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Feb
11
2008

Hey Doc, my heel kills me on my first step out of bed in the morning...what is it?

pfman.gif Ahhh, this one is easy.  I love when a patient comes into my examination room and tells me this.  I always ask, "Does it feel better after about 20 minutes of walking around a bit?"  If the answer is yes, my diagnosis is almost always plantar fasciitis.  Plantar fasciits can be quite debilitating, but in most cases can be solved very easily with conservative treatments.  So...as per request of Cobra...come with me as we explore the world of.......Plantar fasciitis.


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pf.gifpf1.jpgAnatomy -  The anatomy that deals with plantar fasciitis is rather simple, but it is also very important because it explains why this syndrome hurts where it does.  The human foot contains 26 bones and these bones create a dynamic structure know as the arch of the foot.  This arch, like an arch of a building, is for the most part extremely resiliant and can absorb a large amount of force.  The bottom of this arch is held together by a strong band of tissue called fascia.  This band stretches from the calcaneus (heel bone) to all of the toes.  Fascia bands are located everywhere throughout the body, and for the most part this type of tissue provides very little elasticity. 

Mechanism of Injury - This relates directly back to the fact that the fascia band is not very elastic.  The most distal attachment of the fascia as was said is at the toes.  The toes are dynamic, meaning that they move.  However, the calcaneus is for the most part stationary.  So what happens is that non-elastic fascia is tugging on the calcaneus because the toes move up when the foot steps down on the ground.   This can cause inflammation at the insertion into the calcaneus, which can in turn cause pain.  Often times many will say that they have a "heel spur" and this is what is causing the pain.  heel_spur_image.jpgHowever, this is actually false.  The heel spur is created from the force of the fascia tugging on it, which is explained by Wolff's Law.  Wolff's Law states that if a force is applied to a bone, that bone with deform to accomodate that force.  This is what occurs with a heel spur...but in the end, whether there is a spur there or not, the patient may or may not have pain. 

So why is there pain the first thing in the morning?  It is rather simple...when people sleep, they always sleep with their toes point away from them.  This relaxes the plantar fascia and similar to a muscle this fascia band will tighten up...so when the first step down in the morning pushes those dynamic toes flat against the ground and pulls that fascia band tight, the only thing that it can do is pull against the calcaneus...thus causing pain.

Treatment -  The treatment of plantar fasciitis is relatively simple.  For the most part, this syndrome can be resolved conservatively.  However, there are no standard set of treatments.  This is the treatment plan that I use with my patients and my results have been very successful.  If a patient walks into my office and says that they have pain the first few steps in the morning but it becomes less throughout the rest of the day, then I will go with a pure conservative approach.  I will order some x-rays of the foot, just to have a baseline and to make sure there is nothing out of the ordinary going on in the foot.  stretch.gifMy conservative treatment plan is this: 1. Stretch - take a towel or elastic band and placing one end in each hand and wrapping the "U" around the ball of the foot, pull the foot back towards you with your leg extended.  This will stretch the bottom part of your foot and the back of your leg.  Do this for 5 times for 30 seconds each before you even get out of bed in the morning.  2. Freeze a bottle of water, roll it along the arch of your foot until the water is melted.  Do this at the end of the day.  3. Inserts - shoe inserts that provide an arch to support the fascia and not allow it to stretch out and pull against that calcaneus can do wonders.  4.  Ibuprofen - this will be help in two ways, first it will act as a pain reliever, second it will bring down any inflammation at that insertion of the plantar fascia.

epf.jpgIf I have a patient that walks into my office in a lot of pain, then after the x-ray I will offer an injection at the site of the insertion of plantar fascia on the calcaneus.  This injection consist of a local anesthetic and a corticosteroid.  The anesthetic eliminates the pain, so the patient walks out of my office painfree, and the steroid immediately starts decreasing inflammation at the site of injection.  The injection can work to either take away the pain completely and resolve the condition, however often times two or three injections are required.  I also advise the patient to follow the conservative treatment model after receiving the injection.

If these conservative measures are tried and still the patient has pain, then surgical intervention is warranted.  Today, the most common surgical procedure that is practiced for plantar fasciitis is the endoscopic plantar fasciotomy, or EPF.  The EPF is a minimally invasive outpatient procedure that involves a "scope" being placed in the foot and the fascia band being identified and using a small "hooked" scalpel, the middle 2/3 of the band is cut (as seen in the picture above).  This releases the tension that the fascia band places on the calcaneus and essentially eliminates the tug and pain at that insertion.

Rehab -  The rehabiliation for this syndrome is based on the treatment.  Patients using conservative treatments should not have to be limited or out of play for much more than a couple of days.  Patients receiving injections can return to normal activity immediately.  Those that have the EPF done should expect to be out for 3 to 4 weeks, with a return to full activity at about 5 weeks.

Cpt Morgan is a Podiatric Surgical Resident in Rhode Island.

4 Comments
Jack Cobra said

So....come up with a good question here Cobra, you've been waiting a month for this rundown.......the reason why athletes seem to get this injury and have it linger for so long is because the fascia band is not very elastic and once its stretched too far (injured) it takes some good rehab to get it back to normal. So, if they continue to 'play through the pain', it's generally not going to get better until the off-season when the fascia band can go back to its original form?

Cpt Morgan said

Your thoughts would generally make sense, but in this case it is in fact the opposite. Think of it like this...the EPF cuts the band releasing the tension on the bone...if the athlete plays through the injury, there is a good possibility that a) it will loosen up and not bother them that much during play, once they stop and rest it (ie halftime), then it will tighten up again and cause pain or b) they will actually rupture the fascia band themselves which will essentially serve the purpose of the EPF...

Jack Cobra said

Man, the foot is a crazy thing.


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