Plantar Fascitis

I did a 6 mile hike yesterday through the trails of McDowell Forest Preserve

see my hike on everytrail

and decided to go off trail at one point (not sure why) then ended up chasing this Great Horned Owl.  Problem -  I was wearing my Adidas Ax1 mid tops.   Not a good shoe for soft ground, padded with leaves, having to hop over fallen branches.  The mechanics are like stepping up high, over then down straight, deep and unstable (unlike post hole stepping in deep snow where the deep footprint will make a cast of you foot and stop the wobble-the leaves compressed under the new step are really slippery).  Because of 15minutes high stepping with the wrong shoes, I now have left heel pain. 

It can start with the scenario above. wrong shoes for event.  It can also be from breaking in new shoes, wearing shoes without insoles/arch supports, climbing steps, skipping rope, jumping/bounding with poor warm up, or new job/activity on concrete/uncushioned flooring.  Usually when I see patients, the event is not recalled.  Most people just complain they have been suffering for weeks to months and the first step of the morning is the worst.  If you look on the illustration above, the plantar fascia originates from the heel and inserts into the metatarsal heads (the ball of the foot).  It is a tough as nails ligament that is broad and long.  Supposed to serve as structural support to keep the heel bone (calcaneus) pulled into the metatarsals.  If you pull the two bones together, it creates an arch.  Arches in structures work to disperse load.  Think of big flatbed trucks you see on the road with nothing on them.  Usually the center of the flatbed is arched up a few degrees-made that way so when you place heavy equipment in the middle, the flatbed wont sag.  The beauty in human structure is with every step you take (Sting solo) the foot can disperse a little of the body weight to cause less damage over a variety of surfaces.  In my opinion, the best position of the foot for speed is up on the toes, with a natural arch, never letting the heel touch. (I witnessed this with working the Chicago Marathon medical tents.  I would listen for the start over the radio comm, then wait for the Kenyans to pass.  I can still see these tall, thin runners making no impact noise with their feet, high up on their toes, just floating through in a small privileged pack of humans that can run 26.2 miles in just over 120minutes....followed about 2-3 hours by "the pack".  A term I coined designating the majority of marathon newbies that are just in it to have fun.  Costumes, Elvis attire clad groups, the walking wounded.....but mostly flat footed runners who's footstep's sounds like someone taking a 10 pound fish and slamming it on the counter repeatedly)  Picture this style of running where all the weight of the body gets put into a heel that is essentially a short stubby stick with a rounded end.  Now picture the Kenyans running style landing on the ball of the foot, then the heel comes down (but doesn't touch) to decelerate the force of the body weight.  Get the picture? 

Most people will have ligaments that tolerate either style of walking/running.  The problem is if we are in the moment of doing any of the bad activities mentioned below the illustration, our plantar fascia gets stretched.  If we continue past the point of calf fatigue with prolonged sprint, jump or walk, the plantar fascia will start to develop microscopic tears (not painful during the event).  Continue on and the microscopic tears turn into big sudden tears (very painful).  This is a ligament under alot of tensile stretch so when you place a little cut-its like cutting a rubber band that is pulled to length.  Hard for ends of torn ligament to mend themselves when the torn ends are miles apart. So begins the accumulation of blood, injured ligament fibers that want to shorten, inflammation/microscopic swelling of local tissue to heal and the typical pain with first steps of the day, or first steps getting off the couch or chair.  Due to the vast amount of shoes with little to no arch support (especially women's shoes or men's work boots), the 8 hours of standing/walking usually results in the injured ligament getting pulled apart with each step of the day-not being allowed to heal. 


Treatment:  Allow it to heal........thank you for reading, have a good night and don't forget to tip your waiters and waitresses!!

It is harder than it sounds because in early stages, there is just pain in the am....although during a painless work-day, damage is still preventing repair.  For a runner it is slow death.....pain only in am or with certain activities but usually no pain with continued training.  But the "run" not only prevents healing, it causes more micro tears.  Until the overuse goes from pain after exercise to pain with exercise to pain with rest.  The Saguil Approach is to compress the time  frame of healing. 

