Morning Foot Pain: Plantar Fasciitis

 

“.as we know, there are known knowns; there are things we know we know. We also know there are known unknowns; that is to say we know there are some things we do not know. But there are also unknown unknowns—the ones we don’t know we don’t know.”  Donald Rumsfeld former US Secretary of Defense

 

In medicine, what we “know” changes regularly as long as curiosity keeps opening doors.  For many decades, the complaint of pain in the bottom of the foot, just in front of the heel bone and always worse with the first few steps of the morning or after prolonged periods of inactivity, fell into the “known known” category. Doctors and physical therapists confidently made diagnoses of plantar fasciitis, certain there was inflammation in the plantar fascia, the band of tough fibrous tissue that spans the bottom of the foot. The condition was common, especially in runners, in people who spend a lot of time standing on hard surfaces and in post-menopausal women.  Most of the time it resolved but there were enough prolonged and vexing cases that did not get better with anti-inflammatory medications and rest that some practitioners began to suspect that plantar fasciitis was a “known unknown” – maybe the cause was not so simple as the inflammation that they postulated. After all, no one had actually looked at the troublesome tissue under a microscope before.

 Plantar fascia gets an inspection

In 2003, a Philadelphia podiatrist and pathologist, Harvey Lemont, took microscopic samples of the plantar fascia from patients undergoing surgical release of their presumably inflamed connective tissue. In all 50 samples he found no evidence of inflammation. But the tissue was not normal. The collagen structure was disorganized and degenerated, as if it had been deprived of sufficient blood flow. Some samples contained crystals from prior cortisone injections, common treatment for plantar fasciitis, but by 2000 known to carry significant risk of causing the plantar fascia to separate from the heel bone. Degeneration of plantar fascial structure,  a previously unknown unknown, was discovered, and that prompted a change in the name  plantar fasciitis to plantar fasciosis, a term which indicates chronic structural disruption but not inflammation.

Lack of inflammation prompts new thinking

Lack of inflammation in Dr. Lemont’s pathologic examinations explained the failure of conventional treatment many cases of plantar fasciitis. And his work raised significant questions about the cause of the problem. Why does the plantar fascia begin to degenerate? What exactly hurts? Is it the bone where the connective tissue attaches? Is it the connective tissue itself? Study of the feet of non-shoe wearing cultures in which our most common foot problems are practically non-existent, and more attention to foot, leg and gait biomechanics began to yield some different ideas, not only about the heel pain syndrome, but about bunions and hammertoes.

Are shoes the problem?

When we are babies and young children, our feet are widest at the tips of the toes. By the time we wear conventional shoes for decades, with shallow, narrow and tapered toe boxes and elevated heels (even running shoes have a 1-1.5” heel elevation), the big toe begins to curve toward its mates, which begin to curl under. The muscle that normally pulls the big toe away from the other toes is pulled inward and weakens because of inactivity. What does this have to do with the plantar fascia? The big toe muscle runs from heel to toe on the foot’s inside edge, right over the artery near the heel that supplies blood to the plantar fascia. Pulling it inward narrows the artery and decreases blood flow to the plantar fascia. It is possible that morning heel pain is ischemic pain, from lack of sufficient blood flow while the foot is dropped down during sleep.  Gradual Improvement in the pain with walking may reflect better blood flow with activity, but over time insufficient blood flow takes a toll on the integrity of the tissue in the plantar fascia, adding pain from stressed attachment to the heel bone.

Wimpy foot muscles

For many years people with plantar fasciitis were told they had collapsed arches and flat feet. Or high arches and no flexibility. Or that they pronated – walking on the inside of their feet. Or supinated, walking on the outside of their feet. The treatment was external support with rigid orthotics. But feet are very individual in their structure, and there is little solid evidence that arch height causes problems. Much more evidence implicates weakness at the ends of the arch – the toes and the heels, which bear the weight of the body and are supported by muscles in the feet and in the lower legs.

A shift in treatment plans

Treatment of the heel pain syndrome is shifting to restoration of strength and flexibility in the foot. The plantar fascia functions as a windlass, a pulley that adds to the arch strength when the foot lifts at the heel and bends at the big toe joint to propel the body forward. The goal of therapy is not to stretch that windlass, but to realign the big toe and strengthen the not only the foot muscles that flex the toes and the sole, but also the muscles of the lower leg, the knee and the hip.  The toes are coaxed to flatten out and spread by stretching the top of the foot and the front of the ankle and wearing toe spacers. (Useful resource below.)

In the acute phase of plantar heel pain, some external support of the foot under the arch often helps, as does a boot that keeps the foot from dropping down in bed at night. But these aids are temporary while the work of regaining foot strength and flexibility gets under way. It can be difficult to transition from elevated heels to flat shoes, and that process is almost like training for a new physical activity – short bouts at first, gradually increasing over time.

Improvement takes patience, persistence and consistency. All footwear needs to change to shoes with wide, deep toes boxes, flexible soles at the forefoot, and no elevation between heel and toe. Perhaps we will find more unknown unknowns and a way to combine healthy feet with fashionable shoes, but at the moment, the known knowns suggest that changing fashion norms to align them with natural foot function is more likely to be successful.

