Jewish World Review May 5, 2003 / 3 Iyar, 5763

Feeling not so well-heeled? maybe it's all in your shoes

By Marlene Cimons | Does your heel hurt, especially when you first get out of bed in the morning? Is the bottom of your foot stiff and achy? Has exercise become uncomfortable, even agonizing or, worse, a thing of the past?

If so, you're not alone. Heel pain sends more people to foot specialists than just about any other complaint, and is one of the most tenacious and frustrating conditions to deal with, experts say.

"It is extremely common,'' says Dr. Sheldon Laps, a Washington, D.C., foot surgeon and podiatrist. "I see it in young and old, athletic and non-athletic, heavy and thin.''

Hardly surprising, since we ask a lot of our heels. The heel bone is the largest bone in the foot and bears all of the body's weight with each step. The stress on the heel -- and all the structures connected to it -- is enormous. The plantar fascia -- a long band of fibers that attaches at the bottom of the heel bone and extends to the beginning of the toes -- takes the brunt of that stress.

Pain occurs when these tissues become irritated or inflamed -- a condition known as fasciitis -- or when small spurs begin to grow on the heel bone itself. Many feel a sharp pain first thing in the morning because the plantar fascia shortens during the night while you sleep. When you suddenly get out of bed and start walking, the band along the bottom of your foot suddenly stretches and pulls on the heel. And that really can hurt.

Biomechanical flaws, such as flexible flat feet, high-arched foot deformities and a tight Achilles tendon can result in considerable stress on the plantar fascia. Weight gain can exacerbate the problem, especially for women who fail to lose extra pounds gained during pregnancy.

Runners who pronate excessively (who turn their feet outward so that the inner side of the sole has contact with the ground) or who suddenly change their training routines (for example, increasing mileage by more than 10 percent a week or switch surfaces, especially to hard concrete sidewalks) can develop plantar fasciitis.

Women who wear high heels all day and switch into a flat running shoe at night can have problems; the abrupt change often triggers pain, much the same as stepping out of bed after a night's sleep will.

The good news is that plantar fasciitis can be treated successfully in most people without surgery. Even better, a new device (approved by the U.S. Food and Drug Administration in 2000) that delivers shock waves to the affected area -- the same technology used to break up kidney stones -- has shown a high success rate among patients with chronic plantar fasciitis in whom nothing else has worked. It is performed in a doctor's office in less than 30 minutes, and is noninvasive, allowing many to avoid surgery, the treatment of last resort.

Typically, plantar fasciitis is first treated with the usual approaches to athletic injuries, including stretching; icing after running; oral anti-inflammatories, such as ibuprofen; shoe inserts or custom orthotics; night splints; and even injections of steroidal anti-inflammatories, such as cortisone.

Surgery, which involves severing the attachment of the plantar fascia to the heel and/or removal of the heel spur, should be considered only when all else fails. Even then, many foot specialists are reluctant to operate, concerned that it will cause more problems than it will fix.

The mainstay of any treatment program for plantar fasciitis is stretching: specifically, Achilles tendon stretches performed first thing in the morning, before getting out of bed.

"Loop a towel around the bottom of the foot, and bend your toes to your nose for 30 seconds, and do three sets,'' Laps says. "Then, during the day, do wall push-ups with knees both extended and flexed, preferably done barefoot.''

Experts also recommend wearing a heel cup or heel cushion in both sports and regular shoes; they urge men to wear an oxford tie shoe during the day, and suggest that women switch from a flat shoe to a heeled shoe -- or vice versa -- to alter stress on the back and bottom of the heel.

Some doctors will put their patients in a so-called "night splint'' to avoid the plantar fascia from shortening overnight. At night, most people sleep with their feet pointing down, and in that position the Achilles and the plantar fascia tighten up. That's why it's so painful when you first get out of bed because the band stretches. By putting a splint on and holding the foot at an obtuse angle to the leg, you can prevent that.

The shock-wave therapy is for those who have not improved using those measures. The device uses ultrasound first to pinpoint the inflamed area; it finds the place on the ligament that is thicker than the normal 2 millimeters, then delivers high-energy shock waves to the site.

"The plantar fascia ligament has a very poor blood supply, so once it gets injured, it does not heal easily,'' says Eliot Sherr, a podiatrist in Peabody, Mass. "What the shock waves do is inflame the ligament even more, but in a way that creates pathways for new blood vessels to develop. That helps heal the ligament.''

Recovery takes from several weeks to six months, he says; the treatment costs about $2,000 but is often covered by insurance.

If all these approaches fail, it then becomes extremely important to rule out other possible causes of heel pain, such as a stress fracture or arthritis caused by Lyme Disease.

"As long as the cause of the heel pain is mechanical, it's easily treatable,'' Laps says. "The problem is when it's a systemic cause that is missed.''

Surgery that releases the plantar fascia from the point where it attaches to the heel -- in order to relieve the pain -- remains controversial. For years, it traditionally was performed through a conventional surgical incision; more recently, a technique has been developed using tiny fiber optic instruments. Many doctors don't like it.

Laps believes that snipping the plantar fascia results in foot instability and a buildup of scar tissue. "I do not like to do it on an athlete,'' he says. "It's a procedure of absolute last resort. Before I operate on athletes, I'll recommend that they give up running and start swimming or biking.''

There are simple and effective ways to prevent plantar fasciitis.

-- Perform Achilles tendon stretches faithfully.

-- Wear well-cushioned shoes, and make sure the heels do not become significantly worn.

-- If you run, keep your mileage steady. If you must increase it, do so gradually, no more than 10 percent a week.

-- Stick to soft surfaces -- a track or grass is the best; asphalt (roads) and concrete (sidewalks) are the worst.

-- Women, do not wear high heels during the day, and then switch to running shoes in the evening -- it may be better, if possible, to run in the morning and then put on your heels.

Virtually everyone who has ever suffered from this stubborn and painful affliction agrees on one thing: Once you've had it, you'll never want to get it again.

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