1. Do no further harm.  Stop the offending activity (or cut it back by 20%).  Cross train or change your activities for short time. (2-4 weeks)
2. Improve healing, with proper nutrition.  Switch to the antiinflammatory diet  Even if not allergic or sensitive to gluten or dairy, I suggest all patients that are sick or injured to avoid the two groups for 2-4 weeks. 
3. Work to keep the ligament lengthened to the most pain free point to prevent recoil.  Ligament, tendon and muscle always want to keep a shortened position when injured/torn.  You don't want to stretch it to the point of more tears, just want to keep it from healing short and tight.  Note the pain that is usually felt in the am from being off feet for 6-8 hours.  Lying down in bed with feet up allows bones/muscles to relax and an arch to form, allowing the plantar fascia to shrink and heal over a few hours until full body weight is placed straight onto the heel with stepping off the bed......and....pop! All the healing/shortening overnight is re torn.  Wearing a night splint will keep the foot/arch at 90 degrees gently preventing any fiber shortening so even with healing overnight, first step doesn't pop any bridges formed facilitating healing of the heel. 
4. Supplements for improving body healing.  Turmeric/curcumin (see  video); magnesium glycinate or aspartate twice a day, omega 3 fish oil (see video); maximize vitamin D3 (see video); topical botanicals like Helicrysium. Tea Tree;  homeopathic's like arnica montana, Traumeel ointment; acupuncture; even physical therapy/chiropractic care to lengthen the opposing tendons to the heel like the Achilles/soleus, creation of temporary orthotics, increase endurance to the intrinsic foot muscles that help maintain the arch.
5. If it's bad enough, prescription oral antiinflammatories, topical antiinflammatories and yes, considering a steroid injection.  (You hobble in, get the shot, and walk out)....but don't be fooled, if we go prescription meds, numbers 1-4 still get initiated.)

If all the above fail, perhaps the diagnosis is wrong, MRI will be the next step.  Possibly second opinion from my like minded Chiropractic, Podiatric and Orthopedic Colleagues.

Taken from DrRic Frequently Asked Questions

So lesson from last time -"trust your gut feeling when someone hands you a bogus answer".   I expect my consultants to give an expert opinion on a diagnosis, then I expect them to get back to me.  Used to be in the 90's a phone call would be made after an evaluation and plan created.   I understand with low insurance reimbursement that docs have to move patients like cattle to pay the bills, call me old fashioned, I still expect when the door is closed, full attention to whom ever I send for second opinion . 

Here is the flipside:  my patients know I spent extra time after family practice residency in a sports medicine fellowship.  There are a handful of teaching centers in Illinois that many graduates apply for but only few get in.  Most of us in primary care sports medicine are dedicated athletes or just love the musculoskeletal part of healing/health.  I think it's fantastic to know how to prevent asthma attacks with changing shoulder and upper back strength or improve post partum sex with pelvic therapy.  (It aint just knowing how to test for an ACL tear or pop a shoulder back in)   Anyway.....I remember taking a state written exam one year with a bunch of docs, saw an old friend who graduated a year ahead of me.   I was psyched about my sportsmed fellowship and mentioned....."you should consider it as well for more clinical experience"  (your average family medicine residency entails 3 years of training and most programs offer 1 month of orthopedic assisting in surgery or a sports medicine rotation").   His reaction was "a sprain is a sprain".   I honored his opinion but thought to myself, no way am I going near his clinic with any body ache, sprain, tear or dismemberment.  It's good to know first aid, RICE and how to write a note for work/school ...but......spending 4 weeks with splints/narcotics and a pending second opinion vs just 1 week with a handicap when the injury should have been rehab-ed from the start is a gia-normous waste of time!!!!!  On top of that, after 2 weeks of time off the body has now deconditioned, gained a few pounds, developed constipation and drowsiness from the meds plus a little reactive depression from not being able to exercise.  My job as a doc is to help compress the time frame of healing.  Every case is a little different, every personality with its individual desires, every brain has its own tolerance to pain so not all treatment plans fit each person.   (I scoff at hand-outs that say do this 20 repetitions 3 times a day as the sole basis of "rehab")  It does make a difference to see a well trained doc for the symptoms suffered.  



