Plantar Fasciitis

WHAT IS PLANTAR FASCIITIS?
Plantar fasciitis is pain felt at the bottom of the heel. It is usually felt on the first step out of bed in the morning or when walking again after resting from a walking or running activity. However, plantar fasciitis pain can, if it persists, soon be felt any time you are walking, running or jumping. Although the pain is mostly felt at the bottom of the heel, it can also radiate down the entire bottom of the foot toward the toes. Plantar fasciitis is not usually associated with numbness or tingling.

ANATOMY OF THE PLANTAR FASCIA
The plantar fascia consists of dense bands of tissue deep below the skin that extend out in a fan-like fashion from the heel bone to the toes. If you pull your toes and foot toward your head, you will feel this tissue tighten.

WHAT CAUSES PLANTAR FASCIITIS?
Plantar fasciitis is thought to be caused by repetitive stretching of the tight bands of the plantar fascia which result in micro tears in these bands as they extend from the heel. Because these tears usually do not occur from a single traumatic event, an immediate healing reaction is not triggered. A chronic irritation or inflammation process thereby begins which increases with activity. A sudden weight gain may also increase stress to an otherwise normal plantar fascia. Pulling of the tight plantar fascia on the heel bone during activity can result in the formation of a bone spur off the tip of the heel bone, at the origin of the plantar fascia tissue. This bone spur itself is not the cause of pain, but rather the mechanical result of the chronic inflammatory process on the bone caused by the stretching of the tight tissue.

TREATMENT TIPS
Surgery is rarely necessary to treat plantar fasciitis. To decrease your pain and symptoms, you may want to:

• Tape the heel and arch. Custom shoe inserts may be needed to support the arch and the heel. Increase the flexibility of the plantar fascia and calf muscles by doing stretching exercises. Tight calf muscles increase he stress on the plantar fascia and predispose you to plantar fasciitis.

• Massage the plantar fascia by rolling your foot over a round tubelike object with a diameter of 3 to 4 inches. A rolling pin works nicely for this. Strengthen the muscles of the foot and ankle that support the arch. One way to do this is to scrunch up a hand towel with your toes or use your toes to pull a towel weighted with a food can across the floor.

• Warm up well before stretching. Cold tissues cannot stretch as effectively. After stretching, ice your heel for 20 to 30 minutes at the point of maximum tenderness to decrease any inflammation that may result from too vigorous a workout.

• Consider the use of oral antiinflammatory medications such as aspirin or ibuprofen. These medications can decrease the inflammation of the plantar fascia and thus decrease your symptoms so that you can stretch and improve your flexibility. In some cases, your physician may recommend a prescription antiinflammatory for you.

• Try a night splint. These devices, prescribed by your physician, keep the foot flexed at 90 degrees instead of the typical relaxed foot position of toes pointed down that occurs during sleep. Wearing a splint may lessen the pain of the first step in the morning.

• Massage the heel with a sports cream, which may lessen symptoms. A variety of “hands on” therapeutic treatments can also be administered by a physical therapist.

HOW TO PREVENT PLANTAR FASCIITIS

• Always warm up well and stretch before participating in sports. 
• Wear good, supportive shoes for your athletic activities. 
• Keep the muscles of your feet and ankles strong to support your arch.
• Don’t try running to lose weight after a rapid weight gain. Walk first, and stretch the muscles of the foot and calf to help condition your body before running.
• Avoid activities that cause pain in your heel.

See your physician if pain persists despite these measures.

Information obtained from the American Orthopaedic Society for Sports Medicine, 2008.

Dr. McCormick on Stress Fractures of the Foot

Step into Summer

Summer is here with warm weather, outdoor activities and our favorite summer shoes.  Frequently, foot pain or problems with the feet are a direct result of the shoes that we choose, so these are a couple of tips to keep your feet safe in the summer:

·         The warm summer weather often encourages us to participate in new activities.  While outdoor athletic activities are a healthy pursuit, be careful when starting something new.  You should make sure that the shoes that you wear are appropriate for the particular sport or activity.  Overuse injuries are frequently seen in the foot and ankle when you try to do too much of one activity after a long winter.  Start slowly and increase your activity as you become stronger and your endurance increases.

