Description

Plantar fasciitis is the most common cause of heel pain. Pain from plantar fasciitis is often most noticeable during the first few steps after getting out of bed in the morning. The plantar fascia is a thick band of tissue in the sole of the foot.

Anatomy

The plantar fascia is a dense fibrous aponeurosis originating from the plantar-medial aspect of the calcaneal tuberosity. Three distinct bands have been described – medial, central and lateral – with the central band being the strongest, thickest, and also most commonly involved in plantar fasciitis. Distallly, the plantar fascia divides into five slips onto the proximal phalanges terminating as the flexor sheaths of the toes.

Causes

Plantar Fasciitis means inflammation of the fascia at the bottom of the foot. This is caused by microtearing at the origin of the plantar fascia on the heel bone (calcaneus) which can occur with repetitive loading. This microtearing leads to an inflammatory response (healing response) which produces the pain.

Risk factors for plantar fasciitis include: excessive standing, increased body weight, increasing age, a change in activity level, and a stiff calf muscle.

Plantar Fasciitis is not caused by heel spurs. Weight-bearing x-rays of the foot will often demonstrate a calcaneal heel spur. Essentially, the same traction phenomena that causes overloading of the plantar fascia with microtearing may cause excessive bone formation, in the form of a calcaneal heel spur. However, the presence of a heel spur does NOT directly correlate with symptoms. Many patients have heel spurs on x-rays and are asymptomatic, whereas, many patients have significant plantar fasciitis and do not demonstrate a heel spur on plain x-ray.

Symptoms

• Pain to the bottom of the foot or heel generally felt as sharp and sudden
• Pain greatest in the first steps of the day or after rest
• Pain to touching of the heel bone (calcaneus) mostly on the inner (medial) side

Treatment

Non-Surgical Treatment
There is excellent non-operative treatment available for plantar fasciitis. The vast majority of patients will have their symptoms resolve with non-operative treatment. The main elements of non-operative treatment are as follows:

• Activity Modification: Any activity that has recently been started, such as a new running routine or a new exercise at the gym, that may have increased loading through the heel area, should be stopped on a temporary basis until the symptoms have resolved. At that point, these activities can be gradually started again. Also, any activity changes (ex. sitting more) that will limit the amount of time a patient is on their feet each day may be helpful.
• Weight Loss: If the patient is carrying significant extra weight, losing weight can be very helpful in improving the symptoms associated with plantar fasciitis.
• Heat and Ice can be applied to reduce pain and swelling. One common advice is to use a frozen water bottle and roll the foot along the bottle to both apply ice and stretch the bottom of the foot.
• Nonsteroidal anti-inflammatory medicines. Drugs like ibuprofen and naproxen reduce pain and swelling. Like any over the counter medication, please read and follow the label. If you have a history of stomach ulcers, bleeding ulcers or heart conditions, these medications might not be right for you. Consult your physician if you have any questions.
• Physiotherapy. Under the direction of an experienced physiotherapists, many patients do well by:
  • Calf Stretching: Regular daily calf stretching performed over a 6 to 8-week period will alleviate plantar fasciitis in almost 90% of patients. The stretching should be performed for a total of 3 minutes per day minimum 3 times a day. It should be done with the knee straight so that the gastrocnemius is stretched, as this is the muscle that is tight.
  • Plantar Fascia Specific Stretch: Equally good results can be obtained with a formal plantar fascia stretch. Plantar fascia specific stretching has been found to provide symptomatic relief for the majority of patients. This is done in a seated position, and includes crossing the affected leg over the other leg. Using the hand on your affected side, take hold of your affected foot and pull your toes back towards your shin. The stretch position should be held for 10 seconds and repeated 10 times. The timing of when this is performed is important. It should be done prior to the first step in the morning and during the day before standing after prolonged inactivity. Most patients perform the stretch 4-5 times during the day for the first month, and then on a semi-regular basis (3-4 times per week). Decreased pain, with improvement of about 25-50% is expected at 6 weeks, with resolution of symptoms over 3-6 months. With resolution of the heel pain symptoms, it is important to continue calf stretching and plantar fascia stretching on a semi-regular basis (3-4 times per week), so as to minimize the risk of recurrence. These treatment modalities treat the symptoms, but do not fully address the underlying biomechanical predisposing factors. Therefore, ongoing management of this condition is essential!
• Bracing
  • Orthotics: Custom soft orthotics with the addition of a heel cushion and an accommodating arch support has proven to be quite helpful in the management of plantar fascia symptoms.
  • Plantar Fascia Night Splint: A night splint, which keeps the ankle in a neutral position (right angle) while the patient sleeps, can be very helpful in alleviating the significant morning symptoms.
• Topical anti-inflammatories
  • Compound Topical Creams
  • Voltaren
• Injections
  • Steroid (Depo-Medrol, Kenalog, Decadron)
  • Blood (PRP – Platelet Rich Plasma)

Surgical Treatment
About 90% of patients will respond to appropriate non-operative treatment measures over a period of 3-6 months. Surgery is a treatment option for patients with persistent symptoms, but is NOT recommended unless a patient has failed a minimum of 6-9 months of appropriate non-operative treatment. There are a number of reasons why surgery is not immediately entertained, including:

1. Non-operative treatment when performed appropriately has a high rate of success.
2. Recovery from any foot surgery often takes longer than patients expect
3. Complications following this type of surgery can and DO occur