move bones. Ligaments are the principal support
mechanism of the joints of the foot and ankle (and of joints everywhere in the body). As
we age, or as we subject our feet to repetitive trauma, an interesting thing happens: the
ligaments stretch. Since they are more plastic than elastic, they don’t resume their
prior length. Those of us significantly past the age of consent notice that our guts are
not the only parts of our anatomy that sag. The ligaments supporting our feet are also
prey to the forces of gravity. The result is that the shoe size goes up for the simple
reason that our feet are now bigger! Bigger and more painful. Who ever heard of kids with
foot pain? Who ever heard of seniors without foot pain?
Ligaments and fascia have within them nerve endings
extremely sensitive to stretching. When over-stretched, either actively or passively, they
transmit impulses to the spinal cord and thence to the brain where they are finally
recorded and interpreted as pain.
As your foot sags, the plantar fascia, because of
the increased distance between its connections at the heel and the ball of the foot, is
stretched. It pulls at its attachment to the heel. This tension causes inflammation with
bleeding into the soft tissues. The body attempts to keep the fascia attached. Fibrous
tissue is laid down. Calcium is deposited, replaced by bone, and as a result, a spur or
traction osteophyte may be formed. This is the so-called "heel spur." Since no
weight is actually borne directly on it, the spur is not the cause of the pain. Rather, it
is the result of the process causing the pain. Since the plantar fascia is actually a
continuation of the calf muscle and Achilles tendon, the more stress on the plantar fascia
and/or tension in the calf muscles, the more pain and the more spur growth. The process is
gradual, and you may have a very large spur without being aware of it. As a matter of
fact, if we x-rayed everyone’s foot, we would probably find heel spurs in about 40%
of adults only a few of whom would have heel pain!
ACHILLES TENDINITIS
The runner with Achilles tendinitis complains of pain and stiffness directly behind
the ankle, having a gradual onset. It usually starts with stiffness and morning tightness
of the calf, is most painful upon initiation of activity, subsides with moderate activity,
then progressively increases in intensity proportional to duration and intensity of
activity. The pain may be associated with a grinding sensation. It is usually worse going
uphill.
The Achilles tendon represents the extension of the calf muscles into and around the heel,
thence into the plantar fascia, extending to the ball of the foot. Essentially, there is a
degenerative change in the tendon/ paratendon associated with microtears. This is the
result of a combination of faulty biomechanics and repetitive overload stress as occur in
running. It takes a long time for this combination of circumstances to produce these
changes. They show up, on average, after 12 years of training. The faulty biomechanics
involved is usually functional overpronation during the landing phase of running, and
supinatory push-off. Often, an unstable lateral ankle joint (recurring episodes of
"turning" or spraining) may also predispose the Achilles tendon to high shearing
forces.
SHIN SPLINTS
The complaint is usually of pain at the medial border of the tibia, the bone on the
inside of the lower leg. It involves degeneration and micro-tearing of the tendons of the
muscles that flex the toes and the forefoot- the flexor digitorum longus, flexor hallucis
longus and tibialis posterior. The usual biomechanical source of the syndrome is either
functional lowering of the longitudinal arch together with hyperpronation which is
normally compensated for by the tendons of those muscles; or through weakness and
overloading of the muscle in front of the shin, the tibialis anterior.
Shin splints are characterized initially by pain
related to impact activity. Later, pain and tenderness may occur in the lower third of the
shin unrelated to exercise.
Of course, there are many other lower extremity
injuries related to running and other athletic activities, but we are slaves to space
limitations.
Now that we’ve piqued your interest (I hope)
what can YOU do about these problems?
SELF MANAGEMENT
Since you only spend a relatively short time in your running or athletic shoes, your
daily footwear is of primary importance to the health of your feet. Tennis, walking shoes,
or cross-trainers, with an elevated heel and good support through the mid and hindfoot are
your best options if you need to be on your feet for prolonged periods. Avoid flat shoes
at all times. When you wear dress shoes for any prolonged period, make sure the soles are
soft. Lace-ups, of course are best because of the support they give. Hard rubber lifts
approximately ¼ inch thick may be placed in the heels of your shoes.
In physically active people, regular and effective stretching is essential to the
self-management and prevention of all these conditions. Self-massage and ice applications
are appropriate measures as is the judicious use of non steroid anti-inflammatory
medication, such as ibuprofen. Rest must be selective. Physical activity should be
maintained at the highest possible level without incurring re-injury. If you can’t
run, certainly you can bike, lift weights, swim, or (ugh!) use an upper body exerciser,
etc. Maintaining and even improving your aerobic conditioning during the injury recovery
period is essential to successful care. Probably the most important contribution you can
make to your own welfare is timely recognition of the existence of a problem and then
early and appropriate care by a health professional. If you continue to have foot and/or
ankle pain and you’ve done all the above, maybe it’s time to give us a shot (no
pun intended) at it.
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