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HEEL PAIN
Managing Plantar Fasciitis
by Nashville personal trainer Dan DeFigio
Important
It is outside the legal scope of practice for a personal trainer to diagnose
any condition or treat any injury. The information presented in this article
is for information purposes only.
It is estimated that more than 2 million Americans receive treatment each year for heel pain(1). Reacting properly to the symptoms during the onset of the problem can minimize the pain and time away from training, and can rapidly return the client to pain-free performance.
What is Plantar Fasciitis?
Plantar Fasciitis is an inflammation and/or degeneration of the tissue on the bottom of the foot which supports the longitudinal arches of the foot. The tissue runs along the length of the foot, from the heel bone to just behind the toe bones. Typical symptoms of plantar fasciitis include sharp pain at the heel or in the arches. The onset of symptoms is usually gradual. Often, the client will complain of sharp pain at the heel or in the arches of the feet when first stepping out of bed in the morning. Pain typically diminishes as the tissue gets warmed up and used throughout the day, unless high-impact or heavy weight-bearing activities are performed. If a heel spur is present, a nodule may often be felt at the site of pain.
What Causes Plantar Fasciitis?
The main responsibility of the plantar fascia is to support the arch of the foot. This tissue has to flex and stretch with each step, jump, or foot movement. When the tissue gets overused, it becomes damaged and painful. Some factors contributing to the stress include(2):
- Poor foot mechanics -- excessive pronation, flattened arches
- Worn-out shoes with inadequate arch support
- Frequent use of high-heeled shoes
- Tight calf muscles
- Large amounts of high-impact activities like running or jumping
- Knock-kneed (Genu Valgum) and other lower-leg misalignments
- Weak ankle and foot musculature in general
How Can I Treat Plantar Fasciitis?
The mainstay of treatment for plantar fasciitis remains stretching, strengthening, and non-steroidal anti-inflammatory medications. Icing the tissue after use can help. A bag of frozen peas works well, as does rolling a frozen orange juice cylinder along the arch of the foot. A corticosteroid injection is not recommended, as it temporarily decreases the pain, but offers no long-term solution to the problem(6).
1. Don't Exacerbate the Condition
The first step in treating this condition is to minimize the activities
which aggravate it. High-impact activities should be limited, and Step
class is definitely out for a while. Swimming and stationary cycling
are better choices while the pain and inflammation subside.
Important: Before placing
your feet on the floor in the morning, take 30 seconds to perform some
ankle circles and manual stretching. After the tissue gets warmed and
loose, it should not pull and tear when you stand on it.
2. Band-Aids
Buying a new pair of shoes with better support, or adding an arch support
in the existing shoes may relieve some of the stress on the tissue while
healing and strengthening take place. Avoid relying on the orthotic
crutch permanently, though, for you will not have fixed the problem
-- you have only masked it. Often, intelligent use of night splints
can minimize the adaptive shortening of the heel cord while sleeping(3,4,5).
Don't sleep with the toes pointed and the covers tucked tight at the
bottom of the bed. Try to position yourself so that the toes are pulled
up toward the knees (dorsiflexed). Manufactured night splints are available
from orthopedic supply companies, or you can experiment with wearing
high-top sneakers or boots to bed. Don't laugh -- it helps!
3. Flexibility
Stretching the plantar fascia and heel cord is imperative to improving
this condition. Standard calf stretches off the edge of a step should
be performed regularly, preferably without shoes. From a seated position,
manually bending the toes backward while the foot is dorsiflexed will
stretch the plantar fascia. Physical massage should help, either with
the heel of the hand, or with a rolling pin or soda can. Sometimes the
dorsiflexor muscles are tight, which alters the footstrike. In this
case, passive plantarflexion stretches would also be indicated. Don't
forget to do your mini-warmup before getting out of bed!
4. Strengthening the Musculature
Specific strength training exercises should be performed in order for
the plantar fascia to become strong enough to support whatever level
of loading is required. In addition to standard calf and dorsiflexion
exercises, some typical strengthening exercises include:
- Walking on the tiptoes.
- When lying down or while seated, alternate these two movements:
1. Make "fists" with your feet and point the toes (plantarflex).
2. Dorsiflex the feet and fan the toes out, trying to spread the toes as far apart as possible. - Seated towel crawl -- place a bath towel on the floor in front of the seated, shoeless client. Place the ball of the foot on the edge of the towel, and begin curling the toes down to drag the towel under your heel. Continue to a good burn. Stretch well afterward. You can place a book on the towel if you need more resistance.
- Alphabet. Trace the letters of the alphabet in the air with your feet. Move slowly and deliberately.
- Balancing on a wobble board.
- Single-leg tiptoe movements, progressing to an unstable surface such as a trampoline or Airex pad.
- Work towards performing squats, lunges, step ups, and triple extension movements without shoes.
Remember to gradually return to higher impact activities. The amount of activity, not necessarily the type, will have a much greater effect on the speed and success of recovery. You will not be able to start back at the same workload you were performing before you started hurting! Progressively increase the workload until you reach your goals pain-free.
There are many other conditions which can cause heel pain, including calcaneal stress fractures, tarsal tunnel syndrome, flexor hallucis longus tendinitis, and Sever's Disease. Remember that it is outside the legal scope of practice for a personal trainer to diagnose any injury or condition.
References:
1 Gudeman, Eisele, et al; Treatment of Plantar Fasciitis by Iontophoresis or .4% Dexamethasone. Am J Sports Med 1997; 25(3):312-316.
2 Cornwall, McPoil; Plantar Fasciitis: Etiology and treatment. J Orthop Sports Phys Ther 1999; 29(12):756-760.
3 Batt, Tanji; Plantar Fasciitis: A Prospective Randomized Clinical Trial of the Tension Night Splint. Clin J Sport Med 1996;6(3):158-162.
4 Powell, Post, Keener, et al; Effective Treatment of Chronic Plantar Fasciitis with Dorsiflexion Night Splints. Foot Ankle Int 1998;19(1):10-18.
5 Probe, Baca, Adams, et al; Night Splint Treatment for Plantar Fasciitis. Clin Orthop 1999;368(Nov):190-195.
6 Crawford, Atkins, Young, et al; Steroid Injection for Heel Pain: Evidence of Short-term Effectiveness. Rheumatology 1999;38(10):974-977.
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