 

Resources:

https://naturalfootgear.com

Foot Conditions

Over the Counter Pain Relief

Pain stayed so long, I said to him today

“I will not have you with me any more.”
I stamped my foot and said, “Be on your way,”
And paused there,
Startled at the look he wore.
“I, who have been your friend,” he said to me.
“I, who have been your teacher,
All you know of understanding love,
Of sympathy and patience I have taught you.
Shall I go?”   

Author unknown

Pain is a friendly messenger, carrying news from the frontiers of the body to the command center of the brain. Like the messages traveling across telephone wires, pain is just a series of electrical impulses traveling up nerves. The brain sorts the electrical impulses and presents them to you, the conscious mind inside, as a coherent story about what’s going on down below. Sometimes the message triggers an immediate reflex action, like pulling a hand away from a hot stove, even before your mind grasps the problem.

How is pain relieved?

Relief from pain depends on stopping the electrical impulses carrying the pain message or on altering the way the brain puts the message together. Every drug or procedure used in pain treatment works on either the simple electrical message, or on its complex interpretation by the brain. Ultimate relief comes when the conscious mind disappears into sleep, which is of course the great achievement of general anesthesia. Consciousness is the barrier to complete relief of severe pain.

Most pain, however, is not the severe unremitting variety that requires treading the fine line between consciousness and oblivion. Most pain comes in an acute form that gets us to the doctor for treatment of a sudden illness, or in a chronic form related to our heads or our skeletons. Thousands of years ago Cicero made the distinction: “All pain is either severe or slight; if slight, it is easily endured; if severe, it will without doubt be brief.”

Willow bark – the first pain medicine

Time and chemistry have given us surgery, anesthetics, antibiotics and narcotics – life-savers for diseases heralded by severe pain. They have also given us lesser drugs for lesser pains, a long process beginning in the 5th century BC when Hippocrates recommended chewing the bark of the willow tree to relieve pain and reduce fever. A long line of chemical derivatives of the willow bark’s salicilin culminated in a stable powder patented and marketed in 1899 as aspirin, the world’s first synthetic drug. Aspirin launched the world’s pharmaceutical industries.

Anti-inflammation and pain

Inflammation causes pain and the purpose of the pain is to get you to attend to whatever is causing the inflammation. Pain relief from aspirin is best understood in terms of its anti-inflammatory effects, but the drug has multiple other biochemical properties, many still being discovered. One effect, on an enzyme involved in the production of chemicals that produce inflammation, led to the development of ibuprofen and its cousin naproxen. These newer drugs, non-steroidal anti-inflammatory drugs (NSAIDS), are mainstays in the treatment of the aches and pains of daily life.  Anti-inflammatory steroids like prednisone are far more potent and used only when their risks are balanced by the seriousness of the problem under treatment.

Tylenol is not an anti-inflammatory drug

Tylenol, or acetaminophen, is commonly thought to be just like aspirin, but it is chemically unrelated, has no anti-inflammatory effects, produces no gastric upset and doesn’t affect blood clotting. It reduces fever by a direct action on the brain, but no one knows how it reduces pain. The pain-relieving properties of aspirin and the NSAIDS, apart from their anti-inflammatory effects, are also poorly understood. It is possible that they decrease pain perception in the mind, but if so, no one understands how.  They are most effective after an acute injury, after simple surgical procedures, or with infrequent headaches (relief here is also of unknown mechanism).

Frequent analgesic use can increase pain problems

But what about pain of chronic conditions like osteoarthritis and frequent “tension” headaches, in which inflammation plays a lesser role? Much arthritic pain is from tightness and muscle imbalance. Gradual activity warms up joints and removes some of the discomfort. Exercise, heat, ice, massage, weight loss, stretching, Pilates, and yoga help minimize drug use in these chronic conditions. Frequent use of analgesics for headaches (more than once a week) actually lowers the threshold for headache triggers (like lack of sleep, alcohol, lack of exercise, stress, etc.)  and for pain perception, and often leads to a cycle of increasing drug use producing increasing numbers of headaches. This phenomenon is known as rebound headache and it highlights the importance of other methods of headache prevention and relief (adequate sleep, stress management, attention to diet and exercise, etc.).

Selling pain relief like candy

Since 1915, when aspirin became available without a doctor’s prescription, the sale of over-the-counter (OTC) pain relief has achieved the heights late Merck chief Henry Gadsden aspired to when he wished aloud 30 years ago that he could sell drugs to healthy people just like Wrigley’s sells candy and gum. These days, OTC pain medicines are so readily available that they seem as harmless as the candy next to them on the shelf.

Side effects

Unlike candy, OTC pain relievers have to be processed by the liver and kidneys. Chronic use can produce liver and kidney impairment, even failure of these organs. Chronic analgesic use damages hearing. Aspirin and other NSAIDS may erode the stomach lining; all but Tylenol impair blood clotting. Recent statistical studies resulted in withdrawal of two newer NSAIDS from the market because people taking them had more heart attacks than those on placebos. The problem also appears in statistical analysis of those on high doses of the older NSAIDS.

Don’t kill the messenger – heed it

Because no drugs are risk-free and pain is just messenger telling you about a problem, try to reserve the pill option for pain that interferes with sleep or truly inhibits you from carrying out the activities that are important to you. Attend to the causes of the message in as many non-pharmaceutical ways as possible. And remember that an analgesic “virgin” or infrequent user gets more out of a painkiller than an analgesic veteran.

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