Should I rest or just keep plugging along? If you have plantar fasciitis or heel pain from achilles tendinitis, it may feel like you are being stopped in your tracks. At first with these conditions, the pain is acute, sharp, stabbing. It gets your attention. It makes you limp. It makes you feel … old all of a sudden. As the initial inflammatory phase begins to wain, we usually see that the pain is more described as throbbing, aching, nagging, or just stiff and tight.
In the initial phases of this condition, you may not be wanting to head out onto the path or sidewalk and run. You may feel like you can’t get on the treadmill. You may feel like you need to have your foot up. This isn’t a bad thing. Especially in cases where you don’t yet know whether you have plantar fasciitis. Because in these instances, you may still have a stress fracture or another injury. So the fact that your body and pain feedback slow you down is helpful. This helps to reduce the likelihood of further damage - whether it be to your stress fracture or your plantar fascia.
That being said, you must get up and function again sometime, right? So how do you know when to do this? It can be hard to recommend in these cases as every patient and person experiences and responds to pain differently. Some people push through, pushing too hard and causing damage. Some others curl up and stop everything, but then don’t get back to it.
If you are being treated by a Podiatric physician, their recommendations can help to guide you down the right path (or trail, pun intended). We can help to determine how much activity is OK and what should perhaps be avoided or put off for a while.
With plantar fasciitis especially, unless a tear is suspected, your activities should remain relatively constant. If you walk, keep walking, if you run, keep running. You may need to modify your speed, decrease incline (or elevation) or decrease the time you run for. It is also essential to find a terrain that allows some shock absorption (maybe the prairie path instead of the sidewalk). You may need to change up your shoes. Also you will most likely need to add something to your routine before and after your exercise.
We don’t want to let the plantar fascia get tighter and tighter, as this gets more and more difficult than to stretch back out to a more functional capacity. If you don’t use it you lose it, to some extent.
So when you are being treated for plantar fasciitis and/or achilles tendinitis and it is not suspected that you have a tear, your doctor may recommend that you continue your regular routine or exercise, but with the addition of anti-inflammatories, icing and a GOOD long stretching regimen a few times each day.
Another condition may cause this persistent activity to be more painful and less desirable. As described above, a tear in the plantar fascia or the achilles tendon will often be more painful and will continue to get worse with activity. Their healing can be slowed by excessive motion (ie. Running and excessive walking). Also, a condition called bursitis may be at play. If you have hear of bursitis, you may have heard of it with relation to the hip. Bursae are fluid filled sacks present in many different areas of the body. In the feet, we have an infracalcaneal bursa which lies under the heel bone, right near the plantar fascia. We also have a retrocalcaneal bursa which is behind the heel - in close proximity to the achilles tendon. These bursae can become inflamed when you have plantar fasciitis or achilles tendinitis and while this is a protective mechanism, it can be really painful. This condition tends to get work after the pounding of certain exercises, so low impact may be essential while this component of your condition improves.
If you are being treated for plantar fasciitis and/or achilles tendinitis, and you reach a plateau in your progress, there is more to be considered. If you try to diligently follow your doctor’s orders and feel worse despite this, our worry will be that a tear has developed.
As I said earlier, some people manage and handle pain differently. Some people with a plantar fascia tear are very stoic, or have a ‘high pain tolerance’ where they just go go go despite the pain. So, if your pain is not improved or worsening, we will typically evaluate further. At the first visit for any patient with pain in their heel, x-rays are taken. The x-rays are so helpful to see the bones and joints of the feet. We can make sure that there is no obvious damage to the heel bone and we can see if there are bone spurs present indicating chronic tightness of the achilles/plantar fascia. However, x-rays are not designed to view the soft tissues (tendons and ligaments) in the feet. Ultrasound and MRI are the studies we rely on for this information.
MRI and Ultrasound images are still black and white as X-rays are but we can visualize the tendons and ligaments well and the ‘colors’ if you will that we see can even pick up on inflammation and fluid to certain areas on the foot and ankle.
If we do diagnose a tear with the assistance of tendinitis or plantar fasciitis, rest is usually the next recommendation. Tears of tendons and ligaments heal at a similar rate as bones do, but we have to be very careful how we support these structures during their healing. If a cast is applied for a fracture, it is likely no matter the position of the foot, that fracture will heal pretty well. However, if a ligament or tendon is casted with the foot outside of neutral position, we can set ourselves up for more tightness and stiffness that will later have to be mitigated.
In most cases, if a tear of plantar fascia or achilles tendon is stable, it can be treated with a CAM walker boot, which immobilized the area but has the benefit of being removable (as compared to a cast). That being said, removing the boot should be limited. The more time out of that boot, the more movement on your injured fasciae or tendon that can slow healing, slow your progress.
After plantar fasciitis and achilles tendonitis have resolved (whether with use of brace, boot or cast), a careful transition back to normal routine is critical. Starting the same routine as you had two months prior at the initiation of treatment is a bad idea. Your foot and ankle need a slow transition so that the flexibility and elasticity of the tendons and ligaments can be re-established. The bone needs to strengthen slowly over time to reduce stress fracture. In addition, you gait pattern has likely changed since the onset of your pain. That awkward and sad hobble in the morning may be gone, but your foot and your brain still protect that area.
So in recovering from plantar fasciitis and/or achilles tendinitis, a really great component of your treatment may include physical therapy. PT’s are skilled individuals who assist in you regaining strength, range of motion, flexibility, balance AND they guide you in return to play. This could mean back to soccer for a college athlete -with drills for agility etc, but this can also mean proper walking or running and gait training.
The more we suffer from these pains, the more our gait changes and the more likely that other parts of our foot (or even the other foot) will start to suffer as well. Prompt evaluation and treatment reduces the likelihood of long times away from the things you love to do. So whether to rest or not to rest, let your podiatrist tell you what is right for you. Call for an appointment today!