When the feet are in trouble
The average person takes about 5,000 steps every day, which is classified as low level of activity. But if you happen to be suffering from plantar fasciitis, this is akin to climbing a mountain.
Plantar fasciitis is a painful, degenerative condition affecting the connective tissue on the underside of the foot. Like the string of a bow, the Plantar fascia runs along the underside of the foot and connects the heel bone to the bones at the base of the toes, acting as a shock absorber. As the foot strikes the ground, the weight of your body bears down on the foot bones, causing the foot to flatten under the load. This is called pronation.
The Plantar fascia forms part of a system of muscles, ligaments, tendons and other connective tissue that support the bones of the foot as they flatten. It is an important part of the body’s defence mechanism against harmful ground reaction forces that can cause injury to the legs and spine.
Plantar fasciitis is an overload injury. Endurance athletes, such as those who run, play racket sports or field games like hockey or soccer, or those who have recently gained excessive body weight, are most at risk. Other causal factors include over-pronation of the foot, tight muscles at the back of the lower leg, stiff ankle and foot joints, and bad footwear.
The Plantar fascia is built to take a lot of punishment, but it does need rest time. If the recovery time between training sessions is insufficient, microscopic tears and inflammation start to form. These are the first warning signs. Repeated loading through exercise will worsen the damage, turning the stiffness in your foot into lingering discomfort and pain.
Identifying the problem
Your first port of call is your local physiotherapist or family doctor (GP), who will, obviously, ask some basic questions:
When did this start? This lets the doctor know how chronic the injury is and how bad the degeneration in the fascia is likely to be.
When does it hurt the most? Plantar fasciitis usually hurts first thing in the morning. The first few steps out of bed are usually the most painful. Within a few minutes, it eases up and, in the early stages of the injury, will often disappear. As the injury progresses, the pain lasts longer, eventually, it will not go away at all. Alternatively, it may hurt at the start of your exercise and disappear once you warm up, only to return with greater severity once you cool down.
Where does it hurt? Plantar fasciitis usually leads to pain at a specific spot on the underside of the heel.
The doctor may ask if certain footwear is painful to wear. Many people find walking barefoot or in shoes with hard soles more painful, preferring softer-soled shoes to cushion the heel.
Next, your medical practitioner will assess your gait, the shoes that you walk or exercise in, and the insoles you may already have.
If needed, you may be referred for a special investigation, most commonly in this order: X-ray to check for a heel spur, musculoskeletal ultrasound to assess the condition of the Plantar fascia and the surrounding soft tissues and, finally, an MRI, or magnetic resonance imaging, for a more detailed review.
Once the diagnosis of plantar fasciitis is confirmed, your GP may prescribe painkillers and anti-inflammatory medication. S/he may also refer you to a physiotherapist and an orthotist for moulded orthotics, a pair of shoe insoles that provide support to the foot, correct faulty foot mechanics and decrease the effect of ground reaction forces on your body. You may be advised to ice the injury daily and begin a programme of strengthening and stretching exercises at home.
Increasingly, the highly effective extracorporeal shockwave therapy (ESWT) is being used. This uses an acoustic sound wave to increase blood flow to the damaged tissue. It breaks down scar tissue and increases metabolic function in the cells it passes through.
If you are referred to an orthotist for moulded orthotics, s/he will take a series of measurements and produce a pair of insoles for your shoes. You will need to wear these while your foot is recovering, and possibly indefinitely, depending on how bad your foot mechanics are. These insoles keep your feet well aligned, decreasing the stress on the feet and lower limbs.
Your local physiotherapist, trained to treat this injury, will use deep-tissue massage for the sole of the foot and the back of the lower leg to soften and relax the muscles, fascia and tendon tissues. S/he will also use joint mobilization techniques to decrease stiffness in the foot and ankle joints. S/he may use ESWT, or a special low-frequency laser that is applied directly at the site of pain, to assist in tissue healing.
Finally, you will need a stretching and strengthening programme to lengthen the muscles of the underside of the foot, back of the ankle and back of the lower leg, and build up strength in your foot and leg.
If all else fails, an ultrasound-guided corticosteroid injection can provide relief. This steroid is effective in relieving pain and discomfort and can often resolve the pain completely. Unlike their systemic cousins, musculoskeletal corticosteroids rarely have any side effects. Diabetics, however, need to monitor their blood glucose levels closely for up to three weeks after the injection to ensure there is no increase in blood glucose levels.
It’s still important to fix the causal factors to prevent the injury from returning, however, so it is recommended that you try other treatment options first.
Opt for a good treatment plan for plantar fasciitis to avoid lengthy periods away from your sport. Rest alone seldom heals this injury. The key to successful treatment is to act quickly. The sooner you address the problem, the sooner you can get back to enjoying your sport.
Heath Matthews is a consultant sports physiotherapist, at the Centre for Sports Medicine, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Mumbai.