·         Flip-flops rule at the pool!  Many patients ask whether flip-flops are safe to wear, and the answer is “yes and no”.  When protecting your feet from hot pavement at poolside, flip-flops are an excellent choice.  Flip-flops can actually help strengthen feet and are best worn on flat reliable surfaces.  When you head to the local amusement park for a day of walking or to the closest state park for an outdoor hike, leave the flip-flops at home.  Long periods of walking and extensive walking on uneven ground with flip-flops or any open back sandal can cause injury to the foot.

·         Stylish sandals and summertime shoes for men can offer minimal support and risk injury to the foot and ankle when worn for inappropriate activities.  While there is no harm to wearing these shoes to a casual barbeque or dinner party, you may cause injury to your foot if you decide to hop on a bike or participate in the unexpected softball game in this type of shoe.  Wearing your favorite summer dress shoes should be limited to activities that require a very low level of activity.

In summary, choose the shoe to match the activity.  Keep a pair of supportive athletic shoes and socks in the car so that you are ready for anything and have a great summer!

By: Sandra Klein, MD

I sprained my ankle last spring while I was running. The ankle doesn't really hurt anymore, but it keeps 'giving out." What should I do?

Foot and Ankle Surgeon, Jeremy McCormick, MD:

Ankle sprains are the most common foot and ankle injury in sports. Typically, sprains occur when inverts with an awkward step while running or jumping. As the foot rotates inward, the ligaments on the outside, or lateral aspect of the ankle, are stretched, causing swelling and pain. Most frequently, sprains will recover completely with rest, ice, compression, evaluation and early mobilization.

In less than 10% of cases, while ankle swelling and pain improves, the ankle continues to "give out" or feel unstable. Classically, this occurs when walking on uneven ground or when stepping off a curb. Repeated episodes of "giving out" is a condition called chronic ankle instability. Most frequently, this is a result of incomplete recovery from an acute ankle sprain that leaves the ankle with weakness and impaired postural control.

The initial treatment for chronic ankle instability is a program of structured rehabilitation with the help of a physical therapist. Exercises are aimed specially at strengthening the peroneal tendons which run on the outside aspect of the ankle. The regimen should also include use of a balance board or similar device to work on proprioception - awareness of the position of the foot and ankle in space. Improved proprioception helps the ankle react more quickly to stresses, preventing future sprains.

After 6-8 weeks of intensive therapy, if the ankle continues to feel unstable, one might be a candidate for surgery to reconstruct the injured ankle ligaments. At this point, an MRI is helpful to identify any underlying injury such as cartilage damage at the ankle or peroneal tendon tears. Complete recovery from surgery takes at least 3 months, but patients will typically be able to return to full activity without limitation, and, most importantly, without the sensation of their ankle "giving out."

I have bunions, but my feet don't hurt. My sister says that I should have them fixed before they become worse. Is this true?

Foot and Ankle Surgeon, Sandra Klein, MD:
Many people have bunions, but not all bunions are painful. A bunion is more than a "bump" on the side of your foot. It is actually a deformity of the great toe that frequently runs in families. If bunions run in your family, you may be predisposed to developing a bunion over time. Bunions range from mild to severe and are most common in populations of people who wear shoes.

In fact, shoe wear plays a significant role in the development of a bunion deformity. Bunions can worsen over time and become painful if your shoes are not an adequate width for your foot. High-heeled shoes also influence the development of a bunion by increasing pressure on the forefoot. As bunions become worse, they can become painful or the lesser toes can become painful.

Many bunions do not become painful or change over time. With appropriate shoes, bunions can remain stable and may not limit your activity level. The primary indication for surgical treatment of a bunion is pain. If you are having pain that limits your activities, you may consider surgical correction of your bunion. If yu are not having pain, there is no reason to correct a bunion today due to concerns that it may become worse in the future.

Surgical treatment for bunions usually involves an osteotomy, or a cut in a bone to realign the great toe. Sometimes multiple osteotomies are necessary to correct the deformity. The surgical treatment depends on the specific deformity causing the bunion and may vary from person to person. If hammertoe deformities of the lesser toes develop, these are often corrected at the same time. If you have foot pain related to a bunion, an orthopedic foot and ankle surgeon can provide you with a surgical evaluation.