Heel Pain and Plantar Fasciitis

Over the past few weeks, I have seen an increasing number of patients of all ages  complaining of  Heel Pain – usually diagnosed as Plantar Fasciitis (PF).

The pain is usually persistent and occurs under the heel pad and around the heel. Often it only affects one foot, but after questioning and examination, they admit to “a bit of discomfort in the other foot.”

This extremely painful condition also called Plantar Fasciitis (PF), but strictly speaking PF causes pain into the arches and soles too, rather than just the heel.

In 1979, one of the founders of Podiatric Sports Medicine, Dr Steve Subnotnick, devoted an entire chapter to heel injuries, in his book Cures for Common Running Injuries. He was probably the original ‘running foot doctor’ when the surge in road running began to take off worldwide.

Tell me where it hurts!

The pain is usually worse in the morning when taking the first few steps and then gets less with continued movement. This pattern is repeated if you sit for a while later in the day – say in a meeting, classroom, lecture or tea-break – and stand up to walk again.

Patients always point to the exact site of pain. This is right in the middle under the heel pad. On the inside (very common) or outside of the heel and at the back.

Why does Plantar Fasciitis hurt?

Overuse is the phrase we use to explain PF! It’s a bit like saying stress. The basic cause is the malfunctioning of the person’s foot and lower limb structure, what we call your Biomechanics. The normal -for you – rocking and rolling movements are exceeded and the tissues get strained and inflamed at the very point where the plantar fascia is attached to the heel bone.

This can be caused by too much exercise such as increasing your distance and not getting enough rest. Changing the surface you run on; for example: running on a treadmill, starting running without the correct preparation, suddenly running more quickly.

Another common cause as we get older is being overweight.  Or a change of occupation where more walking or standing is required. Old worn shoes for day wear or exercise. Arthritis, a pinched nerve. All these and many more causes need to be identified.

How do you treat Plantar Fasciitis?

With difficulty to be honest! You must let your podiatrist see a good selection of your shoes. Frequently we can provide relief from the symptoms by padding, taping and some anti-inflammatories.

The basis of treatment is the biomechanical assessment to identify what goes on as you walk/run. Orthotics may be necessary, but current therapy is team-based,  so I might send you to a Physiotherapist or Biokineticist for strengthening of other muscle groups in your body.

We talk of core strengthening, to improve posture and alignment above the lower limb. If the pain is at the back of the heel gentle stretching plus raising the heeel helps. Nearly always lifting and cushioning the heel gives some relief. Wearing a higher heeled shoe also helps sometimes.

Can I avoid  it?

Yes, but not always. If you can diagnose the problem yourself then stop doing what caused the PF. We often get heel pain on holiday after a day of sightseeing or playing on the beach or more likely shopping!

Never let your trainers get badly worn, especially if they bulge on the inner side. Keep your weight under control. If you know you are going to have to do a lot of standing or walking, consider wearing your more comfortable shoes and change into your fashionable ones later.

At the first sign of pain seek professional help and advice – a proper biomechanical examnation will identify whether plantar fasciitis is the problem. Remember the basic First Aid of treating any inflammation of the soft tissues of your feet.

• Rest;
• Ice;
• Compression;
• Elevation.

Toxic leather shoes? Don’t panic!

“Warning: toxic leather shoes sold here” This scary headline appeared on page 5 of today’s The Sunday Independent, over an article about the potential danger  to the environment from the toxins/chemicals used in the tanning process of many of  the leathers used to make our shoes.

Chrome tanning has been the method of choice for years now and the article describes a report from the Swedish Society for Nature Conservation and its partners, expressing their concern at their findings. The major concern is the amount of chromium the could spread to the wearer and into the environment. This, coupled with the various dyes used in tanning is the source of the society’s concern.

As a podiatrist, I occasionally see a patient with a skin rash that is clearly associated with the patient’s footwear. Called contact dermatitis, it shows as a clearly demarcated rash at all sites where the skin has been in direct contact with the shoe. It is frequently associated with leather sandals and it shows the patient’s skin is irritated by the chemicals in the leather. However, there are numerous other causes of contact dermatitis, as any Dermatologist will tell you.

For example, with the need to produce shoes at lower cost, synthetic materials are more widely used. This also brought its own problems of skin sensitivity, increased sweating and sometimes burning feet. Environmental experts frequently point out that Plastic is of course another blight on the environment. 

