Why is the pain worst when you take your first steps?
This sign is so characteristic that the diagnosis is often suggested even before examination. Overnight or during long periods of sitting, the fascia is in a shortened position and is partially “grabbed” by new, still immature fibers. The first steps sharply stretch it, these fibers tear - hence the sharp, shooting pain in the heel. After a few minutes of walking, the tissue warms up, the pain subsides, and the person decides that everything is in order. In the evening, after the day's workload, the pain returns - already dull and aching.
- Sharp pain when taking the first steps after sleep or after sitting for a long time
- Pain relief after 5–15 minutes of walking
- Return of pain towards the end of the day and after prolonged exercise
- Painful point when pressing on the inside of the heel from below
- Increased pain when climbing stairs and walking barefoot on hard floors
- Lameness, trying to spare the heel and transfer weight to the toe
The practical conclusion from this mechanism is more important than it seems: the pain subsides not because it has become better, but because the tissue has warmed up. You can’t focus on “it doesn’t hurt after warming up” as a sign of recovery - this way you can continue the load that maintains inflammation for months. A more honest indicator of dynamics is how severe the pain is during the first steps in the morning, and it is worth tracking this, week after week. If the morning pain gradually decreases, the treatment works even if the heel still hurts in the evening.
What overloads the fascia
The plantar fascia works like a bowstring: it stretches with every step and holds the arch of the foot. Problems begin where the load on that string exceeds its ability to recover between loads. Hence the list of factors - all of them either increase tension or reduce recovery time.
- Excess weight is one of the most significant factors; every extra kilogram increases the load with every step
- Prolonged standing and walking on hard surfaces at work
- A sharp increase in running volumes or a return to training after a break
- Flat feet, as well as, conversely, high arches
- Short and tight calf muscles and Achilles tendons are a very common and easily remediable cause.
- Shoes without support: worn out, completely flat, house slippers on hard floors
- Age 40–60 years, when the elasticity of the fascia decreases
- Diabetes mellitus and a number of metabolic disorders
Pay attention to the point about the calf muscles: limited mobility in the ankle joint increases the tension of the fascia with each step. This is why calf stretching is included in the treatment of heel pain, although it hurts in the wrong place.
Most often, fasciitis begins not with one factor, but with their coincidence: several kilograms gained over the winter, a new job with being on your feet all day, and the decision to suddenly start running. Each circumstance individually could go unnoticed; together they exceed the safety margin of the fabric. Therefore, it makes sense to analyze the reasons not as a search for the only culprit, but as compiling a list of what can be reduced: even a partial reduction in the load on several points at once gives more than a heroic fight against one.
Survey
- Осмотр и пальпация: определение болезненной точки в области прикрепления фасции, оценка свода стопы, подвижности голеностопа и длины икроножных мышц.
- УЗИ подошвенной фасции — показывает утолщение и изменения в зоне прикрепления, безопасно и доступно, подходит и для контроля динамики.
- Рентгенография пяточной кости — выполняется прежде всего для исключения перелома, опухоли и других костных причин; обнаруженная шпора не определяет лечение.
- МРТ — при нетипичной картине, подозрении на стрессовый перелом, разрыв фасции или ущемление нерва.
- Анализы крови — при подозрении на воспалительное заболевание суставов, особенно у молодых пациентов с болью в пятке и скованностью в спине.
There are conditions that masquerade as plantar fasciitis and require completely different treatment: a stress fracture of the calcaneus during running, pinched nerves with burning and numbness along the sole, inflammation of the tendon attachments with spondyloarthritis, atrophy of the heel fat pad in the elderly, less commonly, a cyst or bone tumor. Night pain at rest, numbness and tingling, pain in the back and joints in a young man, as well as the complete lack of effect from stretching and unloading for several months should be alarming.
Exercise: The Key to Treatment
Stretching the plantar fascia and calf muscles is the method with the most convincing results for this problem. It's free, safe and works, but it requires one thing: regularity over months, not two weeks. You need to do the exercises every day, and do the first stretch before getting out of bed.
