All You Need To Know About Plantar Fasciitis
What is plantar fasciitis?
Plantar fasciitis is a painful condition that affects the bottom of one’s foot. Also known as a heel spur, it is one of the common causes of heel pain. When there is active inflammation, the right term to use is plantar fasciitis. However, if there is chronic degeneration instead of inflammation, the term plantar fasciosis would be more accurate. Acute plantar fasciitis means that there is inflammation of the origin of the plantar fascia and fascial structures around the area. Plantar fasciitis and fasciosis usually affect only one side, and 30 percent of cases usually have both feet affected.
In this article, we will cover:
- development of plantar fasciitis
- problems caused by plantar fasciitis
- treatment of plantar fasciitis
Which part of the foot does it concern?
Also known as the plantar aponeurosis, the plantar fascia is a thick band of connective tissue. It runs from the calcaneus, which is the front of the heel bone, to the ball of the foot. It is a dense strip of tissue that supports the arch of the foot — similar to the string on an archer’s bow. It is also the source of this painful condition, plantar fasciitis.
Collagen fibres make up the plantar fascia. These fibres are oriented in a lengthwise direction from the heel to toes. It is made up of three separate parts: the medial component which is closest to the big toe, the central component, and the lateral component which is on the little toe side. The largest and most prominent portion is the central component.
Both the Achilles’ tendon and plantar fascia are attached to the calcaneus. Although their connections are separate and they function separately, they have an indirect relationship. If the toes are pulled back in the direction of the face, the plantar fascia tightens up. This position would cause a lot of pain for someone with plantar fasciitis. If force is generated in the Achilles’ tendon, the strain on the plantar fascia increases. This is known as the windlass mechanism. In this article, we will also discuss how this mechanism is used to treat plantar fasciitis through stretching and night splints.
What causes plantar fasciitis?
There are a number of underlying causes that can contribute to the development of plantar fasciitis. It is at times difficult to find the exact reason for heel pain.
As one can probably imagine, a great amount of force — the full weight of the body — is concentrated on the plantar fascia when the foot is on the ground. The plantar fascia is stretched by this force as the arch of the foot attempts to flatten from the weight. This is similar to how the string on a bow is stretched by the force of the bow trying to straighten. This creates stress on the plantar fascia where it is attached to the heel bone. As a result, small tears can form on the fascia. These tears are usually repaired by the body.
As this cycle of injury and repair keeps repeating, a pointed outgrowth of the bone known as a bone spur sometimes forms. This is the body’s response as it tries to firmly attach the fascia to the heel bone. On an X-ray, this would appear as a heel spur. Although bone spurs occur along with plantar fasciitis, they are not the cause of the problem.
As a person ages, the very important fat pad that makes up the fleshy portion of the heel gets thinner and degenerates. This can lead to insufficient padding on the heel. As a result, there will be a reduced amount of shock absorption. These are additional factors that can lead to plantar fasciitis.
Certain doctors feel that the small nerves travelling under the plantar fascia towards the forefoot become irritated and may contribute to the pain. However, studies have shown that the pain from compression of the nerve actually differs from plantar fasciitis pain. In numerous cases, the real source of a painful heel may not be defined clearly.
There are also other factors that may contribute to the development of plantar fasciitis. These include trauma, obesity, poor footwear, weak plantar flexor muscles, excessive foot pronation (flat foot) or other alignment problems in the foot and ankle.
What are the symptoms of plantar fasciitis?
Symptoms of plantar fasciitis include pain along the inner edge of the heel, near the arch of the foot. This pain worsens when weight is placed on the foot, especially after a long period of rest or inactivity. This pain is typically most pronounced in the morning when the foot is first placed on the floor. This symptom is known as first-step pain and is typical of plantar fasciitis.
Painful symptoms can also be increased from prolonged standing. One may feel better after some activity, but most patients report increased pain by the end of the day. The pain usually worsens after exercise instead of during the activity itself. Pressing in this area of the heel may cause it to feel tender. Pulling the toes back in the direction of the face can also be very painful.
How is plantar fasciitis diagnosed?
Diagnosis of plantar fasciitis is usually made during the history and physical examination. There are several conditions that can also cause heel pain. As such, plantar fasciitis must be distinguished from these other conditions. It is possible for pain in the heel and foot to be referred from other parts of the body such as the lower back, hip, knee and ankle. There are special tests that can be performed to help determine if the problem stems from the plantar fascia.
In order to rule out a stress fracture of the heel bone and to see if a problematic bone spur is present, an X-ray may be conducted. Other helpful imaging techniques include MRIs, ultrasound and bone scans. An ultrasonographic exam may sometimes be preferred as it is efficient, low in cost and does not expose one to radiation.
In certain cases, laboratory investigation may be needed to rule out systemic illnesses causing the heel pain. Such illnesses can include Reiter’s syndrome, ankylosing spondylitis or rheumatoid arthritis. These diseases affect the whole body, but they may initially show up as pain in the heel.
How can plantar fasciitis be treated?
Nonsurgical treatments are effective for most patients. Stretching the calf muscles on the back of the lower leg can take tension off the plantar fascia.
A night splint can also be prescribed, which can be worn while one is asleep. This keeps the foot from bedding downwards as it places a mild stretch on the calf muscles and plantar fascia. Certain patients have been known to heal faster when using a night splint. They report less pain when their sore foot is placed on the ground in the morning.
However, a few studies also reported that the addition of night splinting to an anti-inflammatory medicine and stretching program had no significant benefit. Other studies have reported benefits to short-term casting for unloading the heel, immobilizing the plantar fascia and reducing repetitive microtrauma.
