A Body in Motion: Pain in the Foot

By Stacie Lynn Grossfeld, M.D.

A 35-year-old female reader who cross country skis every weekend recently
presented this question:

When I first start my workout the heel of my left foot hurts. It is a sharp stabbing pain that tends to get less painful as I warm up. I notice that if I stop at the warming hut for 15 to 20 minutes and stand back up from a sitting position the pain is present. Again, as I start to ski the pain goes away. I also have noticed that when I get out of bed in the morning the pain is very intense and sharp but as I get going the pain lessens. What do you think is going on?

Cross Country Skier readers may be able to relate to this classic case of plantar fasciitis, an inflammation of the soft tissue that attaches to the heel bone. The plantar fascia is a strip of soft tissue that starts at the heel bone and runs to the bottom of the toes. The inflammation occurs on the undersurface of the heel bone.

The pain is sharp and knife like. Typically plantar faciitis hurts the most when getting out of bed first thing in the morning. Standing up after a long period of sitting will intensify the pain. The plantar fascia tightens while you are sleeping or sitting; standing acutely stretches the inflamed fascia, which results in the pain.

Plantar fasciitis does not go away overnight. I tell my patients it typically takes as long to get over the condition as it has existed. If not treated, the pain can turn into a chronic condition. The longer you go without treatment, the harder it will be to correct the problem.

The good news is that treatment is simple and effective, consisting of stretches, shoe modifications, the use of a night splint and, on occasion, anti inflammatory medications or a cortisone injection.

First line treatment is foot assessment. People with flat feet (pes planus or pronation) are more predisposed towards plantar faciitis and have a difficult time getting over the condition. The flat foot puts undue stress on the bottom of the heel; this irritation causes inflammation which, in turn, makes it difficult to get rid of the problem. Arch supports, purchased at your local running shoe store will help.

The next step is stretching. The stretches should be completed any time you stand up after sitting and before getting out of bed in the morning. Icing the heel two or three times a day for 15 to 20 minutes can also help speed up the healing process. Anti-inflammatory medications may also help, but check with your doctor before starting. Visit www.webmd.com for a guide to appropriate stretches.

At home, wear a shoe with a good built-in arch support. Flip flops are not recommended. A Dansko, Birkenstock or similar clog will work well. Even after the plantar faciitis has cleared up, I recommend continuing to wear a shoe with good arch support. Wait for six months after the pain has stopped before going barefoot. People with plantar fasciitis are prone to relapse.

If these simple measures do not work, the next step in treatment is the use of a night boot. A night boot is worn while sleeping and holds the foot in a neutral position. This keeps the plantar fascia in a stretched position at night, which helps resolve the inflammation.

If none of these solutions help, the next option is a cortisone injection. Cortisone delivers a high dose of an anti-inflammatory medication to a specific area. An injection, however, can cause the fatty tissue over the heel to atrophy. This causes a new and different problem to treat. Injections should be used only when all other treatment fails. Surgical treatment and the use of ultrasound wave therapy have mixed results.

If your heel is giving you discomfort, this information and a trip to your local physician should be able to help get you skiing pain free.