What May Cause Pain Under The Heel To Flare Up

Plantar Fasciitis

Overview

Plantar fasciitis is a poorly understood condition. There is little consensus among medical professionals about what causes the problem, and no treatments have been reliably proven to treat it. A number of theories exists for why plantar fasciitis develops, but the ineffectiveness of conventional treatments suggests something is missing. The plantar fascia is a band of connective tissue that runs along the underside of the foot from the heel to the toes. The fascia helps maintain the integrity of the arch, provides shock absorption, and plays an important role in the normal mechanical function of the foot.


Causes

Plantar Fasciitis is frequently cited as the number one cause of heel pain. The condition affects both children and adults. Children typically outgrow the problem, but affected adults may experience recurring symptoms over the course of many months or years. The syndrome afflicts both highly active and sedentary individuals. Typically, Plantar Fasciitis results from a combination of causes, including, pronation, a condition in which the plantar fascia doesn’t transfer weight evenly from the heel to the ball of the foot when you walk. Overuse of the feet without adequate periods of rest. High arches, flat feet or tightness in the Achilles’ tendon at the back of the heel. Obesity. Working conditions that involve long hours spent standing or lifting heavy objects. Worn or ill-fitting footwear. The normal aging process, which can result in a loss of soft tissue elasticity. Physical trauma to the foot, as in the case of taking a fall or being involved in a car accident.


Symptoms

Plantar fasciitis is usually found in one foot. While bilateral plantar fasciitis is not unheard of, this condition is more the result of a systemic arthritic condition that is extremely rare in an athletic population. There is a greater incidence of plantar fasciitis in males than females (Ambrosius 1992). While no direct cause could be found it could be argued that males are generally heavier which, when combined with the greater speeds, increased ground contact forces, and less flexibility, may explain the greater injury predisposition. The most notable characteristic of plantar fasciitis is pain upon rising, particularly the first step out of bed. This morning pain can be located with pinpoint accuracy at the bony landmark on the anterior medial tubercle of the calcaneus. The pain may be severe enough to prevent the athlete from walking barefooted in a normal heel-toe gait. Other less common presentations include referred pain to the subtalar joint, the forefoot, the arch of the foot or the achilles tendon (Brantingham 1992). After several minutes of walking the pain usually subsides only to re turn with the vigorous activity of the day’s training session. The problem should be obvious to the coach as the athlete will exhibit altered gait and/ or an abnormal stride pattern, and may complain of foot pain during running/jumping activities. Consistent with plantar fascia problems the athlete will have a shortened gastroc complex. This can be evidenced by poor dorsiflexion (lifting the forefoot off the ground) or inability to perform the “flying frog” position. In the flying frog the athlete goes into a full squat position and maintains balance and full ground contact with the sole of the foot. Elevation of the heel signifies a tight gastroc complex. This test can be done with the training shoes on.


Diagnosis

During the physical exam, your doctor checks for points of tenderness in your foot. The location of your pain can help determine its cause. Usually no tests are necessary. The diagnosis is made based on the history and physical examination. Occasionally your doctor may suggest an X-ray or magnetic resonance imaging (MRI) to make sure your pain isn’t being caused by another problem, such as a stress fracture or a pinched nerve. Sometimes an X-ray shows a spur of bone projecting forward from the heel bone. In the past, these bone spurs were often blamed for heel pain and removed surgically. But many people who have bone spurs on their heels have no heel pain.


Non Surgical Treatment

Your GP or podiatrist may advise you to change your footwear. You should avoid wearing flat-soled shoes, because they will not provide your heel with support and could make your heel pain worse. Ideally, you should wear shoes that cushion your heels and provide a good level of support to the arches of your feet. For women wearing high heels, and for men wearing heeled boots or brogues, can provide short- to medium-term pain relief, as they help reduce pressure on the heels. However, these types of shoes may not be suitable in the long term, because they can lead to further episodes of heel pain. Your GP or podiatrist can advise on footwear. Orthoses are insoles that fit inside your shoe to support your foot and help your heel recover. You can buy orthoses off-the-shelf from sports shops and larger pharmacies. Alternatively, your podiatrist should be able to recommend a supplier. If your pain does not respond to treatment and keeps recurring, or if you have an abnormal foot shape or structure, custom-made orthoses are available. These are specifically made to fit the shape of your feet. However, there is currently no evidence to suggest that custom-made orthoses are more effective than those bought off-the-shelf. An alternative to using orthoses is to have your heel strapped with sports strapping (zinc oxide) tape, which helps relieve pressure on your heel. Your GP or podiatrist can teach you how to apply the tape yourself. In some cases, night splints can also be useful. Most people sleep with their toes pointing down, which means tissue inside the heel is squeezed together. Night splints, which look like boots, are designed to keep your toes and feet pointing up while you are asleep. This will stretch both your Achilles tendon and your plantar fascia, which should help speed up your recovery time. Night splints are usually only available from specialist shops and online retailers. Again, your podiatrist should be able to recommend a supplier. If treatment hasn’t helped relieve your painful symptoms, your GP may recommend corticosteroid injections. Corticosteroids are a type of medication that have a powerful anti-inflammatory effect. They have to be used sparingly because overuse can cause serious side effects, such as weight gain and high blood pressure (hypertension). As a result, it is usually recommended that no more than three corticosteroid injections are given within a year in any part of the body. Before having a corticosteroid injection, a local anaesthetic may be used to numb your foot so you don’t feel any pain.

Heel Pain


Surgical Treatment

When more-conservative measures aren’t working, your doctor might recommend steroid shots. Injecting a type of steroid medication into the tender area can provide temporary pain relief. Multiple injections aren’t recommended because they can weaken your plantar fascia and possibly cause it to rupture, as well as shrink the fat pad covering your heel bone. Extracorporeal shock wave therapy. In this procedure, sound waves are directed at the area of heel pain to stimulate healing. It’s usually used for chronic plantar fasciitis that hasn’t responded to more-conservative treatments. This procedure may cause bruises, swelling, pain, numbness or tingling and has not been shown to be consistently effective. Surgery. Few people need surgery to detach the plantar fascia from the heel bone. It’s generally an option only when the pain is severe and all else fails. Side effects include a weakening of the arch in your foot.


Prevention

Maintain a healthy weight. This minimizes the stress on your plantar fascia. Choose supportive shoes. Avoid high heels. Buy shoes with a low to moderate heel, good arch support and shock absorbency. Don’t go barefoot, especially on hard surfaces. Don’t wear worn-out athletic shoes. Replace your old athletic shoes before they stop supporting and cushioning your feet. If you’re a runner, buy new shoes after about 500 miles of use. Change your sport. Try a low-impact sport, such as swimming or bicycling, instead of walking or jogging. Apply ice. Hold a cloth-covered ice pack over the area of pain for 15 to 20 minutes three or four times a day or after activity. Or try ice massage. Freeze a water-filled paper cup and roll it over the site of discomfort for about five to seven minutes. Regular ice massage can help reduce pain and inflammation. Stretch your arches. Simple home exercises can stretch your plantar fascia, Achilles tendon and calf muscles.

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