Hell on heels

LITTLE ROCK — “It all started with step aerobics,” Joyce Wagner recalled.

“I would wake up the morning after a step class and could hardly walk. Then about five years ago I started experiencing a lot of pain in the heel and sole of my left foot.”

Most feet experience heel pain from time to time, but achy heels can be indicative of a more serious problem - plantar fasciitis.

“Plantar fasciitis is very common. I’ve had it,” says Dr.

Ruth Thomas, a professor of orthopedics and director of the Center for Foot and Ankle Surgery at the University of Arkansas for Medical Sciences.

“I would say that probably 90 percent of the population gets it at some point or another.

“It is easier to cure if caught early, but once someone has had it for years it becomes chronic and difficult to address.”

Plantar fasciitis is a painful ailment affecting the fascia, a band of thick, fibrous connective tissue that attaches at the heel and extends to each toe.

The word plantar just means “underside of the foot.” And this fascia is “a normal anatomic structure,” Thomas says. “We have a structure similar to the fascia in the hand. Many years ago on the evolutionary scale, the one in the hand would allow you to pull back the skin and expose your claws.”

The plantar fascia forms the arch of the foot and is essential for support and movement.

When standing, the fascia flattens the arch, and when walking it contracts to coordinate the movement of the heel and forefoot.

Plantar fasciitis occurs when the fascia becomes torn and inflamed. A common cause is overuse. Athletes, runners and avid exercisers often develop the ailment when they drastically increase the intensity, duration or frequency of their exercise. In older people, it is likely (but not always) part of a wear-and-tear, degenerative process.

Wagner’s first bout of fasciitis was likely a result of overuse when she developed it 20 years ago. Her pain became more intense and more concentrated in the heel as it progressed.

Heel pain is the cardinal symptom because the fascia’s largest attachment is to the calcaneus bone. Many experience severe pain walking or standing after long periods of inactivity, like sleeping or sitting.

“The first thing patients complain of is first-step-in-the morning pain. That is caused by tears in the plantar fascia.

Every time they step down, they are ripping these tears that have not fully healed,” Thomas says.

“The next most common complaint is pain right in front of the heel, where the thickest part of the fascia is tearing from running or too much activity in general.”

Pain can also extend into the arch of the foot, a condition Thomas says may be slightly less common in people with flatter feet. High arches are not as flexible as flat arches, and are therefore more prone to injury.

Plantar fasciitis can be mistaken for tendinitis, inflammation of tendons in the foot, or plantar fibromatosis, fibrous growths on the fascia.

If left untreated, plantar fasciitis can result in heel spurs, which are growths on the heel bone.

So how exactly does one go about healing their heels? Thomas outlined five stages of treatment.

REST

The first step is to rest the fascia. If you’ve developed fasciitis from a specific activity, like running, stop altogether or drastically decrease the amount you do.

Try shoe inserts. Heel cups cushion the heel and absorb some of the impact of walking and everyday activity. Inserts that run from the heel to the arch support even more of the fascia.

Casting - putting a cast around the foot - stretches and immobilizes the fascia. Wearing a cast for three to six weeks gives the fascia time to heel without repetitive tearing.

STRETCHING

According to Thomas, stretching is the most important step in healing. She suggests massaging before stretching to increase the blood supply. If stretching is too painful, try rolling your foot over a frozen water bottle. It numbs the foot and increases blood supply.

“If you slowly stretch and elongate the fibers without tearing them, you’ll prevent them from being torn over and over again,” she explains. “You should definitely begin a stretching program before you try to do any running or athletic activity.”

Night splints can help in the same way as casts. They give the plantar fascia a continuous stretch during sleep, which can alleviate the first step pain in the morning.

MEDICATION

Along with rest and stretching, anti-inflammatory medications like naproxen or ibuprofen are often prescribed. They may reduce pain and swelling, but they will not actually heal the fascia.

“I think of these as more of a Band-aid,” Thomas said. “You’re covering the pain but not resolving the problem. Stretching is what will actually solve the problem.”

Orthotripsy, or shock wave therapy, treats plantar fasciitis with high-energy shock waves. The shock waves create tiny tears in the fascia, and the body responds by supplying new capillaries to bring in more blood and quickly heal the fascia. The procedure sometimes must be done twice before it is successful,she says.

Some may find relief with steroid injections. The injections are placed in the area of the heel where the fascia attaches to the bone.

“My orthopedist could see that there was lots of inflammation from my X-ray. The next course of treatment he suggested were steroid injections,” Wagner said, “but the thought of sticking a needle into my already sore heel didn’t sound very appealing at all.”

Wagner decided she needed another opinion and went to see Thomas.

SURGERY

Surgery is a last resort. Although the pain of plantar fasciitis can be distracting and linger for nine to 18 months, in most instances it eventually goes away. But when it doesn’t, there are surgical treatments.

Radiocoblation is a procedure that uses a probe to penetrate the plantar fascia at multiple intervals. The body responds to this by increasing blood flow to heal its damaged tissues.

This procedure is similar to orthotripsy in its method of healing but is an invasive procedure.

Thomas performed radiocoblation on Wagner in March.

“It took a couple of months to really take effect, but the radiocoblation was really very successful for me,” Wagner said. “I woke up one morning and realized I had no pain in my left heel.”

Another surgical option is a plantar fasciotomy, an invasive procedure that severs the fascia’s connection to the bone.

“An open release of the plantar fascia is the ultimate surgical treatment. We encourage stretching and only go into surgery when people have failed all of their other options for at least six months,” Thomas said.

“What we can do is cut the fascia from the bone. It relieves the tension but also slightly drops the arch. Patients with flat feet may have pain in the lateral foot as a result. We try to leave a little of the fascia intact on the lateral side to help support at least the side of the foot.”

NO CRUEL SHOES

The best bet is to begin “treating” fasciitis before it even occurs. Two key preventive strategies are stretching and supporting the fascia with proper shoes.

“My best advice would be stretching. No one is magically immune to this condition, so stretch before you do anything that could strain the fascia,” Thomas says. She recommends making stretching a habit, especially for runners and athletes.

Although she no longer has pain, Wagner still stretches her heels and calves.

Shoe wear is equally important. Shock-absorbing athletic shoes that include arch support are the best for the fascia, and Thomas suggests avoiding shoes with absolutely no padding. She urges sufferers to avoid walking barefoot or wearing flat sandals.

Luckily, this does not mean that women will have to banish their high heels forever. Thomas does, however, emphasize correct sizing and moderating how frequently such shoes are worn.

“When you wear very high heels, the pressure isn’t really on your heels anyhow - it’s going through the bottom of your foot,” she explains. “That may actually give temporary relief from plantar fasciitis, but there are so many problems that occur from chronic high heel use that it is another bag of worms entirely.”

Wearing heels too often might not cause plantar fasciitis, but it can encourage a host of other problems - bunions, bunionettes, hammer toes, Morton’s neuroma and metatarsalgia. The Achilles tendon could be shortened as well, contributing to back pain and shin problems.

When it comes to shoes, sizing can be just as detrimental as style. Thomas says that statistics show women are chronically wearing shoes that are too small for their feet, and that a woman is five times more likely to require surgery on her forefoot than is a man.