Bob

Dear Bob,

It sounds like your pain has been compounded by the confusion of conflicting advice from your doctors. Alice hopes she can shed some light on the situation, and give you the information you need to get effective treatment. Bear in mind, however, that tr eating plantar fasciitis requires much patience on your part because there is no set course of action---no two cases are identical and each one will respond to various treatments differently.

Plantar fasciitis is an inflammation of the plantar fascia, a band of connective tissue in the foot that provides arch support. Somewhat similar to a shock on a mountain bike, the plantar fascia absorbs much of the shock experienced by the foot. Some ch ronic cases of plantar fasciitis involve bone spurs, although they are generally not the primary source of pain, nor are they the cause of the plantar fasciitis. So you ask, "What did I do to develop this painful foot condition?" That question can be ve ry hard to answer in most cases. Usually the condition develops gradually, and patients do not seek help until it becomes quite painful. The majority of plantar fasciitis cases can be attributed to a number of factors, the primary one being a soft tissu e injury due to overuse (e.g., repetitive weight bearing activities that stress, stretch and wear out the plantar fascia). Very few cases are the direct result of a particular trauma or foot incident.

Most plantar fasciitis sufferers are the middle-aged, the elderly, and athletes---all people who, either over time or through considerable impact, have "worn out" the soft tissue of their plantar fascias. Some people are naturally prone to developing thi s condition for a variety of reasons. For example, they may have a foot structure that naturally lends itself to abnormal wear (e.g., high or low arch), unequal leg lengths, a tight and inflexible Achilles tendon, or weak intrinsic foot muscles. Some p atients are obese or have experienced sudden weight gain, which puts extra stress on the foot. Then there are the athletes---runners, basketball and tennis players, for example--- who simply demand more from their feet. For others, environmental factors , such as worn running shoes, poor shoe supports, and excessive walking/running on hard surfaces, can also play a part in the development of plantar fasciitis. In most cases, a combination of factors contribute to the problem, and it may be difficult to pinpoint all of them.

When you first seek treatment, your doctor needs to do a thorough examination; this includes conducting a physical exam and taking your medical history. This will help you and your doctor target the factors which most likely contributed to your plantar f asciitis, thereby making your treatment options a bit more clear (at least in theory). Your treatment needs to include measures that (1) alleviate your pain; (2) restore flexibility to your ankle and arch; (3) strengthen the muscles in and around your foot; and, (4) allow you to gradually take part in all of your usual activities again - pain free!

Let's look at each one of those treatment goals separately to see what they might mean for you. Don't worry---in doing so Alice will get to the question of "heat or ice."

(1) Alleviate the pain. The reason and need for doing so are obvious. This can be achieved by taking anti-inflammatories (not a good idea in your case!), resting the foot, and applying...ice. Alice recommends following your orthopedist's recommendation of applying ice to the foot---several times a day and after athletic activity. You can use an ice pack, or directly apply ice to your foot in what is called an "ice massage." Do this until the foot is decently numb; be careful not to give yourself a mi nor case of frostbite! Resting your foot and giving the damaged tissue time to heal is a crucial part of treating any case of plantar fasciitis. If there is any weight-bearing activity that you do on a regular basis, such as walking a mile or two on har d pavement daily, you will want to think about not doing that for a while. Unless the biking directly causes foot pain, Alice again recommends taking the advice of your orthopedist, and keep on peddling.

(2) Restore flexibility to your ankle and arch. A more flexible foot and ankle will be able to help absorb shock better, and not leave the job entirely to the plantar fascia which, quite frankly, is tired and worn out and doesn't want all that responsib ility any more. Stretching exercises which target your heel cord are important for relieving pain and tension on the plantar fascia. Stretching helps to improve flexibility and prevent recurrence of pain. Be aware of how you stretch; it's best when you feel a gentle pull (versus pain). Since plantar fasciitis pain often peaks in the morning, doing these stretches soon after you wake up is a good idea Then stretch one or two more times during the day.

(3) Strengthen the muscles in and around your foot. This will eventually pay off by providing extra support to the arch. Stronger muscles will also reduce the amount of wear and tear to the bones and joints. Ask your orthopedist to show you some more exercises you can do that will help build up these muscles---some of your stretches are probably already helping. Alice knows of one exercise that consists of picking small things off of the floor. Do this while sitting in a chair with your leg (with th e "bad" foot) crossed over the opposite knee. Gently pull up on your foot, and use only your toes to pick the items up. Alice hopes you will ask your orthopedist about this exercise so that s/he can guide you in doing the exercise, and perhaps sh ow you a few more. Other ways of strengthening the muscles and providing/maintaining good arch support involve the use of devices, such as orthotics, heel cups and pads, strapping the foot with a pad and some sort of "tape," and night splints. The night splints are a bit unwieldy, and not in the least bit romantic!

All of these treatment methods are called "conservative," as they do not involve expensive procedures, comparatively. They are often hit-or-miss and can take a while to produce results. Most patients with plantar fasciitis can expect to try a few types o f treatment before finding one that works, and they usually do not experience positive results for about six months give or take a few. In general, the longer it takes a person to seek medical care for plantar fasciitis pain, the longer it takes for tha t pain to go away.

Alice cautions you to be leery if either of your doctors prescribes physical therapy or steroid injections---there is insufficient proof that they are beneficial. Also, consider surgery only as a last resort. Because most cases are treated with conserva tive measures, not many plantar fasciitis surgeries are performed. Surgery is usually recommended only after six to 12 months of unsuccessful conservative treatment, and when the patient is considerably disabled in daily activities.

Well, there's the long and long of it. Alice wants to point out that if you don't like the approach of one doctor, you can always try another. If your pain has not been relieved at all by either of these doctors, you may think about seeing a podiatrist.

Alice

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