Obviously I cant speak enough for the specialty of primary care sports medicine.  Even if you aren't an athlete, kinesiology/musculoskeletal medicine/disease pathology all play into designing the best way to get someone to optimal health.  (ie....if I have an out of control diabetic who is obese, I wont just say "lose weight by starting a walking program" ... I'd get physical therapy involved, make sure his/her nutrition knowledge is maximized for her activity, then steer her toward and exercise physiologist for brainstorming a sustainable fun calorie burning activity.)   True sports medicine looks deeper than just exercise injuries.   So how to choose a doctor:



1-Primary care sports medicine fellowship trained (just ask the office if the doc completed a fellowship)

2-Orthopedic surgery is different in that all specialist can "cut".  I like sending my patients to an orthopod that has trained specifically for the region of the body involved.  (ie.....one of my favorite shoulder guys is Tony Romeo from Rush/White Sox,  most young grads have gone through enough knee scopes that they all know about ACL/meniscus repairs-so for the knee guy I go for the best bedside manner, hand injuries still go preferentially to hand surgeons.)   A must for any of my "Pods" is good bedside manner.  There used to be a magnificent hand surgeon that worked down the street when I was with CDH.  His talent in the OR was famous.....so was his anger.   Dude used to throw sterile instruments to the ground and have a tantrum if everything wasnt perfect.  I guess thats ok if he is looking out for you but I dont use healers that hurt inside or outside the office.

3-Chiropractic physicians have excellent training around Illinois so I like the ones that listen in and get the true dynamics of the patients pain.  The chiros I use have turned pain/function around faster than patients going through conventional methods.  Dr Joe Musolino in my office does great work, graduate from National University in Lombard.  Great communicator with me and physical therapy and this is what gets people better fast-coordinated efforts between all providers.   You have to research training and experience and see how they are active in the community.   Just like medical schools, if the chiro school has been around for years and continues to expand curiculum, probably a good school.  On the flipside, I spoke with a DC that took care profighters in MMA, he just wanted to refer patients to me for writing scripts of anabolic steroids, saying alot of docs he refers to do it for him.  (obviously fell into the dark side of healing for the glory of rubbing shoulders with the rich and famous.....doesnt have to be that way-see my pics!)

4-Medical Acupuncturists are powerful in their own world of healing (and have been for the last 2500 years)  When combined with conventional healing, I consider bringing them in like calling a left handed pitcher to a tie game.  For any injury that has plateaued or if an athlete needs to get better fast for a fight, game or match in 2 weeks-call in the needle doc!   I originally studied medical acupuncture at UCLA to see if I could speed up healing while waiting for the physical therapy HMO referal to be approved.  When I used it, it worked like a charm, sometime the patients would get better and not need therapy or surgery second opinion any more.  Ahh...unfortunately, insurance caught on and discontinued covering acupuncture as a benefit so I had to retire my skill.  (Only bring them out for special cases like in getting my pro MMA fighters to relax before a fight....see my pics!)
 

So if you are injured at work, in a league event, or during training; dont be embarassed to ask your provider what kind of training s/he went through.   If it seems like the injury is taking longer than expected, seek out one of us (see above) and get better faster!!!!  A "sprain is not just a sprain".  

Colorado Springs Olympic Training Center

Illinois Gynmastics Association Bravo Meet

Chris Chelios ex-Chicago Blackhawks

David Reid Gold Medalist 1996

DonWilson martial arts 1990's

Sean Murnane Chicago Bears

Felice Herrig Bellatore Fighter (the non athlete is Julian from B96 morning radio show jumped into the pic as he was leaving my office)

DrRic Post Marathon Recovery

    The Chicago Marathon finished last weekend. Good news is I havent had too many walking wounded come in. (Working medical tent at the end, most injured will come in walking well but draped in aluminum and assisted by a volunteer) Finishing is a great accomplishment but at a price. I attribute my finishing the '09 and '10 events with yoga, good nutrition and anti-inflammatory supplement rescue. (...and that was with only a few days of summer pre-race training. Disclaimer! I do not suggest entering into a marathon without proper training/coaching-I just did it my way to prove a point that the practice of clean living allows the body to heal itself insanely fast! If in Chicago, please visit CARAruns.org for proper training I'll tell you about my patient who was unconscious for 2 days later)

