PLANTAR FASCIITIS TIPS
A Popular Recommendation That Works — Or Does It?
One of the most common things one hears from podiatrists, friends and advice Web sites is that you should roll a frozen water bottle under your heel. The idea is, apparently, that the cold is good for something that is inflamed and helps to numb the pain and makes it feel better, and that the rolling action is a kind of massage. Rolling the heel on anything, it has been suggested by at least one source, breaks up scar tissue and helps the plantar fascia to heal itself better.
People are advised to roll all kinds of things, from golf balls to those wooden cylinders lathed into patterns of ridges. Or tennis balls. One sports medicine doctor says to experiment with a tennis ball by making a slit in it to make it softer, trying different lengths of slits for the softness or hardness that feels right when you roll the heel on it. The Web offers a wonderful profusion of things to buy and roll under your heel, such as the assortment of different-sized balls offered by the Hand and Foot Treatment Kit that my sister-in-law bought from meltmethod.com, and which she believes helps greatly.
So does this rolling the heel on objects like frozen water bottles actually work, or is it just more of that pseudoscientific gibberish being passed around in the guise of wisdom?
“There are a lot of theories on what that accomplishes,” says with Dr.John Wilson, a faculty member in the University of Wisconsin School of Medicine and Public Health, and a team physician for the University of Wisconsin Athletic Department. “My opinion is that it probably stretches the plantar fascia to some degree, and with the ice bottle you get a cooling effect. Some people believe that massage of that tissue, deep massage, increases blood flow to the tissue, which might augment the healing process. There’s little evidence that helps in a cure at the tissue level, but it may help alleviate symptoms.”
The “frozen” part of this formula – frozen water bottle – is questionable as a treatment, although if one has pain, numbing it always seems like a good idea. In 2011, when I was spending long days hiking the mountains for a mineral exploration job, I did roll the frozen water bottle under my heel. I also rested my heel on a frozen bag of peas to get the icing effect. But does icing the heel really have any value?
Icing is what one does in injuries to reduce inflammation, but plantar fasciitis is “not really an inflammation as we traditionally think of it, as in a tendonitis or bursitis inflammation,” says Debbie Nawoczenski, PT, PhD and professor in the Department of Physical Therapy at Ithaca College–Rochester Center. “Icing won’t hurt, but some people say it actually makes them feel more stiff. I’m not sure that’s a good thing. Stiff is not what you want it to feel like. You want to feel like those tissues are stretching out.”
Forgetting about the icing, how about rolling ANYTHING under the foot. It seems to feel like it’s doing something good, and it seems to be a way of massaging the tissue. Massage is said to accomplish all kinds of things, helping the plantar fascia to stretch, busting up on the scar tissue that thickens the plantar fascia and impairs blood flow, and relieving the entrapment of the medial calcaneal nerve beneath the heel.
According to Dr. Jeffrey Ross, Associate Clinical Professor in the Baylor College of Medicine and a fellow of the American College of Sports Medicine, in the article “Plantar Fasciitis in the NBA,” “deep cross-friction massage” serves “to break up scar tissue, thickness, increase blood flow and try to break apart the adhesions and tightness that are trapping the nerve branch.”
Debbie Nawoczenski describes how manual therapy techniques can “get really deep into the soft tissues … People who have had that kind of ‘trigger point’ myofascial release in combination with the stretching do even better.”
And isn’t rolling a ball under the heel a way of massaging the tissue? “I don’t know that we know what the ball does,” says Nawoczenski. “People sometimes feel better because maybe it is creating a stretch with the pressures put on it. There’s speculation that it’s breaking up tissue. We don’t know that to be true. You don’t see it out there as one of the recommendations on medical Web sites.”
Caution When Considering Cortisone Injections
Quite a few caveats about cortisone injections are cited on our Cortisone Injections for Plantar Fasciitis page, but it’s always interesting to hear a few other sources on the topic. One is an online article, Caution When Considering Cortisone Injections.
Surgery: Podiatrists vs. Orthopedic Surgeons
About plantar fasciitis surgery, interesting insight from Dr. Jeffrey Johnson, Professor of Orthopaedic Surgery at Washington University: “Podiatrists are much more prone to recommend surgery for the problem than an orthopedic surgeon is in general, and most orthopedic surgeons don’t do nearly as many plantar fasciitis procedures as the podiatry community. It’s almost bread-and-butter for them, and a very rare one for us. The main reason is that we see some really significant complications from doing that, and we don’t have good solutions for those complications. When such a high percentage of patients can get better without surgery, then you really have to drag your feet as far as offering surgery to make sure you’re not dealing with somebody in that 90 percent.”
