As a Podiatrist one of the most common conditions we treat is heel pain. Whether it be Achilles tendonitis or plantar fasciitis the success of patient recovery is highly dependent on the duration of their symptoms and the health of the connective tissue associated.
Although I wish every patient presented to my office at the initial onset of symptoms unfortunately this is usually not the case. The average patient often presents after experiencing heel pain for 3 months, 6 months or sometimes over a year.
The patient may have tried the occasional over the counter insert, a little stretching and maybe even icing, however their lack of consistency has provided little relief. So now they have turned to me to give them that quick fix, immediate relief in one visit.
It’s time to break the news to them that this is not possible….
One of the biggest misconceptions among patients (and I’d have to argue also among professionals) is regarding how connective tissue gets injured and the consideration of collagen health in soft tissue injury. You can correct the muscle imbalances and movement patterns however attention must still be directed at the injuries connective tissue and collagen structure.
We are going to focus primarily on the connective tissue of the foot as it is uniquely associated with a majority of impact forces during closed chain movements.
Acute vs. Chronic Injury
With each step we take 1 -1.5 x our body weight in impact forces is entering the foot / body. Perceived as vibrations which are damped (absorbed) through isometric contractions, these impact forces are stored as potential energy in our connective tissue (tendons, fascia). To properly absorb and store impact forces as energy our connective tissue must be under a state of tension and have a certain degree of elasticity.
I often associated our connective tissue to a rubber band. When we load impact forces and store them as potential energy this would be equivalent to stretching the rubber band.
Now what happens when we do not have tensile stiffness and elasticity this would be analogous to a dried out rubber band. When you load the rubber band by pulling it you eventually reach a “fatigue point” and the rubber band breaks. This is analogous to our connective tissue micro-tearing at a certain fatigue point.
Micro-tears in fitness is often associated with the overload principle, strength gains and muscle hypertrophy. When we strength train (especially when doing eccentrics) we micro-tear the muscle fibers which are repaired created larger muscle fibers. All positives. However with connective tissue it’s not so positive.
In connective tissue (tendons / fascia) when there is not enough elasticity in the tissue, micro-tears occur. These connective tissue micro-tears are repaired with a different type of collagen than what the connective tissue is primarily composed of (Type III vs. Type I).
Type III collagen is stiffer and less elastic then Type I collagen, and is laid down in a haphazard manner. In addition, all micro-tears whether it be in muscle or connective tissue is associated with inflammation. Persistent inflammation around connective tissue whether it be bone or tendon creates thinning of tissue.
This micro-tear, inflammatory cycle which begins as an acute stress to the tissue now becomes a perpetual cycle and we start to hit a road block in the tissue repair process. The longer the patient’s connective tissue sits in this micro-tear / inflammatory cycle the more the tissue begins to change composition and the harder it is to establish any long lasting pain relief.
Enter chronic heel pain. These are the patients who do not respond to just muscle balancing and corrective exercise.
So what can this patient with chronic connective tissue pain do?
Two-Step Recovery Process
Whether I am treating acute or chronic heel pain I approach tissue recovery in two steps:
1st – Connective Tissue Health
2nd – Muscle Imbalances or Connective Tissue Stress
In connective tissue health, if we are in a chronic state my goal is to drop the patient’s inflammation as quickly as possible. Although corticosteroid injections are of great debate with conflicting research, I have seen the greatest and fastest results when I incorporate them into my patient recovery (especially in the acute patient). I am quick to give injections in my acute patients to get them out of this inflammatory cycle and have had great success with this approach.
Being able to drop the inflammatory process and allow the tissue to move forward in the repair process is a necessary step.
If steroid injections are not your cup of tea there are other options that are also available including:
- oral anti-inflammatories (my go-to is Mobic)
- topical anti-inflammatories
- ice (I never only do ice)
- Class IV laser
- Supplements such as bromelain, quercetin (or eat pineapples, tart cherry juice)
If you are not in the acute state > 6 months then the above options may not be as effective. The longer the chronic state of tissue injury the harder it is to bring it back to it’s youthful state.
In the patient that is not responding to inflammatory treatment and is in the chronic state then we need to consider options to get the connective tissue back to it’s pre-injury state.
This is where we start to consider:
- PRP (platelet rich plasma),
- bone marrow aspirate,
- amniotic membrane or
- procedures such as Tenex and Topaz.
The way that the above procedures work is by creating fresh tissue injury and restarting the inflammatory / injury cascade. The above procedures must be followed by limited activity / immobilization and no NSAIDs can be taken as in this case the inflammation is good.
Once the connective tissue state is dropped down to a non-inflaammatory state (acute) or re-injured / inflamed (chronic) then it is time to start focusing on the stress that is being placed on the connective tissue.
At this same time all patients are assessed for biomechanical imbalances, compensation patterns and movement dysfunction which is driving the faulty loading of the connective tissue. During this part of the recovery process I am often incorporating the barefoot science of BarefootRx and emphasize the importance of how the body is designed to load / unload impact forces and react to movement – from the ground up!
Integrating into Practice
The next time you have a patient or client with heel pain, or really any connective tissue injury consider the duration of symptoms, state of the connective tissue and stress being placed on the tissue.
All to often I see a patient addressing only inflammation, and not the stress being placed on the tissue or vice versa. Both must be considered to for the most successful patient recovery.
Finally, I’m often asked patients how quickly they can recover from their heel pain. I often give patients the general guidelines:
Heel pain 1 month = Recovery 2 weeks
Heel pain 3 months = Recovery 4 weeks
Heel pain 1 year = Recovery 3 months
*Please note that the above is not inclusive of all patients experiencing heel pain. All treatment protocols include exceptions in which patients do not respond and require surgical management. The above is intended to guide professionals and stimulate thought processes toward current patient protocol.*
Dr Emily Splichal
To learn more about EBFA’s BarefootRx Program please visit www.ebfafitness.com