Using a well-fitted arch support, or orthotic, may also help to reduce pressure on the plantar fascia. Placing a special type of insert into the shoe, known as a heel cup, can reduce pressure on the sore area. Additionally, wearing a silicone heel pad adds cushion to a heel that has lost some fat pad from degeneration.
There is also a newer form of nonsurgical treatment known as shock wave therapy. In this treatment, a machine is used to generate shock wave pulses to the sore area. This treatment is usually done weekly for up to three weeks. The reason why it works in treating plantar fasciitis is not exactly known. One possible reason is that the shock waves disrupt the plantar fascial tissue enough to ignite a healing response. The resulting release of local growth factors and stem cells causes an increase in blood flow to the area. Recent studies have shown that this form of treatment is able to help ease pain while also improving range of motion and function.
There are clinical trials underway to investigate the use of radiofrequency to treat plantar fasciitis. It is a straightforward and non-invasive form of treatment. It allows for pain relief and a speedy recovery within seven to ten days. In radiofrequency, the radio waves promote angiogenesis, the formation of new blood vessels, in the area. This once again increases blood flow to the damaged tissue, encouraging a healing response.
At times, anti-inflammatory medications are used to decrease inflammation in the fascia and reduce pain. Studies have shown that about 50% of people get better with antiinflammatories, while the other half do not show any improvement. Furthermore, these medications are rarely used alone, so it is hard to gauge their true effectiveness.
Another method is to inject cortisone into the area of the fascia. However, this has not been proven effective yet. Studies have shown better results when ultrasound is used to improve the accuracy of needle placement. It is important to use cortisone sparingly as it may cause rupturing of the plantar fascia, fat pad generation and atrophy, which will worsen the problem.
Lastly, we have botulinum toxin. Otherwise known as Botox, this is another method that has been used to treat plantar fasciitis. The chemical is injected into the area, causing paralysis of the muscles. It has direct analgesic (pain-relieving) and anti-inflammatory effects and has not proved to have any side effects.
Surgery is used as a last resort to treat heel pain. Over the last century, physicians have developed numerous procedures for the curing of heel pain. Majority of procedures that are commonly used today focus on several areas:
- removing the bone spur (if any)
- releasing the plantar fascia (plantar fasciotomy)
- releasing pressure on the small nerves in the area
The procedure is typically performed through a small incision on the inner edge of the foot, although some surgeons nowadays use an endoscope. An endoscope is a tiny TV camera that can be inserted into a joint or underneath the skin to allow the surgeon to see the structures involved. This allows for surgery to be completed using a smaller incision, along with presumably less damage to normal tissues. However, it is unconfirmed as to whether an endoscopic procedure is better than the traditional small incision for this condition.
Surgery typically involves identifying the location where the plantar fascia attaches to the heel and releasing the fascia partially from the bone. If a small spur is present, it is removed. The small nerves that travel under the plantar fascia are identified and released from anything that seems to be causing pressure on the nerves. This procedure is usually conducted on an outpatient basis, meaning one can leave the hospital on the same day.
What kind of rehabilitation should one expect after treatment?
Most cases of plantar fasciitis do well nonsurgically, with a 90 percent success rate. Patients are commonly prescribed physical therapy. Exercises are designed to improve flexibility in the Achilles’ tendon, calf muscles and the plantar fascia itself.
There are treatments directed to the painful area to help control pain and swelling. Such examples include ice packs, taping, ultrasound and soft-tissue massage. At times, therapy sessions can include iontophoresis, in which a mild electrical current is used to push anti-inflammatory medicine to the sore area.
A customized foot orthotic may be used to support the arch of the foot and to help cushion the heel. Alternatively, a heel cup may be recommended. This fosters healing by off-loading the plantar fascia and allowing it time to heal without repeated microtrauma. On top of that, the pressure of the orthotic or cup against the skin may also interrupt sensory input and prevent pain messages from travelling to the brain.
Home rehabilitation recommendations can include doing stretches for the calf muscles and plantar fascia. A night splint may also be fitted to wear while asleep. This is designed to put a gentle stretch on the calf muscles and plantar fascia while one is sleeping.
Most of the time, it takes a combination of different approaches to obtain the best possible results. A one-size-fits-all plan does not exist. Some patients do best with a combination of heel padding, stretching and medications. If this does not prove to be effective after four to six weeks, physical therapy and orthotics may be added. Certain studies have shown that using an orthotic in the first few weeks, followed by stretching, can yield good results of improvement.
It may take some time to figure out a combination that works best for each individual. One need not be discouraged even if it takes a few weeks to months to find the right fit. This condition is often self-limiting, which means it does not last forever and usually gets better with a bit of time and attention. In certain cases, though, it can take a whole year or more for the condition to resolve.
The tissues usually take several weeks to heal. A bandage or dressing is used to protect the incision for about a week after surgery. Crutches might be needed for a short period of time, and one will be taught how to use them by a physical therapist.
Stitches are generally removed within 10 to 14 days. Dissolvable sutures will not require a removal procedure. It takes about six weeks to resume full activity.
Although the surgical release of the plantar fascia decreases stiffness in the arch, it can lead to a collapse of the longitudinal arch of the foot. Releasing the fascia alters the biomechanics of the foot and may decrease the stability of the foot arch. This may result in increased stress on the other plantar ligaments and bones. Up to 40 per cent of patients who have had a plantar fasciotomy have reported fractures and instability.