- Растяжка фасции сидя: закинуть стопу на противоположное колено, одной рукой потянуть пальцы стопы на себя до ощущения натяжения по подошве, удерживать 20–30 секунд. Повторить 3 раза, до 3 подходов в день, обязательно утром до первых шагов.
- Растяжка икроножной мышцы у стены: упереться руками в стену, больную ногу отставить назад прямой, пятку прижать к полу, подать таз вперёд. Удерживать 30 секунд, повторить 3 раза.
- Растяжка камбаловидной мышцы: то же положение, но задняя нога слегка согнута в колене — растяжение ощущается ниже, ближе к ахиллову сухожилию.
- Прокатывание стопы по бутылке с холодной водой или мячику 5–10 минут вечером — снимает напряжение и уменьшает боль.
- Захват пальцами стопы полотенца и сбор его с пола — укрепление мелких мышц стопы.
- Подъёмы на носок с опущенной за край ступеньки пяткой, медленно, с постепенным увеличением количества — упражнение на укрепление, добавляется, когда острая боль стихла.
A mistake that nullifies the effect is to do exercises only when it hurts. The fascia is rebuilt slowly; the program is continued for several more weeks after the pain disappears, otherwise a relapse is very likely.
What else helps and what is overrated
- Unloading: temporary reduction in running, long walking and standing; replacing the impact of cycling or swimming
- Shoes with shock-absorbing soles and a slight heel rise; avoiding walking barefoot on hard floors and wearing flat slippers at home
- Orthopedic insoles and heel pads - reduce fascial tension; for severe flat feet, individual
- Weight loss has a stronger effect on the outcome than most procedures
- Night orthoses, which hold the foot in a neutral position, help specifically with morning pain by relieving nighttime shortening of the fascia
- Shock wave therapy is a method with a proven effect in chronic pain, when exercises and unloading for several months have not produced results.
- Taping - temporary support, useful during exercise and sports
- Injections of glucocorticoids - provide quick, but often temporary relief; are performed limitedly and according to indications, since they are associated with the risk of fascia rupture and thinning of the fat pad of the heel
- Surgical treatment is a last resort when long-term conservative treatment is ineffective; in this case, the task of the operation is related to the fascia, and not to the removal of a bone outgrowth
It is also worth calibrating the procedure, because in practice it is often reversed. They always start with free and safe measures - stretching, unloading, changing shoes, working on weight; they are given a minimum of 2–3 months, not two weeks. Only if this was not enough, shock wave therapy is discussed, and only then injections. The reverse sequence, when treatment begins with an injection in the heel, is common and usually leads to the return of pain after a few months: the cause of the overload has not gone away, but the time during which the fascia could have been rebuilt has been spent.
How long does it take to treat and how to avoid relapse
- У большинства людей боль значительно уменьшается за 3–6 месяцев регулярной растяжки и разгрузки; у части процесс занимает до года.
- Улучшение идёт неравномерно: периоды затишья чередуются с ухудшениями после нагрузки — это нормальное течение, а не признак неудачи.
- Оценивать эффект имеет смысл по утренней боли: она уменьшается раньше, чем вечерняя.
- Возвращение к бегу — постепенное, с увеличением объёма не более чем на 10% в неделю и обязательной разминкой.
- Растяжку икроножных мышц стоит оставить в постоянной привычке — это самая простая профилактика рецидива.
- Регулярно менять изношенную обувь и не тренироваться в кроссовках с продавленной подошвой.
A simple organizational technique also helps: tie exercises to existing habits, and not to a separate “treatment time.” Stretching in bed before the first step, stretching against the wall while brushing your teeth, rolling your foot on a ball in the evening in front of the TV - three points in the day that do not require special time to devote to them. This is how the program survives into the third month, and does not end in the second week with the initial enthusiasm.
