June 2014

Patient Perspective: Walking 600 miles is tough; plantar fasciitis is tougher

9_FA_patient_perspBy Laura Potts

In 2008 I walked the 500-mile Camino de Santiago, the medieval pilgrimage route through northern Spain leading to the Cathedral of Santiago de Compostela. It was my first long distance walk, and because I completed it without injury, pain, or a blister, I fancied myself a walking superhero, immune to suffering or discomfort. I had trained diligently for the trek, starting with short walks, and, over the course of months, worked up to daily walks of eight miles, with weekend walks of 12 to 18 miles.

The experience was so enjoyable that I returned to Spain twice in the following two years and walked similar routes. This fueled my feeling of invincibility. So, in early 2012, when I found myself with a five-week window of time, I took the opportunity to return to Spain to walk the longer, and arguably more challenging, 650-mile route from Seville in the south to Santiago in the north. Due to little planning time and bad weather, I didn’t have an opportunity for adequate training. Thus, I arrived in Spain with just a handful of short walks under my belt, the longest topping out at 12 miles.

LER-Resource-Guide-Products-Plantar-Fasciitis

I set out on my first day with great enthusiasm and vigor. The first week went well, until I got a couple of painful blisters. It was during the second week that I developed discomfort in my left heel. I continued walking, averaging about 18 miles each day, and the discomfort worsened into strong pain. Each day started out about the same; in the early morning, the heel was very painful, but after about an hour of walking, it subsided somewhat and I continued on throughout the day.

During previous treks there were days when I felt energetic enough to walk a few miles longer than I’d planned, but this time I was ready to stop even before reaching my planned rest point for each night. The last few miles were a struggle as I walked with fairly severe pain. Because I wore the same boots and socks as I had on previous treks, and carried the same weight, I attributed the pain to a lack of preparation and training, combined with many miles on the paved roads and stone paths that made up this route.

Other experienced walkers whom I met also complained of aches and pains that they had not experienced in previous treks. At this point, I considered my heel pain a consequence of walking on hard surfaces. I imagined that once I finished my walk, returned home, and rested for a few days, the pain would disappear. Foolishly, it didn’t occur to me that continued, strenuous walking might exacerbate the problem. I persevered, with pain, and completed the journey in five weeks.

Rest, but no relief

I returned home and rested for three or four days but, much to my dismay, the pain did not subside. It was horrendous, especially in the morning as I hobbled through the house. I had prescheduled a full-body massage that I had intended to be a relaxing treat after my tough walk. I tried to turn it into an opportunity for a cure and asked the massage therapist to see what she could do for my heel. She tried manipulating the heel, but it was so tender that I couldn’t bear it. I was beginning to realize that I had a problem that might not disappear on its own.

I recalled runner friends speaking of plantar fasciitis and I did a bit of Internet research. My situation (female, aged 47 years, walking long distances on hard surfaces, sudden change in activity, and overuse) and symptoms (heel pain and first steps in the morning were the worst) seemed to tick all of the boxes. To my great dismay, I read that recovery could take months, if not a year. During this time, I had back-to-back house guests for two weeks; therefore, I didn’t get to a doctor until about three weeks after my return home (about six weeks after the initial injury).

Having relocated some months before to Cambridge, UK, I made my first visit to my assigned general practitioner through the UK’s National Health Service (NHS). After the consultation, she diagnosed plantar fasciitis, gave me a printout of exercises, and reiterated that it could take months to heal. She also encouraged me to stay off my feet as much as possible. I asked about physical therapy and she suggested I phone either the NHS physical therapy self-referral service or a private physical therapist. This NHS service is primarily for patients with long-term conditions and for those who have a diagnosis from their general practitioner for a treatable condition. As I understand it, initial consultations for physical therapy through the NHS are often done by telephone interview with some follow-ups for more severe conditions warranting in-person visits.

The physical therapist I spoke with conducted a 45-minute telephone interview, and, as a follow-up, sent me some additional exercises. He also suggested freezing a water bottle and rolling my foot over it for some comfort. He advised that I phone back for a follow-up if there was no improvement in six to eight weeks.

Slow going

The author after arriving in Santiago at the end of her 650- mile walk.

The author after arriving in Santiago at the end of her 650- mile walk.

