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Michael Smith, MD (Host): Persistent pain in the bottom of your heel could be plantar fasciitis, inflammation of the thick ligament that connects your heel to your toes. Welcome to The GW Hospital HealthCast. I’m Dr. Mike Smith. And today’s topic: Finding Relief from Plantar Fasciitis. My guests are Drs. Arnold Ravick and Dr. Sheldon Laps. Both guests are Assistant Clinical Professors of Surgery at The George Washington University School of Medicine and Health Sciences. Doctors, welcome to the show.

Sheldon Laps, DPM (Guest): Thank you.

Arnold Ravick, DPM (Guest): Nice to be here.

Host: So, Dr. Ravick, let’s start with you. How about a nice lesson on exactly what is plantar fasciitis and why does it happen?

Dr. Ravick: It’s really involved. I think people simplify it. I think one of the things that people miss is there are a lot for causes for it. Some people, it’s overweight. A lot of people, it is actually overuse. And I think that comes a lot from the lifestyle of our society which is we sit a lot and then we are very active. We run, we walk, we exercise and the band which is the fascia can’t take that and tightens up and it’s the tightening that often pulls away at the bone causing heel spurs and the chronic pain which you get with plantar fasciitis.

Host: Yeah, you mentioned a couple of causes. There are risk factors. Are there any others, other than say being overweight?

Dr. Ravick: Again, it’s overuse with physical activity. I also think there are different types of plantar fasciitis. Everybody thinks it’s the exact same thing. I sort of separate it into what I call a fat pad problem which is almost like the bruised heel feeling. So, the padding on the bottom of the heel thins and that’s usually with aging or it can be being overweight and the smashing down on the fat pad causes this chronic bruising. That’s different than the tightness plantar fascia type which again, I think is the chronic type of overuse and the band loses its elasticity and gets too tight. And then there are some people that actually get acute plantar fasciitis where they actually tear some of the fibers. So, there are a lot of different ways. Usually it’s physical activity, but sometimes it’s inactivity. It’s an odd kind of phenomenon where people feel worse again first thing in the morning, they feel worse after they sit at work all day and that tightness flares up and as soon as they get up, it starts to tear and that’s where they get the pain from.

Host: Got you. So, Dr. Laps, I went on Google and I did a Google keyword search and I found that a lot of people when searching for plantar fasciitis are asking the questions are there home remedies for taking care of this. I’d like to ask you about that and how in general, are mild cases treated?

Dr. Laps: So, one of the common denominators we see with plantar fasciitis is patients that have a very tight Achilles tendon or heel cord. We also see patients that have – the majority of patients are flexible and have a flat foot. So, two of the mainstays of treatment that I use are aggressive stretching of the Achilles tendon as well as support of the arch. We can stretch the Achilles tendon as simply as keeping a towel next to your bed and wrapping a towel around the ball of your foot and basically bending your foot up or bending your toes to your nose, holding that stretch for about 30 seconds a couple of times in the morning as well as support for the arch. We deal a lot with fabrication of custom molded orthotics to support the arch and stabilize the flatfoot and support the plantar fascia.

Host: Yeah, I’d like to get into the orthotics coming up in a bit. I want to go back to this idea of these more mild cases, home remedies and thank you, that’s a great suggestion about how to stretch. But Dr. Ravick, what if somebody doesn’t do anything? What if they just try to ignore it, it’s left untreated? Are there complications from this?

Dr. Ravick: There can be. One of the things I failed to mention is one of the predisposing factors would be shoes. One of the theories is people have changed from more formal attire, we don’t wear coats and ties as much anymore, women don’t dress in heels as much anymore and they wear floppy shoes, flip flops, Toms, things that are very lightweight and flexible lacking support which leads to this. The sequalae or the problem that can come from it is one you can get a bone spur and then you can actually you can fracture the bone spur or need surgery for the bone spur in the worst-case scenario. I would say the worst thing that really happens though is it becomes very chronic. Most people will have this without any treatment for six months to a year, but you do hear of people and if you Googled you will hear lots of them that have it for a lifetime. I mean they get it and they just never get rid of it. And I think that’s the danger of really doing nothing or trying to handle it yourself in a way that I would consider not scientific. In other words, they don’t keep – they keep jumping from method to method. They stretch, they change their shoe, they do everything in a month, nothing works and then they basically give up and go back to the same behavior.

Host: Yeah. So, in this kind of situation where somebody is maybe dealing with this off and on, maybe even kind of chronically, Dr. Ravick, at what point should somebody seek help from a professional like yourself?