From a foot health point of view, we recommend the use of natural materials, such as leather, because we believe it ‘breathes’, absorbs natural foot moisture (sweat) and is altogether more healthy. Unfortunately, all leather shoes are expensive and over time become dry and cracked due to the cycle of moisture and dryness associated with the normal foot. [which is on reason why leather is tanned in the first place].

So don’t panic, rather read the article and if possible the original report, before throwing out or burning your shoes; the smoke is also toxic! We are polluting our environment with far worse things than leather shoes.

Try to alternate your shoes from day to day. Keep them clean and polished to preserve the leather [if they are leather]. wash and dry your feet carefully to prevent the build-up of bacteria which cause smelly feet. Socks of natural fibre will protect your feet from direct contact with the materials used in manufacture, if you are sensitive.

If you do develop a rash or an itchy foot, after wearing a particular pair of shoes. Stop wearing them and see your podiatrist or doctor as soon as possible, because their are tests that will be done usually by the skin specialist – Dermatologist – to identify the exact cause and what you are sensitive to.

Whilst I think this particular article is a bit sensational, it does appear to be based on research evidence. Perhaps the take home message should be a timely reminder that we should all be doing more to re-cycle paper, plastic, metal and household refuse than we are.

Holiday Foot Problems?

Foot problems can spoil our holidays, because they are so unexpected. If you click on Foot Health Articles on this site, you can get some tips on holiday care for people with diabetes, I also wrote about a patient who suffered a holiday foot injury when he fractured his metatarsal as a result of a swimming pool fall!  Also, check out the post on Holidays: Sore feet and sun back on 13 December 2008.

If you have been spending lot’s of time in the pool you might have felt your feet burning. Watch out for the surface of the pool – if it is a bit rough -rubbing the skin on your soles away. [This happened to a little girl I know recently]. You get red-raw skin because the protective outer layer is worn away. Just  treat the area with antiseptic and a plaster, to keep the ‘bugs’ out and avoid an infection.

You can get a similar effect after that first, long-awaited barefoot walk along your stretch of beach! Our feet are usually protected in shoes and the skin is quite soft; our soft city-dwellers’ feet  need a gentle introduction to the great outdoors!

Even regular runners can get burning soles after that early morning barefoot  ‘quick 5 kays’ along beach! So don’t be afraid to wear your tekkies on the beach.

Sunburn on the foot

Sunburn is probably the most obvious holiday foot problem. Mostly to the tops of our feet and the front of the ankles. Use a high SPF cream or spray and re-apply during the day and if you go in the water.

Shoe rubbing is very common on holiday, as we spend more time in sandals. So look out for pressure or friction points that cause blisters – often made worse when there is sea sand added to the mix.

If you are somewhere exotic this New Year, try not to let sea anemone spines, puffer fish or jelly fish spoil your fun – but  who really sees them coming anyway?

Then there are always the snakes! Whenever you go into potential ‘snake- country’, think ahead and be prepared. Make sure at least one person in your group is equipped to deal with a snake bite.

Unfortunately, this time year produces a number of common injuries like cuts from hidden glass and metal, plus aches and pains from too much walking, golf or frisbee! So don’t worry too much about that new heel pain, achilles tenderness or arch pain. It should settle down – if not – see a podiatrist.

The same goes for that itchy rash – could be fungus!

However you celebrate the New Year – from where I am, I’ll get a free fireworks show on Kleinleeuwkoppie at Hout Bay, courtesy of Sol Kerzner – I wish you and your families all the best for 2010.

After A Fall, Don’t Ignore The Pain

At the end of last week, a 60-something lady was brought to me complaining of a very painful ankle, three weeks after she tripped and fell whilst walking in the Bush.

She was uncertain which way her ankle had bent when she fell, but said there was a lot of swelling and bruising, which was only now starting to go down. Whilst in the Bush she had managed only basic First Aid with a bandage, to keep the swelling down so that she could get her foot into her trainers, but walking was extremely painful.

