Plantar Fasciitis - Heel Pain

‘Hey Doc, I have a spur la’, said my buddy and hockey devil Avtar. ‘What makes you think so huh?’ I asked worried. ‘I have pain over my heel. What else can it be la?’ he retorted.

That started me on a long lecture about how not all heel pain is caused by a spur. Well, I concede that while plantar fasciitis is the most common cause of heel pain, other causes need to be ruled out by the treating doctor for effective and accurate care. These include  stress fractures of the calcaneum, tendonitis of the tendo Achilles or foot flexors, arthritis of the foot joint and nerve irritation being the more common differential diagnoses.

Once other causes have been ruled out, getting rid of that irritating pain of Plantar Fasciitis is a logical end goal!

So… The million-dollar question - How do we do that? To treat plantar fasciitis one must understand the condition well.

What Is Plantar Fasciitis?
The plantar fascia is a band of tissue attached to the heel and extends to the toes - specifically from the medial calcaneal tubercle to the bases of the proximal phalanges. It functions to maintain the longitudinal arch of the foot and is important in the dynamics of proper foot function. In plantar fasciitis, the fascia  becomes inflammed due to repeated injury-irritation resulting in heel pain. This can be as a consequence of a poorly treated acute injury or the end result of overuse.

Causes
The most common cause of plantar fasciitis relates to faulty structure of the foot whether congenital or acquired:

1.                   Reduced flexibility at the ankle especially that due to a tight Achilles tendon is a independent risk factor for fasciitis

2.                   Poor footwear especially with hard heel regions place an undue stress to the region of the plantar fascia. This coupled with job descriptions that require prolonged standing and walking predispose to plantar fasciitis.

3.                   Obesity may also contribute to the development of plantar fasciitis.

Symptoms
The symptoms of plantar fasciitis are:

• Pain on the bottom of the heel. This is worse upon rising in the morning and usually subsides with activity. There may remain  a residual dull ache in the heel. The pain returns or is worsened by long periods of immobilization.

Diagnosis
Accurate diagnosis requires a detailed history and clinical examination. Other causes of heel pain should be ruled out systematically. Pain to pressure over the medial part of the heel is pathognomonic. Palpation of the fascial band is essential to not miss a rupture or tear of the fascia. Associated assessment of the tendoachilles for tightness is essential for optimal care.

Although diagnosis is essentially via clinical evaluation, diagnostic imaging studies such as x-rays or other imaging modalities may be used to distinguish the different types of heel pain.

Sometimes heel spurs are found in patients with plantar fasciitis, but these are rarely a source of pain. When they are present, the condition may be diagnosed as plantar fasciitis/heel spur syndrome.

Non-Surgical Treatment
Treatment of plantar fasciitis begins with first-line strategies, which you can begin at home:

• Stretching exercises. Exercises that stretch out the calf and toe flexor muscles help ease pain and assist with recovery. These concentrate of stretching the Achilles tendon
• Shoe modifications. Wearing supportive shoes that have good arch support and a slightly raised heel reduces stress on the plantar fascia. This aids in the acute phase. Prevention of recurrence circles around continuance of optimum footwear.
• Medications. Oral nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, may be recommended to reduce pain and inflammation.

If these methods fail or if symptoms worsen, it is good to get an expert opinion from your Orthopaedic Surgeon. You may be then advised on these methods:

• Orthotic devices / Splints. Custom orthotic devices that fit into your shoe help correct the underlying structural abnormalities causing the plantar fasciitis. Splints are usually used as an adjunct to stretching exercises and are usually prescribed for night use.
• Injection therapy. In some cases, corticosteroid injections are used to help reduce the inflammation and relieve pain. Newer options such as platelet rich plasma to restart the healing process are currently popular in recalcitrant cases.
• Extracorporeal Short Wave Therapy. The use of ESWT is gaining popularity as a therapy in chronic symptomatic cases.

When Is Surgery Needed?
Although most patients with plantar fasciitis respond to non-surgical treatment, a small percentage of patients may require surgery.  The decision for surgery is usually taken in the group of patients who remain symptomatic in spite of compliance to a structured stretching and rehabilitation programme. Post surgery, rehabilitation has to be continued to obtain optimum benefit.

Long-term Care
It is important to understand that the causative elements of plantar fasciitis may often remain. This underlines the need for continued preventive measures. Appropriate supportive shoes, properly done stretching programmes and using orthotic devices where appropriate are the mainstay of long-term treatment for plantar fasciitis.

Tennis Elbow - Lateral Epicondylitis

FROM THE DESK OF DR. HARJEET SINGH

My elbow is killing me today! I often hear this from my patients and friends alike.

Most of them are weekend warriors and active at racquet sports. But it is not only them who complain, a fair share are non-sporting and a good number are homemakers.

