“I hate putting my foot on the floor in the morning. It feels like a nail in my heel,” said Carolee when I asked her about first step pain.
She was describing a common symptom of the most frequently seem problem in a podiatry office: the first step pain after periods of rest seen with plantar fasciitis.
The pain is usually caused by the too-strong pull of connective tissue that stretches from the toes to the heel. At one time the plantar fascia was useful to its owner by making the foot rigid when climbing barefoot, but now it seems its most important job is filling podiatry waiting room chairs.
Like many patients, Carolee was worried about having a heel spur, imagining a boney spike on the bottom of her heel. I could see one on her X-ray, but she was skeptical when I told her that it was not the cause of her pain.
In fact, about 40 percent of patients without heel pain have a spur and half of all patients with heel pain do not have a spur. As proof that the heel spur is not the cause of pain, surgery, which is rarely done anymore, usually just involves cutting the fascia, leaving the spur alone. It is routinely successful.
Carolee demonstrated the most common causes of the overuse of the plantar fascia: being overweight, wearing flimsy shoes while working and walking on hard surfaces. She worked in retail in sandals and was walking to lose weight in flexible deck shoes. (This is not to say that underweight men who wear dress shoes cannot also have this pain.)
Carolee suspected, correctly, that her flat feet contributed to her problem by excessively stretching her fascia.
When she arrived at my treatment chair, I touched a spot on her heel where the fascia inserts on the heel bone and she jumped a little, indicating that she had pain in the correct location for plantar fasciitis. (Sorry, Carolee). I measured the thickness of the fascia with ultrasound, and it was an overly large and painful 7 mm thick. Her other heel, the one without pain, was a normal 3 mm in thickness. Normal thickness is up to 4.3 mm.
The ultrasound measurement has become the easiest confirmation method used and is especially useful for atypical plantar fasciitis, where the problem is not exactly at the insertion site of the fascia on the heel. Here it can be used to guide injections into the correct location for greater effectiveness.
The treatment provided at this first visit was a special, almost magical, tape strapping called a low-Dye, after Dr. Ralph Dye, who first described it. The tape will often stop the pain in its tracks. This works so well that I use a positive response to the tape as one of my four criteria to make a presumptive diagnosis of plantar fasciitis; the other three being first step pain, pain with pressing on the insertion spot and thickness of the fascia over 4.3 mm on the ultrasound.
Home instructions for Carolee included wearing stable shoes; using an over-the-counter arch support; reduction in the most forceful activities like the treadmill in favor of cycling, swimming or a healthrider; and the application of ice to the heel for 20 minutes several times a day.
For icing I recommend using a plastic bottle filled with water that has been frozen. Sometimes patients can learn to apply the low-Dye on their own; videos are available on YouTube.
Over-the-counter medications like two or three ibuprofen two or three times a day are often helpful. Wall stretches of the Achilles tendon and plantar fascia are also helpful. The technique is available on the Internet.
If the low-Dye strapping is consistently more helpful than over-the-counter arch supports, more effective custom orthotics can be made. If patients wear a stable shoe, they can often achieve pain relief with custom orthotics.
Unfortunately Carolee could not be talked out of her sandals and deck shoes because, as she said, her feet “get too hot,” requiring another approach. For immediate pain relief I injected a little cortisone near her fascial insertion site, and she received profound pain relief. Cortisone injections in the heel are safe and effective, and usually can be done with little to no pain.
For more resistant pain I can repeat the injections up to three times, and physical therapy can do marvelous things with the techniques and tools at their disposal. Our office has the luxury of two inoffice licensed physical therapists.
Statistics show that, on average, heel pain resolves on its own in 18 months. These techniques can certainly improve on that, so Carolee does not have to wait until 2014 for relief.
For those few that do not resolve in an appropriate time period, both high-energy shockwave therapy and surgical approaches that are described on the website below are available.
Meanwhile, three low-Dye strappings and two cortisone injections have helped Carolee become pain free. Now all she fears in the morning is her alarm clock.
Dr. Michael Zapf, along with his partners, Drs. Darren Payne and Steve Benson are podiatrists with offices in Agoura Hills and Thousand Oaks. For more information on plantar fasciitis, call the office at (805) 487-6979 or visit www.ConejoFeet.com.