    So for pain I suggest adding Turmeric. Love this stuff! Great reproducible studies now out (did a post back in 2008 just suggesting herbal use based on anecdote....now we have data!!!) Janet Funk from UofAz researched the effects of turmeric on arthritis and found it was critical to have the combination of turmeric and black pepper (piperine) for optimal absorption from the gut. So although I have suggested New Chapter in the past, I called the company and asked about their data on absorption and no one gave a straight answer on if their "super critical" prep technique helped the curcumin get into the body. (Sorry for the technical mubojumbo but data is essential to make proper recommendations for my patients-learned that from Andy Weil). There are a few formulations that have the combo together Source Naturals is "ok", but around my area GAIA brand is available at Whole Foods Market and Fruitful Yield. I usually go for high dose at 1 cap 4 times daily for 3-5 days. Magnesium glycinate or oxide is great for muscle spasm (blood tests for proper mag level stinks unless you do an RBC/erythrocyte testing) This one is sensitive as it can cause problems with diarrhea or palpitations if taking too much. Usually 400mg twice a day is good. (caution with thyroid hormone users in that it will mess around with your medicine so dont take together) Make sure you are on Vitamin D3 1000IU twice a day (at the least......and I usually burst high at 4000-5000IU per day) and take it with Omega 3 fish oil. Omega3 I feel is always necessary for balancing omega6 intake for an average American diet. For the 7-10 days following a hard work out, stay aggressively on an anti-inflammatory diet and avoid dairy. (Even if you aren't lactose intolerant, I feel dairy is just to much of a wild card in eliciting a reaction-whether bloating and diarrhea or just slowing healing time). In the first days of crossing the finish line, push Fluid and pee like a race horse. Nothing worse than asking the body to get byproducts of inflammation out from the muscle fiber, through the vascular system and into the liver for breakdown when the vascular space is bone dry. Remember, as a culture, we abuse hydration by ignoring thirst (especially at work), over indulging in caffeine and alcohol (diuretics), and opting for sugary bottled drinks instead of a glass of water (reverse osmosis carbon filtered). So push fluid to the tune of 3 L/daily (13 cups) for men and 2.2 L/daily (9 cups) for women at the least! (8 - 8ounce glasses/daily is oldschool). If it isn't palatable, drop an Airborne fizz tab into the bottle/glass and keep it cool. Cut back at dinner time (6pm) or you will be cursing me as your dream state gets interrupted with a trip to the urinal/toilet.    (There is also the IV therapy option-by coming into the office for a "Meyers Cocktail".   Essentially a whole bunch of vitamins in a bag of fluid we place directly into the vein to bypass an irritated stomach and insure 100% absorption to the areas of inflammation. 

    For muscle stiffness I like manual healing. From massage therapy, to manual therapy by physical therapists to acupuncture/yoga healing. This post marathon time period when I highly suggest investing in a manual healer. Acupuncture can sometimes be reimbursed by HSA or flexbenefit spending accounts (with a prescription), physical therapy is usually covered by medical insurance (with a prescription), chiropractice therapy is usually covered by medical insurance, massage comes out of your wallet. Movement/contraction of muscle helps to get out the lactic acid and keep the stretch receptors from spasming and getting tighter. Moving your own joints when in pain is difficult to do on a regular basis. Get someone to move for you! One way to "self massage", is a technique called Abyangha. Known in yoga circles, the technique is to move "energy" to heal better and apply a thin layer of warm oil to the body. Those who have been to a good massage therapist know the well versed healer will choose oil depending on the mood/nose of the patient/client. In the case of recovering after a tough work out, I would use sesame seed oil, olive oil, apricot kernel oil or lavendar/sandalwood essential oil.  (I prefer PanAway by Young Living for my sorest of sore spots)  Apply the oil warmed from "tips to heart"; start at the finger and toe tips and firmly apply/knead the oil into the skin with long strokes in the direction of "pushing" the lactic acid out of the muscle back to the heart. (actually pushing lymph fluid from out of the extracellular space back into the vascular system to be recirculated by the pump). For the true technique, the oil is left on. My realworld application is to keep the oil on for at least 10 minutes, wrap with a comfortable robe, have a cup of tea then shower off as usual. Not only does this help with sore muscles but great for dry skin winter itch.

    Finally, mornings are usually met with the tightest knees, hamstrings and calves. Like my plantar fascitis sufferers, before you move out of bed, warm up/wiggle the small joints (fingers toes), circle the medium size joints (wrists ankles), flex and extend the big joints (elbows and knees) for 10-20 seconds each, then sit up and take your first steps of the day. Been there, done that and still in pain? Get to a sports medicine specialist ASAP! Running on an injury changes the dynamics of your gait and you will strain or sprain an unrelated body part and have to deal with another injury. See my post on how to pick a healthcare provider. Happy running!