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Plantar Fasciitis:

Plantar fasciitis is a common cause of heel pain in adults. The pain is usually caused by collagen degeneration (which is sometimes misnamed "chronic inflammation") at the origin of the plantar fascia at the medial tubercle of the calcaneus. This degeneration is similar to the chronic necrosis of tendonosis,

which features loss of collagen continuity, increases in ground substance (matrix of connective tissue) and vascularity, and the presence of fibroblasts rather than the inflammatory cells usually seen with the acute inflammation of tendonitis.¹ The cause of the degeneration is repetitive micro tears of the plantar fascia that overcome the body's ability to repair itself.

The classic sign of plantar fasciitis is that the worst pain occurs with the first few steps in the morning, but not every patient will have this symptom. Patients often notice pain at the beginning of activity that lessens or resolves as they warm up. The pain may also occur with prolonged standing and is sometimes accompanied by stiffness. In more severe cases, the pain will also worsen toward the end of the day.

The plantar fascia is a thickened fibrous aponeurosis that originates from the medial tubercle of thecalcaneus and runs forward to form the longitudinal foot arch. The function of the plantar fascia is to provide static support of the longitudinal arch and dynamic shock absorption. Individuals with pesplanus (low arches or flat feet) or pescavus (high arches) are at increased risk for developing plantar fasciitis.

Causes:

The condition is usually caused by a change or increase in activities, no arch support, lack of flexibility in the calf muscles, being overweight, a sudden injury, using shoes with little cushion on hard surfaces, using shoes that do not easily bend under the ball of the foot, or spending too much time on the feet. The cause is usually unknown and mysterious to the patient. It has often been said that those with flat feet or high arches are more likely to get plantar fasciitis (heel spurs), but I do not know if that is the case. 30% of our visitors indicated they have high arches and 20% indicated they have flat feet, but this may not be different from the rest of the population. Arthritis, heel bone damage ("stress fracture"), loss of natural tissue for cushioning under the heel ("fat pad atrophy"), tarsal tunnel syndrome (the foot's version of carpal tunnel syndrome), and other conditions can cause similar foot and heel pain. Many of the ideas presented here can be helpful in dealing with these other conditions. Excess body weight is a major cause of heel pain. Our visitors are 27 times more likely to be overweight (BMI>25) than underweight (BMI<20). Our visitors are twice as likely to be obese (BMI>30) as the average American. But our visitors often do not know they are overweight because they are comparing themselves to other Americans who are the heaviest people in the world. Calorie restriction experiments since the 1930's in many species have shown that for every excess dry ounce of food (28 grams, 120 calories) you eat, you lose one hour of your life and health. People who eat nutritious food and have a BMI of 19 live the longest and are often called "little old ladies".

Other anatomic risks include over pronation, discrepancy in leg length, excessive lateral tibial torsion and excessive femoral anteversion. Functional risk factors include tightness and weakness in the gastrocnemius, soleus, Achilles tendon and intrinsic foot muscles. However, overuse rather than anatomy is the most common cause of plantar fasciitis in athletes. A history of an increase in weight-bearing activities is common, especially those involving running, which causes micro trauma to the plantar fascia and exceeds the body's capacity to recover. Plantar fasciitis also occurs in elderly adults. In these patients, the problem is usually more biomechanical, often related to poor intrinsic muscle strength and poor force attenuation secondary to acquired flat feet and compounded by a decrease in the body's healing capacity.

On examination, the patient usually has a point of maximal tenderness at the anteromedial region of the calcaneus. The patient may also have pain along the proximal plantar fascia. The pain may be exacerbated by passive dorsiflexion of the toes or by having the patient stand on the tips of the toes.

Diagnostic testing is rarely indicated for the initial evaluation and treatment of plantar fasciitis. Plantar fasciitis is often called "heel spurs," although this terminology is somewhat of a misnomer because 15 to 25 percent of the general population without symptoms have heel spurs and many symptomatic individuals do not.² Heel spurs are bony osteophytes that can be visualized on the anterior calcaneus on radiography. However, diagnostic testing is indicated in cases of atypical plantar fasciitis, in patients with heel pain that is suspicious for other causes (Table 1) or in patients who are not responding to appropriate treatment.

Treatment:

Symptoms usually resolve more quickly when the time between the onset of symptoms and the beginning of treatment is as short as possible. If treatment is delayed, the complete resolution of symptoms may take 6-18 months or more. Treatment will typically begin by correcting training errors, which usually requires some degree of rest, the use of ice after activities, and an evaluation of the patient’s shoes and activities. For pain, nonsteroidal anti-inflammatory drugs (e.g. aspirin, ibuprofen, etc.) may be recommended.

Next, risk factors related to how the patient’s foot is formed and how it moves are corrected with a stretching and strengthening program. If there is still no improvement, night splints (which immobilize the ankle during sleep) and orthotics (customized shoe inserts) are considered. Cortisone injections are usually one of the treatments of last resort, but have a success rate of 70% or better. The final option, surgery has a 70-90% success rate.

In one study, 25% of plantar fasciitis patients cited rest as the treatment that worked the best. Wearing shoes with more arch support may help decrease

stress on the area. Changing shoe size may also help. Athletes and active people may have to reduce the amount running or jumping they do to relieve stress on the plantar fascia.

Using an ice pack or ice bath on the area for about 15 minutes may relieve pain and inflammation after exercise and work. Massaging the foot in the area of the arch and heel before getting out of bed may help. Stretching is also important.

As reported in one study, 83% of patients in a stretching program were successfully treated for plantar fasciitis; 29% of study participants cited stretching as the most helpful treatment, compared with nonsteroidal anti-inflammatory drugs, orthotics, ice, heat, steroid injection, heel cups, walking, night splints, plantar strapping and shoe changes.