During my examination I isolated a point of severe pain over the tip of the lateral malleolus. [That’s the bit of your fibula that sticks out on the outside of your ankle joint]. The area was also swollen and hot to touch. Moving the ankle caused pain and the lady walked with a stiff-legged limp. The provisional diagnosis was to eliminate a fracture as the ankle joint is very stable and usually the injury in these situations is of severe ligament damage. However, because of the local symptoms I was thinking fracture. The obvious thing to do was send for X-ray.

The X-ray report confirmed a fracture of the tip of the fibula bone, only slightly displaced, fortunately. However, perhaps more importantly, the radiologist reported the appearance of ‘low bone density’ and therefore the possibility of osteoporosis.

The lady is now wearing a “Moonboot” below knee walker – with some difficulty – and was referred to her GP for investigation into the low bone density, which is now underway.

Now I know this isn’t really podiatry, but when questioned further, before I referred her, the lady revealed that she had never had a mammogram or bone density test. These tests are as important for older women as the prostrate examination is for men.

So if you have a fall or trip, don’t just put it down to a sprained ankle and put up with pain; monitor the pain, bruising and swelling. Also, ladies, don’t wait for the next time you need an X-ray to check your bone density.

Remember:  podiatrists don’t just treat feet, we treat people.

You may also find these articles interesting linked to osteoporosis and bone density loss.

• Women not getting bone treatment (news.bbc.co.uk)
• Coeliac bone loss link uncovered (news.bbc.co.uk)

Interesting cause of Heel Pain

Heel pain can be a really crippling  problem at all ages and especially for adult males. I have recently had an email from a 60 year old man complaining of heel pain. 

He described “sharp shooting pains in the left heel area. Usually when it comes under tension – even slightly, say from bending at the waist – or on impact – even the slightest.”

He went on to explain the pain as “odd, insignificant, but very sharp when it occurs.” He had only become aware of the pain in the past few days and said that the only change of habits was that he had started doing quite a lot of swimming. He didn’t indicate that he had had any injury.

My first thoughts were a series of questions:

 – “Do you have any lower back pain?

 – “How strong are your abdominal muscles?”

– “Does it come on spontaneously when sitting in the car or at the computer?”

– “Do you have any residual joint damage from sports injuries or osteo-arthritis?”

Shooting pains like this are usually associated with nerve entrapment,  pinching, or tight muscles like the hamstrings. At this age, osteoarthritis of the spine is a common cause. However, in this case, I suggested that the pain could be associated with the new range of movement since he started swimming.

Treatment for heel pain, begins with trying to find the cause, including the possible underlying cause at this age of being overweight, with a protruding belly! Not so in this case. Bearing in mind that this was an email communication and the symptoms were clearly described, I suggested the following:

• Start by gently stretching your lower back when lying on your back on the floor
• In this position, with knees bent and feet flat, roll gently side to side, all the time pressing your lower stomach into the ground
• In the same position, curl your knees up to your chest
• Another fun exercise is to kneel on all fours; extend your left arm out in front and your right leg out behind you; hold this for 10 seconds and change sides!
• A Physiotherapy consult is advisable at the same time

A few days later, the gentleman diagnosed the problem as tension-related. He actually tried a rather risky move – “I can provoke sustained pain by crouching and then arching my back to put the whole back, rear leg muscles under tension.”

 Luckily he was able to get up from this position, not call the Fire Brigade to lift him up and take him to hospital!

There is no apparent foot problem of pronation or flat feet, so it does sound like a nerve – related problem.

Then out of the blue, another man of similar age visited the practice with similar symptoms. By me moving the foot into certain positions that stretched his lower back, I was able to reproduce the burning, shooting and tingling pains he complained of.

Doing some research on heel pain reveals many causes; nerve entrapment is one of the more difficult to diagnose.

Undiagnosed Achilles Tendon Tear

When an Achilles tendon ruptures, the patient may tell you they heard a sound like a gunshot and they cannot walk, but with an Achilles tendon tear it is still possible to walk around without knowing your injury.

This week a lady consulted me complaining of pains at the back of both heels and into the calves, which had been there for more 6 weeks. She experienced aching, throbbing and a stretching sensation, especially in the evening. She felt less pain wearing higher heeled shoes. In addition, the pain was worse when she got up after sitting for some time.

There was a history of a right ankle fracture and some persisitent left knee pain. She  also told me that she had been diagnosed with calcaneal spurs many years ago. The lady was overweight and of short height.