Pain over the outer part of the elbow has been called several things. Most people call any pain in the region of the outer elbow Tennis Elbow. This is dangerous as not every painful condition over the outer part of the elbow is – Details of these other conditions at some other time.

             Coming back to Tennis Elbow - Mind you, it doesn’t only happen in tennis players! The medical terminology is Lateral Epicondylitis and it is the most common of elbow injuries, typically occurring between the ages of 40 – 60 and affecting up to 3 percent of the population.

What is the Pathological Process?

Tennis elbow occurs when there is damage to the muscle and its tendon over the outer aspect of the elbow. The muscles, which run over the back of the forearm, are mainly attached to the outer part of the elbow. Theses muscles help to extend the wrist and fingers (movements which cause you to curl your wrists upwards and straighten your fingers)

Small tears (micro tears) form in the tendons and muscles, which control the movement of the forearm. These tears happen because the tendons do not stretch. Repeated stress strains the tendon causing it to fray in a similar way that a rope frays. This then causes a restriction of movement, inflammation and pain. As this area is prone to heal poorly with high chance of repeated injury, these micro tears eventually lead to the formation of scar tissue and calcium deposits. This tissue is of poor quality and is prone to further tearing, thus causing persistent pain and dysfunction.

What Causes Tennis Elbow?

The most common cause of tennis elbow is repeated injury due to over use. Any action which places a repetitive and prolonged strain on the forearm muscles, coupled with inadequate rest, will tend to strain and overwork those muscles. Poor technique in sports increases strain on the involved muscles and will contribute to the condition, such as using ill-fitted equipment, like tennis racquets, golf clubs, work tools, etc. It is important to remember that these injuries don’t only occur in those involved in sports. Movements that predisposed to tennis elbow are:

• Rotation of the elbow with a bent wrist such as using a screwdriver.
• Gripping something strongly while rotating the wrist.
• Hitting movements such as usage of a hammer.
• Throwing movement that is not done smoothly (jerky).

There are also many other causes, like a direct injury - a bump or fall onto the elbow. Understand that poor levels of general fitness and conditioning will also contribute to the development of this condition

Signs and Symptoms

Pain is the most common and obvious symptom associated with tennis elbow. Pain is most often experienced on the outside of the upper forearm, but can also be experienced anywhere from the elbow joint to the wrist. Weakness, stiffness and a general restriction of movement are also quite common in sufferers of tennis elbow. Even tingling and numbness can be experienced.

Preventing Tennis Elbow.


WARM UP: Thorough and correct warm up will help to prepare the muscles and tendons for any activity to come. Without a proper warm up the muscles and tendons will be tight and stiff. There will be limited blood flow to the forearm area, which will result in a lack of oxygen and nutrients for the muscles. This is a sure-fire recipe for a muscle or tendon injury.

STRETCHING: Flexible muscles and tendons are extremely important in the prevention of most strain or sprain injuries. Proper flexibility levels allow muscles to move and perform without being over stretched.  Tight and stiff muscle on the other hand, may be pushed beyond their natural range of movement. This predisposes to injury.

STRENGTHENING:  Strengthening and conditioning the muscles of the forearm and wrist will also help to prevent tennis elbow.

Stretches for Prevention of Lateral Epicondylitis (Tennis Elbow) – These are to be done with controlled movements.  The exercises should not be done if it brings about pain or causes more pain.

·        Lift your arms to about shoulder height and place your hands together in front of your chest, keeping your fingers together. Your fingers should be just under your chin. Lower your hands towards your waist and stop when you feel a mild stretch. Hold for 20 seconds and repeat 4 times.

·        Extend your arm out in front of you, palm down, and push your hand towards you with the other hand until you feel a stretch. Hold for 20 seconds.

·        Extend your arm out in front of you, palm up, and push your hand towards you with the other hand until you feel a stretch. Hold for 20 seconds.

·        Practice squeezing a tennis ball, holding the ball for a few seconds before releasing. Do this twice a day.

·        Place a rubber band around all of your fingers, including thumb, and practice opening your fingers against the rubber band. Do this twice a day.

Treating Tennis Elbow.

The occurrence of acute pain should bring about cessation of the initiating activity.

It is advisable to obtain a consult from an Orthopaedic Surgeon to obtain diagnosis. Not every painful episode over the lateral (outer aspect) of the elbow is due to tennis elbow.

The RICE protocol should be carried out for the first 24-48 hours. This involves R – Rest; I – Ice; C – Compression; E – Elevation.  Usage of ice treatment should be done properly for best benefit (Use of Cold and Heat in Injury)

The next phase of treatment (after the first 48 to 72 hours) involves a number of physiotherapy techniques. This begins with passive methods such as heat and ultrasound therapy and thereafter moves on to the preventive and rehabilitative phase once the pain control is good.

The ultimate aim of this phase is to regain and improve the strength, power, endurance and flexibility of the muscles and tendons that have been compromised.