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Don't let heel pain keep you from exercising

Heel pain is a common foot problem, with pain occurring under the heel or just behind it, where the Achilles tendon connects to the heel bone. Although heel pain makes walking difficult, daily walking is actually one of the best therapies.1

Did you know?


  • Plantar fasciitis is one of the most common causes of foot pain in adults.2 It involves inflammation of the plantar fascia, a thick band of connective tissue under the foot that stretches from the heel to the toes,3 and may also be associated with heel spurs.1

  • One in 10 people will experience plantar fasciitis in their lifetime,2 resulting in one million doctors’ visits per year in the US alone3.

  • It is most common in people aged 40 to 60 years1, or even younger in runners4, and affects both feet in up to one-third of cases5.

  • In North West Adelaide, South Australia, more than 1 in 6 adults reported having foot pain6.

  • A large systematic review of sport-related ankle and foot overuse injuries found that half involved soccer, running, gymnastics, and dance.7 

The Facts:


Diagnosis and testing

  • In most cases, a physical examination and patient history are used to diagnose plantar fasciitis, without the need for other tests.
  • However, imaging may be used to help check for alternate diagnoses when pain lasts longer than three months and doesn’t respond to therapy.16

Symptoms

  • The classic presentation is pain with the first step of the morning or after a period of inactivity. Pain levels gradually improve or disappear with activity, only to return at the end of the day. Numbness or tingling is uncommon. The patient may have recently increased their weight-bearing activity levels.8

What increases your risk2?

  • Being overweight (body mass index > 27 kg per m2)9
  • Excessive running
    • Plantar fasciitis is common in runners, suggesting that, in this population, it may be due to injuries caused by repetitive microtraumas. In this group, proposed risk factors include:10, 11
      • Excessive training (particularly with a sudden increase in distance)
      • Poor running shoes
      • Running on hard or unyielding surfaces (including some synthetic running tracks)
  • Dance
    • Plantar fasciitis is common among ballet dancers and those performing dance aerobic exercise.12
  • Poor flexibility
    • Foot muscle, calf muscle and hamstring tightness are associated with plantar fasciitis.13
  • Leg length discrepancy
    • Having one longer leg is associated with one-sided plantar fasciitis.14
  • Prolonged standing or walking at work
    • In assembly-line workers, plantar fasciitis was associated with prolonged time spent walking or standing on hard surfaces, and frequent jumping in and out of vehicles ( e.g. truck/forklift drivers).15
  • High arched foot

  • Flat foot

  • Reduced ankle dorsiflexion (less able to raise the foot towards the shin, usually due to shortened Achilles tendon)

  • Sedentary lifestyle

What can we do about it?


Approximately four out of five patients with plantar fasciitis will improve without surgery within 12 months.17


Non-surgical treatments include rest, ice massage, anti-inflammatory medications, taping, stretching and strengthening, supportive shoes and heel cups, and activity modification.


The American Orthopaedic Foot and Ankle Society recommends using non-surgical treatments for at least six months before considering surgery for plantar fasciitis. Non-surgical treatments have a much higher success rate, without the risk of post-surgical complications.18


To reduce the pain of plantar fasciitis, try these self-care tips:

  • Maintain a healthy weight
    • Carrying extra weight can put extra stress on your plantar fascia. Weight loss can be helpful in lowering pain levels if you are currently overweight or obese.17, 19, 20
    • A plant-based diet has been proven to reduce body fat in people who are  overweight and obese, even when controlled for energy intake.21
    • Plant-based diets have also been shown to decrease pain and disability in general musculoskeletal conditions.22
  • Choose supportive shoes
    • Buy shoes with a low-to-moderate heel, thick soles, good arch support and extra cushioning, and replace them regularly
    • Don’t walk barefoot
  • Change your sport
    • Try a low-impact sport, such as swimming or cycling, instead of walking or jogging
  • Apply ice
    • Ice massage can help reduce plantar fascial pain and inflammation
    • Either wrap a cloth around an ice pack and hold it onto the painful area, or roll a frozen water bottle with moderate pressure, for 15 minutes three or four times a day.23
  • Stretch your arches
    • Simple home exercises can stretch your plantar fascia, Achilles tendon and calf muscles.
    • Several systematic reviews suggest that stretching the ankle and foot may provide short-term relief for people with heel pain or plantar fasciitis.24, 25
  • Exercise
    • Activities should be modified to avoid repetitive impact (eg. with running) in the treatment phase. Non-weight-bearing activities like cycling, swimming and rowing are preferable for maintaining fitness while minimising repetitive strain.
  • Use foot orthoses/orthotics (either custom-made or off-the-shelf)
    • Orthotics help support the medial longitudinal arch and cushion the heel. They are particularly useful for people who respond well to taping and help reduce pain and disability for anything from 2 weeks to 1 year.26 
    • Prefabricated silicone heel inserts combined with stretching exercises (see below) may also be of value.27  
  • Reduce the impact
    • Wearing cushion-, or crepe-rubber-soled shoes, and avoiding jumping or excessive heel strike when walking, can help reduce impact from living or working on hard concrete floors.26
    • Rotating shoes throughout the workweek can also reduce the risk of plantar fasciitis.15

Summary:

The vast majority of patients with plantar fasciitis will improve with conservative therapies alone. Weight loss, activity modification, stretching and strengthening exercises, supportive shoes and ice massage may provide relief and healing.

 

 

REFERENCES:

1.         Nahin RL. Prevalence and Pharmaceutical Treatment of Plantar Fasciitis in United States Adults. J Pain. 2018;19(8):885-96. doi:10.1016/j.jpain.2018.03.003

2.         Trojian T, Tucker AK. Plantar Fasciitis - American Family Physician. Drexel University College of Medicine. 2019.