Dr. Ravick: I think sooner is better. I mean most people, if it’s a mild case where it feels just sore, it doesn’t feel sore all the time, and you kind of get two versions of that. One, it’s sore with a lot of activity. In other words, I just had somebody yesterday tell me when they walk over their 10,000 steps per day on their Fit Bit, that’s when it hurts. And I said well that’s because it has built up the tightness over time and we can mitigate that by doing certain things, stretching being one of them. The other kind of person is it hurts all the time when they get up, it hurts all throughout the day. If it is getting to that point, you should seek care. The sooner you get care, the faster it goes away. The sooner we catch it, the easier it is to get rid of. I mean you get a lot of people, I’m sure Dr. Laps has the same experience, that when they come in and I’ve had it for years, you are looking at a really long road to get better.

Host: Yeah, so Dr. Laps, if somebody were to come in to your clinic, maybe the pain is constant, it’s definitely a chronic situation; at what point do we call this severe plantar fasciitis and how do we treat that?

Dr. Laps: Well we treat it multiple ways. If it’s acute, we initially try to get rid of the acute pain and that can be done as simply as putting the patient in a protective boot, a CAM walker, a compression type boot to offload pressure from the bottom of the heel, oral anti-inflammatories simple as over-the-counter ibuprofen or Advil. I like ice massage as a terrific therapy. We have patients take a bottle of water and freeze it, take it out of the freezer, put it down on the floor, roll their arch along the ice water bottle a couple of times a day for five to ten minutes to reduce inflammation at the heel.

Host: And so, when you apply these types of therapies, what’s the outcome for most people? Does this resolve the issue for most people or is it more common for this to kind of come and go for the average patient?

Dr. Laps: Well it really depends on the patient. We have the patients that are the athletic patient that come in with heel pain because they’ve done repetitive activities. They’ve jogged every single day, or they’ve done elliptical machine everyday or they’ve done extended walking on the treadmill on a daily basis. And it may be as simple as alternating their exercise, alternating their activity. And then we have patients that have just constant pain throughout the day. That’s the most or more severe case and that has to be treated more aggressively with as I said, sometimes oral anti-inflammatory medications, sometimes steroid or cortisone injections, offloading them, getting them into a more supportive shoe, trying to change their lifestyle with regards to their shoe gear. Their shoe gear is very, very important. Particularly in the spring and summer with patients wearing flip flops and clogs and non-supportive shoes. Try to get them into a more supportive shoe environment.

Host: Right, right. And of course, where I’m at, in south Florida, we are wearing flip flops all year long. It’s not just during the summer months as well so I think that might be something to keep in mind is like where people are living and where they are coming from in that case. But so, let’s end this way with a nice summary. I’ll give each one of you an opportunity to speak here and we will start with Dr. Ravick. Dr. Ravick, what would you like the listeners to know about plantar fasciitis?

Dr. Ravick: I think it is treatable. I tell patients all the time that anything that has a lot of different solutions, there is usually no great solution, because we would all be using the great solution, it would get around and it would be easy to use. I think it’s important to figure out what the causative reason is. In other words, is it overuse like Dr. Laps said? Do we need to cross train? I differ from him a little bit. I actually like heat on the chronic one, a chronic patient, because I think it’s gotten too tight, we need to use heat and we need to stretch it, we need to loosen it.

There are a lot of new therapies though. You asked about that a little bit. We use a laser, there’s electrical stim, there’s shockwave therapy. There are a lot of newer things that have come on and those are usually used more – on the more extreme cases. The easy ones are change your shoes, do your stretching, and look at your activity and those really go a long way to help. And one quick tip, where you mentioned the chronic flip flop use. Tell them to use a wedge, something thicker, more supportive. I tell women to get into a higher heel. I know that sounds kind of crazy coming from me, but it changes the effect of the Achilles and the pressure on the plantar fascia. And there are some simple things you can do, but if you get guidance, I think it will get better a lot faster.

Host: Okay. Dr. Laps, what would you like people to know?

Dr. Laps: Number one, don’t ignore symptoms. If they have significant heel pain or arch pain; see a medical professional. Initiate treatment as soon as possible, try to avoid repetitive stress. Don’t do the same activity two days in a row whether it’s lifting weights, running, walking. And the old mantra used to be, exercise through pain or no gain without pain and I believe people should seek medical care as soon as they have any type of constant discomfort and not try to exercise or run through the pain.

Host: Doctors, I want to thank you for the work that you are doing and thank you for coming on the show today. You’re listening to The GW Hospital HealthCast. For more information, go to www.gwdocs.com, that’s www.gwdocs.com. I’m Dr. Mike Smith. Thanks for listening.