Caution after Injections
About therapeutic plantar fascia injections of fluids – be it cortisone, platelet-rich-plasma (PRP) or even just saline solution – animal studies show that it weakens the structure of tendons or ligaments, inflating it, making it susceptible to rupture. Just putting fluid in has a negative effect biomechanically, even though that fluid does not stay in a long time before it is processed out. That is one good reason why doctors want you to be non-weight-bearing with crutches and/or a boot for a few days after injections, and why it’s important to focus on doing that.
Seeking the Perfect Night Splint
NIGHT SPLINT #1:
I bought an inexpensive [well, $35.46 with sales tax] “Ace” brand “Plantar Fasciitis Foot Sleep Support” at Walgreens and strapped it on before bed. It has the benefit of being easily adjustable to increase the angle at which it pulls the foot up at the front. But as one who sleeps with a wool blanket and not a sheet, I also found it troublesome when the Velcro straps on calf and foot kept catching on the wool.
NIGHT SPLINT #2:
So I tried the Strassburg sock [$39.95], which has a connection, typically a tube of cloth or other knit material, from the toes to the shin, pulling the toes closer to the shin, more specifically stretching the plantar fascia in the “dorsiflexion” stretch described in the Stretching page of this site. The Strasburg sock is just that, a sock, with no rigid components. It also has Velcro to hold it on the calf, and to secure the connection between calf and toes, but slips more smoothly under the blankets.
The sock is so narrow that it’s devilishly hard to slip and roll it on. At the foot store, they told me no, there is not a larger size sock to make it easier to pull on. It’s supposed to be tight. A real pain for me, however. And another pain: with the sock pulling over the top of your big toe, it wakes you at night with the sensation that something hard has been pressing too long on the front of that big toe, and it hurts.
NIGHT SPLINT #3:
Now I bought online the Adjustable Plantar Fasciitis Night Splint w/Wedge, by Ovation Medical and ordered throught National Brace & Splint. http://www.nationalbraceandsplint.com/Adjustable-Plantar-Fasciitis-Night-Splint-wWedge_p_661.html. What attracted me was the stiff plastic shell that goes down the back of the calf and under the foot, so the whole foot is cradled. And the fact that the straps have plastic buckles you can snap closed, and snap open by squeezing on the buckle release.
Drawbacks: Biggest drawback is that the two lower buckles are way down on the side of the foot, and to snap them in you have to go through yoga-freak contortions that wrench your lower back. So the buckles are useless. You just have to leave them clasped and pull on the straps to tighten and affix with the Velcro. Also, if you have a sizeable foot, the end of your foot is sticking past the “shoe” of the thing, and there is no uplift on the foot front. And you can’t increase the angle at which your foot is being held up and plantar fascia stretched, because the hard shell is rigid in the approximately 90 degree angle. Also, unlike the first two night splints, it has cushioning under the foot that makes a sqeaking noise when I get up and walk in the middle of the night, which of course is not good if there is another person sleeping in the bedroom. I thought about sending it back for a refund of the cost of $26.97, but the additional $9.95 I paid for shipping is nonrefundable. So I would have to pay another $9.95 to send it back, which would reduce the refund to $17.02, and the hassle is not worth it. National Brace & Splint does have a Dorsiwedge night splint that has a wedge under the toes to lift them up more, but it’s $80 and I’m not in the mood to spill even bigger cash to order online something I’m not sure will not have its own drawbacks.
For now, I’ll just have to use the “Ace” brand “Plantar Fasciitis Foot Sleep Support” and the Strassburg sock (adjusted with minimal as little uplift on the toes as needed to avoid pain) until I find something good.
Plantar Fasciitis Vs. Plantar Fascia Tear
What’s the Difference? Dr. Jeffrey Johnson, Professor of Orthopaedic Surgery at WashingtonUniversity in St. Louis was kind enough to answer that question.
“Plantar fascia tear is an acute injury where this ligament structure stretches due to sudden jumping or pushing off. Plantar fascia tear is treated with immobilization and then rehab and foot orthotics and many of the things done for chronic plantar fasciitis. In plantar fascia tear, the history is more clear for a sudden change in symptoms, and sometimes you can feel a defect at the tear on a physical exam. Occasionally the long-term residual of a tear is a feeling of arch ‘weakness’ with push-off. This is sometimes associated with mid-foot overload pain, especially lateral mid-foot due to loss of arch support of the plantar fascia.”