3.         Riddle DL, Schappert SM. Volume of ambulatory care visits and patterns of care for patients diagnosed with plantar fasciitis: a national study of medical doctors. Foot Ankle Int. 2004;25(5):303-10. doi:10.1177/107110070402500505

4.         Taunton JE, Ryan MB, Clement DB, McKenzie DC, Lloyd-Smith DR, Zumbo BD. A retrospective case-control analysis of 2002 running injuries. Br J Sports Med. 2002;36(2):95-101. doi:10.1136/bjsm.36.2.95

5.         Sadat-Ali M. Plantar Fasciitis/Calcaneal Spur among Security Forces Personnel. Military Medicine. 1998;163(1):56-7. doi:10.1093/milmed/163.1.56

6.         Hill CL, Gill TK, Menz HB, Taylor AW. Prevalence and correlates of foot pain in a population-based study: the North West Adelaide health study. J Foot Ankle Res. 2008;1(1):2. doi:10.1186/1757-1146-1-2

7.         Sobhani S, Dekker R, Postema K, Dijkstra PU. Epidemiology of ankle and foot overuse injuries in sports: A systematic review. 2013.

8.         Yi TI, Lee GE, Seo IS, Huh WS, Yoon TH, Kim BR. Clinical characteristics of the causes of plantar heel pain. Ann Rehabil Med. 2011;35(4):507-13. doi:10.5535/arm.2011.35.4.507

9.         Van Leeuwen KDB, Rogers J, Winzenberg T, Van Middelkoop M. Higher body mass index is associated with plantar fasciopathy/'plantar fasciitis': Systematic review and meta-analysis of various clinical and imaging risk factors. 2016.

10.       Hotta T, Nishiguchi S, Fukutani N, Tashiro Y, Adachi D, Morino S, et al. The association between plantar heel pain and running surfaces in competitive long-distance male runners. Journal of Sports Medicine and Physical Fitness. 2016.

11.       Waclawski ER, Beach J, Milne A, Yacyshyn E, Dryden DM. Systematic review: Plantar fasciitis and prolonged weight bearing. 2015.

12.       Oloff LM, Schulhofer SD. Flexor hallucis longus dysfunction. J Foot Ankle Surg. 1998;37(2):101-9. doi:10.1016/s1067-2516(98)80088-4

13.       Labovitz JM, Yu J, Kim C. The role of hamstring tightness in plantar fasciitis. Foot Ankle Spec. 2011;4(3):141-4. doi:10.1177/1938640010397341

14.       Mahmood S, Huffman LK, Harris JG. Limb-length discrepancy as a cause of plantar fasciitis. J Am Podiatr Med Assoc. 2010;100(6):452-5. doi:10.7547/1000452

15.       Werner RA, Gell N, Hartigan A, Wiggerman N, Keyserling WM. Risk factors for plantar fasciitis among assembly plant workers. PM R. 2010;2(2):110-6; quiz 1 p following 67. doi:10.1016/j.pmrj.2009.11.012

16.       Schneider HP, Baca JM, Carpenter BB, Dayton PD, Fleischer AE, Sachs BD. American College of Foot and Ankle Surgeons Clinical Consensus Statement: Diagnosis and Treatment of Adult Acquired Infracalcaneal Heel Pain. 2018.

17.       Buchbinder R. Clinical practice. Plantar fasciitis. 2004.

18.       American Orthopaedic F, Ankle S. Don’t perform surgery for plantar fasciitis before trying six months of non-operative care. 2014.

19.       Crawford F, Thomson CE. WITHDRAWN. Interventions for treating plantar heel pain. Cochrane Database Syst Rev. 2010(1):CD000416. doi:10.1002/14651858.CD000416.pub2

20.       Muth CC. Plantar fasciitis. 2017.

21.       Najjar RS, Feresin RG. Plant-Based Diets in the Reduction of Body Fat: Physiological Effects and Biochemical Insights. Nutrients. 2019;11(11). doi:10.3390/nu11112712

22.       Towery P, Guffey JS, Doerflein C, Stroup K, Saucedo S, Taylor J. Chronic musculoskeletal pain and function improve with a plant-based diet. Complement Ther Med. 2018;40:64-9. doi:10.1016/j.ctim.2018.08.001

23.       Lim AT, How CH, Tan B. Management of plantar fasciitis in the outpatient setting. Singapore Med J. 2016;57(4):168-71. doi:10.11622/smedj.2016069

24.       Landorf KB, Menz HB. Plantar heel pain and fasciitis. 2008.

25.       Sweeting D, Parish B, Hooper L, Chester R. The effectiveness of manual stretching in the treatment of plantar heel pain: A systematic review. 2011.

26.       Martin RL, Davenport TE, Reischl SF, McPoil TG, Matheson JW, Wukich DK, et al. Heel pain-plantar fasciitis: revision 2014. J Orthop Sports Phys Ther. 2014;44(11):A1-33. doi:10.2519/jospt.2014.0303

27.       Pfeffer G, Bacchetti P, Deland J, Lewis A, Anderson R, Davis W, et al. Comparison of custom and prefabricated orthoses in the initial treatment of proximal plantar fasciitis. Foot Ankle Int. 1999;20(4):214-21. doi:10.1177/107110079902000402

28.       Sheon RP, Buchbinder R. Plantar fasciitis and other causes of heel and sole pain2011 May 5, 2020. Available from: https://somepomed.org/articulos/contents/mobipreview.htm?13/49/14097.

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Dr. Luiz Fernando SellaMD, MPH
Author
Medical Doctor at the Federal University of Santa Catarina, Brazil, a Certified Lifestyle Medicine Physician and Health and Wellness Coach.