Plantar fasciitis/heel pain
Heel or arch pain first thing in the morning, or post-static dyskinesia, is commonly plantar fasciitis. Technically speaking, this is a partial tear of the dense, fibrous tissue that runs across the bottom, or plantar surface of the foot. If the tear is at the heel bone (calcaneus) a heel spur may form as a result of the bone attempting to repair itself. Several recent studies refute the partial tear explanation and support the theory of decreased blood circulation (vascularity) to the area. Nerve entrapments including the calcaneal nerve or tarsal tunnel syndrome may also be a source of heel pain. When at rest due in part to gravity and position, the plantar fascia is shortened. Stepping down following rest creates a sudden dynamic stretching of the fascial tissue. This may cause micro-tears in the fibrous tissue resulting in that sharp pain you feel.
Fasciitis is attributed to three causes: 1) tight posterior muscles; 2) running on hard surfaces and/or 3) overuse. In regards to tightness, any repetitive motion can cause shortening in the calves, hamstrings and lower back, (posterior muscle groups). Indeed, most of us suffer from this condition. Stretching would help but most of us do not spend enough time doing this. Some solutions for the tightness include the old standby of 30 second yoga-type stretching of the calf muscles done slowly and in a controlled manner. For a different take on stretching, see Mark Allen's article in the current issue of Triathlete. A heel lift sometimes helps by functionally shortening the calf muscle, thereby reducing tension on the fascial tissue. That's why some female patients who come in with fasciitiis only feel comfortable in their high heels. Wearing a night splint has also been shown to be very effective. This helps keep the calf and fascia on stretch throughout the night. If you're running shoes are too flexible, or bend behind the toes in the arch area, then replace them. And do not walk barefoot.
As for the second cause, running on hard surfaces, obviously a softer surface may help alleviate some fascial pain. Treadmills or boardwalks serve well here. Be aware however that too soft a surface, such as the sand, may exacerbate the problem by increasing the pull on the calf/fascia. If you do run on the beach, always wear your sneakers. Finally, overuse is another common cause of fasciitis. This is most common in the beginning of the season when we're increasing mileage before our tissue has adapted to the increased stress.
Regardless of the root causes, I believe that our current treatment methods adequately address the pathology in the large majority of cases. In addition to some of the suggestions that we already discussed, there are several other treatment options ranging in intensity and medical intervention. On a more simple scale, daily ice applications are helpful. I advise patients to use a frozen water bottle and roll it under the foot for an ice massage. Do this for approximately fifteen minutes on, with a ten minute break, and then repeat. Anti-inflammatories may alleviate some of the acute pain if it's at the point where walking is difficult.
Strategies that involve medical management include cortisone injections. It's important to keep in mind that there are several different types of injectable cortisone. Some are insoluble, remain in the tissues for long periods and can only be injected once in a six-month period. Others are soluble, leave the system quicker and can be injected safely on a weekly basis for short periods. Again, this treatment is for those who haven't gotten relief from more conservative methods of treatment.
Of course, physical therapy is always an option. For the past few years, orthostatic shock wave therapy has been used on runners who have not gotten relief after several months. This one-time treatment induces a localized inflammation, causing increased blood supply to the area to facilitate tissue repair. For those with long term pain, it's worth checking out.
Treatment options must also include a consideration of the biomechanical aspects of fasciitis. High-arched/rigid foot types as well as low-arched/flexible foot types are both susceptible. Runners with leg length inequality may also be at risk. A prescription orthotic plays an important part in addressing biomechanical faults.
Most triathletes do not have a problem biking with fasciitis. Only occasionally will biking exacerbate the problem. Though we wear rigid, supportive bike shoes and are not weight-bearing in the full sense of the term, there's still posterior muscle group involvement. If there's no pain within several hours or the next day after riding, then biking is not increasing the inflammation.
Cutting back on running is an important part of the solution, though. Overall, most people do improve within three months. Have patience and do not get discouraged after a couple weeks.
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