Heel spurs and plantar fasciitis are treated by measures which decrease the associated inflammation and avoid re-injury. Local ice applications both reduce pain and inflammation. Anti-inflammatory medications, such as ibuprofen or injections of cortisone are often helpful. Orthotic devices or shoe inserts are used to take pressure off plantar spurs (donut-shaped insert) and heel lifts can reduce stress on the Achilles tendon to relieve painful spurs at the back of the heel. Similarly, sports running shoes with their soft, cushioned soles can be helpful in reducing irritation of inflamed tissues from both plantar fasciitis and heel spurs. Infrequently surgery is performed on chronically inflamed spurs.

Stretching and Strengthening:

To reduce pain and help prevent future episodes of discomfort, stretch the calves on a regular basis. Stand with your hands against a wall. With one foot forward and one back, press against the wall, shifting weight over the front foot, while straightening the back leg. Keep the heel of the back foot on the floor and feel the stretch in the heel, Achilles tendon and calf. Then, switch legs.

A similar stretch can be done by standing on a stair step with only the toes on the stairs. The back two-thirds of the feet hang off the step. By leaning forward to balance, the heel, Achilles tendon and calf will be stretched. A similar stretch can be performed when standing where the heel is on the floor and the front part of the foot is on a wood 2x4. Some patients place a 2x4 in an area where prolonged standing is done (such as in front of the sink while washing dishes). Rolling the foot over a tennis ball or 15-ounce can may also be helpful.

Almost 35% of patients in another study cited strengthening programs as the most helpful treatment. To strengthen muscles, do towel curls and marble pick ups. Place a towel on a smooth surface, place the foot on the towel, and pull the towel toward the body by curling up the toes. Or, put a few marbles on the floor near a cup. Keep the heel on the floor and use the toes to pick up the marbles and drop them in the cup.

Another exercise is toe taps. Keep the heel on the floor and lift all of the toes off the floor. Tap only the big toe to the floor while keeping the outside four toes in the air. Next, keep the big toe in the air and tap the other four toes to the floor.

Shoes and Splints

Wearing shoes that are too small may cause plantar fasciitis. Shoes with thicker, well-cushioned midsoles may help alleviate the problem. Running shoes should be frequently replaced as they lose their shock absorption capabilities.

Studies have shown that taping the arch, or using over-the-counter arch supports or customized orthotics also help in some cases of plantar fasciitis. Orthotics are the most accepted option as a plaster cast is made of the individual’s feet to correct specific biomechanical factors. One study found that 27% of patients cited orthotics as the most helpful treatment of plantar fasciitis. Heel cups, on the other hand were ranked the least effective treatment in a survey of 411 patients.

Night splints, which are removable braces, allow passive stretching of the calf and plantar fascia during sleep, and minimize stress on the inflamed area. According to several studies, approximately 80% of patients improved after wearing a night splint. It may be especially useful in patients who have had symptoms for more than a year.

For individuals with flat feet, motion control shoes or shoes with better longitudinal arch support may A change to properly fitting, appropriate shoes may be useful in some patients. Some individuals wear shoes that are too small, which can exacerbate many types of foot pain.⁷ Patients often find that wearing shoes with thicker, well-cushioned midsoles, usually made of a material like high-density ethylene vinyl acetate (such as is found in many running shoes), decreases the pain associated with long periods of walking or standing. Studies⁵ have shown that with age, running shoes lose a significant portion of their shock absorption. Thus, simply getting a new pair of shoes may be helpful in decreasing pain.

Arch Supports and Orthotics

Patients with low arches theoretically have a decreased ability to absorb the forces generated by the impact of foot strike.⁵The three most commonly used mechanical corrections are arch taping, over-the-counter arch supports and custom orthotics. Arch taping and orthotics were found to be significantly better than use of NSAIDs, cortisone injection or heel cups in one randomized treatment study.⁸ Arch taping was cited by 2 percent of patients as the treatment that worked best for plantar fasciitis in another study.³ A single taping treatment is much less expensive than an over-the-counter arch support or an orthotic.

Taping provides only transient support, with studies showing that as little as 24 minutes of activity can decrease the effectiveness of taping significantly. Arch taping can be used as definitive treatment or as a trial to determine if the expense of arch supports or orthotics is worth the benefit. Taping may be more cost effective for acute onset of plantar fasciitis, and over-the-counter arch supports and orthotics may be more cost-effective for chronic or recurrent cases of plantar fasciitis and for prevention of injuries. In athletes, arches must be retaped at least for every new game or practice session, whereas an over-the-counter arch support usually lasts a full sports season and a custom orthotic usually lasts for many seasons.

Over-the-counter arch supports may be useful in patients with acute plantar fasciitis and mild pesplanus. The support provided by over-the-counter arch supports is highly variable and depends on the material used to make the support. In general, patients should try to find the densest material that is soft enough to be comfortable to walk on. Over-the-counter arch supports are especially useful in the treatment of adolescents whose rapid foot growth may require a new pair of arch supports once or more per season.

Custom orthotics are usually made by taking a plaster cast or an impression of the individual's foot and then constructing an insert specifically designed to control biomechanical risk factors such as pesplanus, valgus heel alignment and discrepancies in leg length. For patients with plantar fasciitis, the most common prescription is for semi-rigid, three-quarters to full-length orthotics with longitudinal arch support. Two important characteristics for successful treatment of plantar fasciitis with orthotics are the need to control over pronation and metatarsal head motion, especially of the first metatarsal head. In one study orthotics were cited by 27 percent of patients as the best treatment..