During my examination, I could see and feel that both Achilles tendons were swollen and had nodules in them. Her walking stride was short and stamping. There were other significant biomechanical problems too.

Temporary treatment consisted of  in-shoe wedging. I also referred the lady for an ultrasound scan of the Achilles tendons.

Two days later the scan reported the left tendon as having “….an almost full thickness intra-tendon tear ……approximately 2.8mm thick, extending 30mm longitudinally.” On the right “……loss of fibrillar pattern, consistent with fraying.”

There were other features, but this was one lucky lady, because there could have been a rupture at any time. This time she was referred to an orthopaedic foot surgeon.

So whether you are a patient or podiatrist, when managing chronic pain at the back of the heel, consider the benefits of ultrasound scanning to assist in diagnosis and always act quickly, you might discover an Achilles tendon tear.

702 Walk the Talk – footwear

Choosing the correct footwear for walking is very important. With the Talk Radio 702 Walk the Talk coming up this Sunday 26th July, there will be 50,000 people strolling, walking, meandering, marching and even racing through the streets of Johannesburg.

The most important thing is to keep to the footwear that you have been  using, don’t treat yourself to a new pair of trainers for the day, because although they may feel quite good at first, they need a bit of wear to ‘bed in’.

Walk the Talk 2009 - Click to Enlarge

I suppose that there will be some serious hikers/walkers in the race and they will know that the best footwear is your regular well worn (not worn out) footwear. If you are walking, just for fun,  in your old worn out trainers, you might be better to walk in your most comfortable more formal shoes!

A firm but cushioning sole is best. Firmly laced, not too tightly, because your feet will swell a little and if laced too tightly, the lacing and tongue will press on the nerves on top of your feet, making them numb or tingly.

If you do get these symptoms, stop and re-tie your laces, rather then get pain. The fit around the heel must be close, so that there is no excessive sliding of your foot, because excessive sliding or shearing causes blisters.

Choice of socks is very personal. Thick or thin they should be able to absorb some of the sweat that you are going to shed. It’s worth using a thicker cotton sock rather than a woollen one.

Although many walkers and runners use no socks or even the feet out of stockings, again use what you are used to.

If you have been getting blisters during your preparation for the race, try putting a ‘blob’ of Vaseline over the place that blisters, it works as a lubricant and will reduce the risk of blistering.

An alternative is to cover a sensitive area with plaster, just beware of putting it where it could roll up and cause a sore spot.

Tactically, watch out for getting sucked along at a faster pace than you want to, or are able to go. This is one way to pick up an injury and get painful feet. You must try to keep to your own pace.

After the race, if you have blisters or any foot problem, look out for the University of Johannesburg Podiatry Caravan and treatment area, they will be able to help with most foot problems.

South African Podiatry Association

The Biennial Congress of the South African Podiatry Association took place this last weekend.

The first two days were a Biomechanics Boot Camp taught by renowned Australian podiatrist Craig Payne and today there were presentations by local podiatrists on rheumatology, diabetes, paleo-anthropology and education.

Most podiatrists  routinely perform biomechanical examinations on their patients – but this Boot Camp was something else – it has changed my thought paradigms and will alter the way I examine my patients and any orthotic treatment I decide to use. (I know this is true for every one else who attended the Boot Camp).

There was another interesting development at the Congress, I was elected Chairman of the South African Podiatry Association for the next two years.

This is a real privilege and challenge as podiatry in South Africa needs to have a much higher profile and take a more prominent place in the South African health care scene.

Expect to see much more about feet and foot care in the future.

Prevent a fall-visit your podiatrist

Many older people suffer a fall with consequent injury such as a fractured  shoulder, wrist, hip, ankle or foot. In the UK there is an active falls prevention initiative, promoted by the National Health Service.  Not so in South Africa, although we are aware of the problem.

Have you ever thought how the state of your feet could contribute to a fall? Podiatrists should be  involved in preventing falls and your visit to one could help to prevent one.

Hazel Tomkins, a British podiatrist, writing in Podiatry Now has detailed how your feet can cause a fall.

So, if you want to stand on your own two feet here’s what to look out for.

Any corn, callus, ulceration, painful nail condition alters the way your foot hits the ground. This usually makes walking uncomfortable and unsteady. With age, the cushioning fatty pad on the soles  of the feet thins out – giving less protection to the bones and joints underneath.

