Friday, November 23, 2012

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.