The Heel of Achilles Affects Mortal Men

The Simpson's episode: "New Kids on the Blecch"

Guess who hurt himself this weekend? That’s right, this guy! You know those people who think they can go out and run a marathon without any training? Well, I’m not quite that crazy, but the mental hospital is not far off the horizon for me. I haven’t ran over 2 miles since high school, and while I’m in pretty good shape thanks to cycling and rowing, running 10 miles is a different story. That’s right, 10 miles. I won’t go into detail about why I did this, or the physical trials I endured. What’s important is I finished, and I did it while sustaining only three injuries! The most painful being plantar fasciitis.

Plantar Fasciitis is also commonly known as heel pain. “Plantar” means bottom of foot, and Fasciitis means inflammation of fascia tissue. Fascia is similar to a tendon, but flat like plastic wrap, and spread out over a larger area. Basically, plantar fasciitis is like a tendonitis on the bottom of your foot, typically focused on the heel. It can be very painful and will limit how much weight you can put through that foot, and how much walking you can tolerate.

Image by A.D.A.M.

There’s a problem with plantar fasciitis, other than the pain and limited function it causes; it’s also not fully understood. There are many possibilities to what causes it, some are clear and some are hazy. An example of a clear cause would be a hard fall onto your heel. Lets say you slipped off a ladder and landed on your heels first. Not a graceful way to land on your feet. Landing normally on the balls of your feet helps to absorb the force of the fall. If you hit the heels first, you’ll take a lot of force through a stiff area of your foot, a recipe for injury.

Let’s go through a hazy cause. Billy’s car has transmission problems and will be in the shop for a few weeks… he’ll probably be broke afterward. So Billy has to walk to the bus stop a half mile away so he can take the bus to work. Well, that’s a one-mile round trip walk everyday. After a week of this, he starts to get heel pain. What’s the cause? Well, your first thought is probably the extra walking he is doing. Correct! … Partially.

Yes, the foot pain timed well with the extra walking, but one mile a day really isn’t that far to walk. Humans are made to walk long distances. Some other causes to think about are: type of shoes he wears, his weight, the way he walks, or his age. All of these can decrease the tolerance to walk one extra mile a day. I remember in undergrad walking a mile a day for a few weeks in dress shoes, and developed a nasty corn on my big toe. I know, a great image to throw in here. The corn is gone now; my feet are beautiful again.

So, my latest article read deals with possible causes of plantar fasciitis. This article by Irving et al. is actually a systematic review. This type of article provides strong evidence, since they compare information from multiple articles on the same topic. It’s similar to when you buy a car and review different sources, like Consumer Reports or Auto Trader, to help you find the best car. Since there are hundreds of articles related to plantar fasciitis, they have to weed out the crappy ones. I won’t go into detail the process they use to select articles to review, but it’s fairly rigorous.

The higher up the pyramid, the stronger the evidence. Filtered info means they weeded out the unimportant articles.

So what did they find out? Well in short they found that increased weight in non-athletic populations, increased age, decreased ankle and big toe motion, prolonged standing, and bone spurs on the heel all show some association with plantar fasciitis (*Remember that I said ‘association’, this will be important later).

The Breakdown:

1. Increased weight in non-athletic populations is pretty self-explanatory. Extra weight means more stress on your heels. Athletes may be able to get away with it because they have stronger bones or muscles to support their heels.

2. Increased age is also somewhat self-explanatory. The body in old age just does not withstand stress or heal as well as the body of a young individual. Sucks, huh?

http://sports.jrank.org/article_images/sports.jrank.org/dorsiflexion.1.jpg

3. Decreased ankle and big toe motion is a tricky concept. The specific motion is called dorsiflexion. You dorsiflex your ankle when you raise your foot to the sky while keeping the heel on the ground. Just like tapping your foot when listening to music. Dorsiflexion of your big toe is similar; just raise that piggy up off the ground toward the sky. Essentially, if you have poor flexibility in this motion for the ankle and big toe, it can cause excess stress on the heel (I can describe in detail but it would likely take another long blog to do it).

4. Prolonged standing is also somewhat self-explanatory. Standing is low stress on the heel, falling off a ladder is high stress on the heel. Low stress, over a long time can still cause injury.

5. Bone spurs don’t always cause problems. But, if they grow too big, or into sensitive tissues, then that’s when they make your life troublesome. Bone spurs on the heel are the same way; therefore, not everyone with bone spurs on the heel has plantar fasciitis.

The Catch:

*Side Note: Correlation is very similar to association, but both are different from causation.

Remember that word ‘association’? Association is different from cause. Try as they could, Irving et al. only found articles that could find associations instead of causes. Basically, that means the five factors above are commonly seen with plantar fasciitis, but they do not necessarily cause it. For example: increased weight could have caused plantar fasciitis, or the pain from plantar fasciitis caused Bob to walk less and gain more weight. The studies did not address this Chicken or Egg conundrum.

So the point of this?? To screw with your mind… jk. Yes, the four factors listed above are associated with plantar fasciitis, but it has yet to be determined if one causes the other. But, 3 out of 5 can be controlled. Loosing weight, increasing ankle/big toe dorsiflexion, and avoiding excessive periods of standing are common treatments physical therapists give patients with plantar fasciitis.

Well, I’m off to treat my plantar fasciitis. Got to increase my ankle dorsiflexion and stop aging. I left an abstract below for you to reference. It is heavy on the terminology, but if you’re a PT then it shouldn’t be too bad.

Thanks for scanning with CN III and transmitting through CN II. Peace!

Article Reference and Abstract
Irving DB, Cook JL, and Menz HB. Factors associated with chronic plantar heel pain: a systematic review. Journal of Science and Medicine in Sport. 2006;9:11-22

Chronic plantar heel pain (CPHP) is one of the most common soft tissue disorders of the foot, yet its aetiology is poorly understood. The purpose of this systematic review was to examine the association between CPHP and the various aetiological factors reported in the literature. Seven electronic databases and the reference lists of key articles were searched in August 2005. The resulting list of articles was assessed by two independent reviewers according to pre-determined selection criteria and a final list of articles for review was created. The methodological quality of the included articles was assessed and the evidence presented in each of the articles was descriptively analysed. From the 16 included articles, body mass index in a non-athletic population and the presence of calcaneal spur were the two factors found to have an association with CPHP. Increased weight in a non athletic population, increased age, decreased ankle dorsiflexion, decreased first metatarsophalangeal joint extension and prolonged standing all demonstrated some evidence of an association with CPHP. Evidence for static foot posture and dynamic foot motion was inconclusive and height, weight and BMI in an athletic population were not associated with CPHP. The findings of this review should be used to guide the focus of prospective cohort studies, the results of which would ultimately provide a list of risk factors for CPHP. Such a list is essential in the development of new and improved preventative and treatment strategies for CPHP.