There is no surgery for repair of plantar fascia tear.
Plantar fasciitis is a thickening and soreness from chronic repetitive stress, and the structure is NOT torn or elongated.
Sometimes plantar fasciitis is improved following a rupture, but usually they are not associated.
Stretching Tip #1
A lot of the illustrations that show how to stretch show people doing it barefoot. NO BAREFOOT stretching and, in fact, no barefoot at all. When you get out of bed in the morning – even if you’ve had a night splint or done the plantar fascia stretching – you must not walk barefoot, says Deborah Nawoczenski, PT, PhD and professor in the Department of Physical Therapy at Ithaca College–Rochester Center.
“You have to be in something supportive,” she says. “Get good slippers and put insoles in the slippers, and inserts that you can get over the counter at a good running store. You want to stretch the plantar fascia but you don’t want it to micro-tear by barefoot walking. I even tell people to put on flip-flops or Crocs when they go into the shower, so they’re still not stressing the plantar fascia.”
When you are doing the Achilles stretch or other stretches (except for the bedside plantar fascia stretch), do it as you do the rest of your day: wearing shoes with orthotics. Nawoczenski recommends eliminating barefoot walking throughout the day.
And just to clarify, she adds, “shoes with orthotics” does not necessarily mean a custom arrangement, it can be an over-the-counter insole, just something supportive of the sole of the foot.
Stretching Tip #2
Also not made clear in many instructions, and some illustrations: stretching should be done slightly pigeon toed during the Achilles stretches and during the stair-drop stretch. If not, you may be stretching your arch but not your Achilles.
FootCare MD, a Web site of the American Orthopaedic Foot & Ankle Society, has some good illustrations of stretches.
Stretching Tip #3:
About the plantar fascia (or “dorsiflexion”) stretch, where one crosses the affected foot over the knee of the other leg and pulls back on the toes and balls of the toes with one hand: Some of us old fat boys, with bellies that get in the way and sensitive lower backs prone to spasms when we contort in the wrong way, may find this plantar fascia stretch on the edge of the bed almost prohibitively uncomfortable.
One recommendation is to use a towel, around the ball of the foot, and pull back with both hands keeping the knee straight. Some podiatrists suggest that, from a standing position, you place the foot with toes and balls of toes against a wall, lean forward and hold for the stretch.
I find that at any time of the day it’s convenient, and therefore more conducive to doing it often, to stretch the plantar fascia on the floor. Periodically I will pause and do the stretch against a wall; or slightly crouch, knee of the unaffected leg bent and the affected foot slightly behind and – keeping the toes and balls of the toes on the floor – rock the heel upward to stress the underside of the foot, and hold…as long as you want. This seems to work for me, but if any experts have a reason why this is less effective or ineffective, I’m happy to hear the anatomical reasons why.
Who doesn’t enjoy walking around barefoot? Plantar fasciitis advice:DON’T! You’re going to a lot of effort (constant specialized foot and leg stretching, footwear and orthotics, etc.), so why aggravate your condition by going barefoot? That includes padding around the house in socks which, to a plantar fasciitis suffer, is equivalent to barefoot.
“Most people have more pain when barefoot, and we say if it hurts, don’t do that,” says Dr. John Wilson, a faculty member in the University of Wisconsin School of Medicine and Public Health, and a team physician for the University of Wisconsin Athletic Department.
So the experts tell you not to go barefoot. When you step out of bed, make sure you are stepping down in to a supportive shoe or slipper, with arch supports or heel pads. Some advise that, even when you go to the shower, wear Crocs, plantar-fasciitis-friendly sandals or even flip-flops or some other shower-friendly footwear that keeps your heel from bearing on a hard surface. [A liability disclaimer here, and don’t say I didn’t warn you: but rubber or plastic footwear may involve a risk of slipping in the shower, especially if it’s in a bathtub. One of those no-slip tub mats might be a good idea.]
But wait, one might think. Why not walk on your toes and ball of foot like animals do (what we call the heel being, on dogs and cats, halfway up the back of the leg and never meant to be walked on. So THEY are walking on their toes, and it’s natural.). Then you are not walking on your heel, right?
“Humans are not designed to walk like that,” Dr. Wilson says. “Walking on toes creates other problems long term, like Achilles tendonitis or pain in the knees and back.”
Tip: Stabilizing Arch Supports
Arch supports in a shoe are a problem if they move around when you are taking the shoe on and off. I know it was a royal pain grinding my foot into a hiking shoe and then having to take it off again because the arch support slid out of place.