Because I wasn’t working at the time, I had the luxury of staying off my feet as recommended by both the gener­al practitioner and physical therapist. Being so idle, however, was difficult for me, as I had gone from walking 18 miles a day to sitting on a sofa. I did my exercises twice a day with gusto, hoping for a quick recovery. Throughout the day, when walking up stairs I would stop and do additional stretches by hanging my heels down below the step. I did foot flexes throughout the day, and picked up pens with my toes. As I watched TV or read I rolled my foot on a tennis ball or frozen water bottle. I was very eager to heal but it was slow going. The only immediate improvement I noticed was when I did the foot flexes in bed in the morning before taking my first steps. This simple practice definitely made getting up much less excruciating.

Although neither the doctor nor the physical therapist suggested orthotic devices, I took matters into my own hands. As I was spending so much time at home, I put a pair of green Superfeet insoles into my house slippers for extra shock absorption. I tried a variety of footwear and insole combinations. Oddly, the most comfortable for me was wearing an old pair of Naturalizer Mary Jane-style shoes with store-bought inserts (Dr. Scholl’s Pain Relief Orthotics for Heel).

The comfort was relative. Before the injury, I had always gone on foot to run errands, yet afterwards, walking on the beautiful, yet painfully hard, stone surfaces of the sidewalks and streets of Cambridge became a nightmare. I did walk a bit, but I planned routes through parks so I could get some relief by walking in the grass or on a dirt path. I could notice a substantial difference in my level of pain depending on the surface.

Two months after the initial injury, apart from some relief in the early morning pain, I felt there had been no improvement. I struggled with my sedentary lifestyle. I was gaining weight and began to feel somewhat depressed, mainly with the notion that this situation could last for an entire year. Although I still had a significant degree of pain when walking, I increased my level of activity. I did volunteer work that required standing for a few hours at a time. I noticed then that standing was not nearly as painful as walking. I went through with a previously planned sightseeing trip to Budapest, but when I think back on it, I recall not only the beautiful sights, but how painful it was to get around. I used every mode of transport available to avoid extra steps, on some occasions even taking a tram just one or two blocks to avoid having to walk those few steps.

All along, I continued with the exercises. I probably should have talked to, or better yet, visited, the physical therapist, but I felt that there was nothing he could do. The general practitioner had not given me a precise timeline for recovery but indicated that it could be several months. And she and the physical therapist had emphasized that staying off of the foot as much as possible would be most beneficial. I was unhappily resigned to the fact that the healing process required time.

From pain to discomfort

Three or four months after the injury, I became increasingly more active and began to feel that the pain might have diminished somewhat, or that I could be on my feet for longer periods of time without increased pain. Five months on, I had moderate pain but was beginning to feel optimistic that it might eventually heal. At six months, some walking buddies asked me to join them for a three-mile walk. It was the first time that I had gone for a walk for the sake of walking, or exercise, rather than for necessity. At that time, there was more discomfort than pain. From then onward it continued to improve.

In retrospect, I feel I should have been more assertive in conveying my concerns to my clinicians during my recovery. I was unfamiliar with treatment practices within the NHS. As the physical therapy consultation was merely a telephone interview, I didn’t expect much more out of a follow-up. In the US, where I am more familiar with my healthcare providers, I may have contacted them to schedule another appointment, press them for additional treatment, or, at the very least, express my concern about a lack of improvement. At the time, it seemed as if it would never improve, but, had I spoken to either the general practitioner or the physical therapist and gotten any feedback or reassurance that I was on the right path, it may have made me feel less frustrated.

Recovered, but wary

Now, two years later, I feel recovered. Sometimes, after a long day on my feet, or after walking on hard surfaces, I might feel a slight twinge that, real or imagined, never materializes into anything. I no longer do all of the daily exercises, although I do continue to flex my feet 10 times before getting out of bed each morning and, when going upstairs, I sometimes stop and hang my heel down for a stretch. I have not resumed a regular walking schedule, and the idea of another long distance walk frightens me.

I suspect my plantar fasciitis was caused by walking long distances for five weeks with insufficient preparation. I imagine if I trained carefully and worked up to long distances, it would not recur, yet it is still a daunting proposition for me as I remember the six months of pain and inactivity. Walking 600 miles is tough, yet not as tough as sitting on a sofa for six months.

Laura Potts is an elementary school teacher living in Cambridge, UK.

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