Changes to the basic shape of the feet alters the ability to walk evenly. Often the cause of these changes is reduced muscle strength. On the other hand, any change in posture – quite common as we age – is associated with weakening of our muscles, so there is the potential for loss of balance or unsteadiness.

Watch out for changes to the length of your legs after hip or knee replacement surgery. The pain has gone but you really do need to do all the physiotherapy to restore muscle strength and balance.

At the same time there are many changes to hearing and eyesight which affect the ability to balance and see clearly what is going on around us.

If you have any nerve changes associated with diabetes (neuropathy), you are disadvantaged, because you have a reduced ability to respond to the sensory stimuli around you. On the other hand, arthritis can cause deformity as well as stiffness, making movement difficult, slower or unsteady.

Research into barefoot walking showed a 19% worse performance when barefoot compared with even a least unstable shoe. Going barefoot or stocking feet dramatically increases the falls risk.

Simple you might think, I’ll wear slippers or shoes. Well this is an area of some dispute. There is good scientific evidence that if you change to a lower or flat heel after a lifetime of wearing high heels, you have a greater risk of falling! At the same time there is research which suggests that the most important feature of footwear in preventing falls is the grip of the sole on the ground. Added to that is the need for good fit and thicker soles.

So what to do?

Keep mobile – exercise regularly – start walking, even if you use a walking aid. Maybe you need to start using one? Make sure that you can see and hear as well as possible.

A visit to a podiatrist for a biomechanical assessment is an important way to identify any underlying structural and functional problems. Treatment of any painful foot condition, such as corns and calluses, is essential and  information on the best shoes for you, will be provided.

Avoid higher heels, barefoot walking and slippers. Consider wearing trainers with a rippled sole. A word of warning though, some trainers have really ‘grippy’ soles and that can cause a fall!

Try to remove all loose carpet runners and potential hazards that you could trip over. Make sure the lighting in your home is adequate (most falls occur at home!).

It takes team work to prevent falls, so get any advice that you can, or share it with those who you know are at most risk of a fall.

Onychomycosis – A Fungal Infection

I recently had an enquiry by email which brought home to me the advantages that we have in this day and age because the patient included some photographs of his condition.

It also illustrated the importance of making regular inspections of your feet which are a frequently neglected extremity of our bodies.

His story went like this:  “Until recently, toenail number 2 used to look like number 4, i.e. a bit of white at the base of the nail that I put down to left over soap from the shower when I glanced at it from a great height.

(Click the photos to Enlarge)

When the edge of the nail is pressed back from the front edge it appears that the nail is cracked across about half way down the length as though it has had an impact.  As a result it curves down from mid point towards the front.  I don’t have any shoe problems that might cause this so if an impact rather than constant pressure has caused this then I was unaware of it. (or maybe aware at the time but not of the ongoing effect.)

Left foot is normal.”

From the written description it might be difficult to understand what might be happening.  But the inclusion of the photographs (not difficult in this age of digital cameras) made the diagnosis much easier.

The description and the appearance is typical of Onychomycosis = fungal infection.

The 4th toe shows the typical crumbly? yellow, patchy discolouration the 2nd is a classic presentation.

An alternative diagnosis is psoriasis; with this, developments like you describe are more associated with stress; however,normally there is a history of the underlying condition (psoriasis), which I don’t think you have.

Mycoses or fungal infections are usually picked up from communal shower facilities – gyms, change rooms, boarding school – they develop in a warm, moist environment -closed shoes, stockings, central heating, high humidity in summer.
They are contagious and spread easily when the growth conditions are optimal. (Like mushrooms).

Simplest treatment: Tea Tree Tincture or Oil twice daily.
Use an emery board to GENTLY abraid the nail, this creates a rough surface, then drip on the solution and wipe away the excess. Does not matter if solution gets onto the surrounding skin.

Commonly prescribed treatment: topical anti-fungal agents, some of which are over the counter. Or prescription oral agents if there is multiple toe involvement.

Warning: watch out for any rash in your groin or the soles of your feet. That indicates surface Tinea i.e. fungal infection.

Just be patient and observant for more toes getting it.

In an otherwise healthy person the development of this fungal infection of Onychomycosis is easily passed over as happened in this case until it had a good hold.  So keep a careful eye on your extremities.