With the full-length insole arch supports, this is less likely to be a problem, of course. But for those ¾- length arch supports, there should be something like the “Superfeet” brand arch supports, where they come with Velcro pads, one that sticks on the bottom of the shoe and one that sticks on the bottom of the arch support, holding support to one place in the shoe.
I use the extra Velcro pads I buy at the Good Feet store, for example, to hold in place the “Blaue Fussbett” arch supports recommended and sold by my podiatrist. The Blaue Fussbetts are among the arch supports that do not come with Velcro stabilizers, but the folks at the local shoe store where I bought a second pair of Blaue Fussbetts say you can probably pick up Velcro tab combinations at other places, a fabric store for example.
Cushioning Tip: Floor Pads
Walking and standing on hard, flat surfaces, are among those things that make plantar fasciitis a real pain.
Docs and physical therapists recommend considering cushioned floor mats. A ½-inch to ¾-inch rubber mat that is a little denser will give true cushioning, they say: something dense and thick enough that the heel doesn’t bottom out on the floor.
Cushioning floor mats don’t help to cure plantar fasciitis any more than do icing the heel or taking ibuprofen or other inflammatories. But like those other measures, they help make it less painful while you’ve got it.
Say you’re a hair stylist who spends a lot of time standing in one place, for example. Or maybe you spend a lot of time standing in the kitchen, cooking and washing dishes and so on. Or maybe you want something comfortable in front of the bathroom vanity. Or maybe you spend a lot of time behind a counter at the job. Anywhere you’re going to stand, you need something better than a cloth rug. Cushioning floor mats are widely available, and they don’t have to just look like a big patch of rubbery cheap.
GelPro brand gel-filled floor mats, for example, come in umpteen colors and styles as well as different thicknesses, for household as well as commercial uses. But don’t take too seriously the photo on the GelPro home page, which shows a model standing on a GelPro mat at the kitchen counter in bare feet. Maybe that’s fine for the other physical complaints such mats are intended to help, but the experts advise against us plantar fasciitis people walking in bare feet because it irritates, and “microtears” the plantar fascia and counteracts all the other things we work so hard at to self-cure the problem.
Tip: How Active Should You Be?
Resting the foot is sometimes recommended as part of the orthotics/stretch/etc. self-cure regimen, but what about people who have to keep working their feet? People who work in retail and service sectors, for example. And what about activities we want to do or should do simply for exercise?
“There’s no study showing that activity modification makes it better,” says Dr. W. Hodges Davis, a Charlotte, North Carolina Foot and Ankle Surgeon and 2012-2013 President of the Outreach and Education Fund of the American Orthopaedic Foot & Ankle Society. “I usually say, just don’t increase your activity. The majority of people can do that. There’s a small group, where it’s disabling, they can’t. But that’s a very small group. Most people while stretching can continue with what their activity limits were. For walkers, even for runners, it’s variable. Some runners stretch, and they’re fine during the run. It just hurts for a while afterward.”
If you like to ski, go ahead. Especially with the rigid boots, skiing won’t hurt the plantar fasciitis recovery. Bicycling is another good activity, although if one goes for a long bike ride and it seems to have irritated the condition, you may be just stressing the ligament that’s partially torn.
There’s a balance between getting it stretched out, which activity helps to do, and continuing to irritate or re-injure it, Dr. Davis says. “I would probably think in terms of cross training. If you get to a point where it starts hurting, then do something else. And continue to stretch.”
Foot Arch-ery — Haw
About stretching (and footwear and orthotics) aimed at maintaining and extending the plantar fascia longitudinally, the idea is that it’s the tightness of the plantar fascia that causes the irritation/inflammation that is plantar fasciitis. That’s what they do in plantar fasciitis surgery, the “partial transection” which lengthens the plantar fascia, but those other approaches are what more than 90% of people can do to “self-cure” without surgery.
I thought I’d share a great word-image of this that I noticed on a Facebook site, the Facebook page of a company, www.heel-that-pain.com/ That sells plantar fasciitis products, and I know I’ve stated a policy of not promoting products which I have not used myself or which have not been mentioned by the medical experts I interview, but it’s a great description:
“The arch of the foot functions like a bow (as in a bow and arrow), and the plantar fascia is like the string of the bow. The tension in the “bow string” holds the shape of the arch. But every time you step, the “bow string” stretches… and when stretched too hard and too often, it gets irritated, and then it’s like a bow shooting you in the foot!”