The plantar fascia is a thick band of connective tissue that runs along the underneath of the foot from the heel bone to the toes. At the heel it can also have fascial connections to the achilles tendon. Its job is to maintain the arch of the foot, it acts as a bowstring pulled between the heel and the toes. “Itis” as a suffix indicates inflammation, but with the plantar fascia there is still some controversy over what exactly happens to the tissue when it becomes painful.
A number of factors can contribute to plantar fasciitis. While men can get plantar fasciitis, it is more common in women. You’re also more likely to have this condition as you age or if you are overweight. Take up a new form of exercise or suddenly increase the intensity of your exercise. Are on your feet for several hours each day. Have other medical conditions such as rheumatoid arthritis or lupus (systemic lupus erythematosus). Tend to wear high-heeled shoes, and then switch abruptly to flat shoes. Wear shoes that are worn out with weak arch supports and thin soles. Have flat feet or an unusually high arch. Have legs of uneven lengths or an abnormal walk or foot position. Have tight achilles tendons, or ‘heel cords’.
If you have Plantar Fasciitis, you will most likely feel a sharp pain under the ball of you heel and it will often give pain when standing after a period of rest. For example when you get out of bed in the mornings or after being sat down. Some patients describe this feeling as a stone bruise sensation, or a pebble in the shoe and at times the pain can be excruciating. Patients with Plantar Fasciitis can experience pain free periods whereby the think they are on the mend, only for the heel pain to come back aggressively when they appear to have done nothing wrong. If your plantar fasciitis came on very suddenly and the pain is relentless, then you may have Plantar Fascial Tears. We will be able to differentiate between these 2 conditions, sometimes with ultra sound imaging. The treatment for each of these conditions will need to be very different.
Plantar fasciosis is confirmed if firm thumb pressure applied to the calcaneus when the foot is dorsiflexed elicits pain. Fascial pain along the plantar medial border of the fascia may also be present. If findings are equivocal, demonstration of a heel spur on x-ray may support the diagnosis; however, absence does not rule out the diagnosis, and visible spurs are not generally the cause of symptoms. Also, infrequently, calcaneal spurs appear ill defined on x-ray, exhibiting fluffy new bone formation, suggesting spondyloarthropathy (eg, ankylosing spondylitis, reactive arthritis. If an acute fascial tear is suspected, MRI is done.
Non Surgical Treatment
To alleviate the stress and pain on the fascia, the person can take shorter steps and avoid walking barefoot. Activities that involve foot impact, such as jogging, should be avoided. The most effective treatments include the use of in-shoe heel and arch cushioning with calf-stretching exercises and night splints that stretch the calf and plantar fascia while the patient sleeps. Prefabricated or custom-made foot orthotics may also alleviate fascial tension and symptoms. Other treatments may include activity modifications, NSAIDs, weight loss in obese patients, cold and ice massage therapy, and occasional corticosteroid injections. However, because corticosteroid injections can predispose to plantar fasciosis, many clinicians limit these injections. For recalcitrant cases, physical therapy, oral corticosteroids, and cast immobilization should be used before surgical intervention is considered. A newer form of treatment for recalcitrant types of plantar fasciosis is extracorporeal pulse activation therapy (EPAT), in which low-frequency pulse waves are delivered locally using a handheld applicator. The pulsed pressure wave is a safe, noninvasive technique that stimulates metabolism and enhances blood circulation, which helps regenerate damaged tissue and accelerate healing. EPAT is being used at major medical centers.
Plantar fasciotomy is often considered after conservative treatment has failed to resolve the issue after six months and is viewed as a last resort. Minimally invasive and endoscopic approaches to plantar fasciotomy exist but require a specialist who is familiar with certain equipment. Heel spur removal during plantar fasciotomy has not been found to improve the surgical outcome. Plantar heel pain may occur for multiple reasons and release of the lateral plantar nerve branch may be performed alongside the plantar fasciotomy in select cases. Possible complications of plantar fasciotomy include nerve injury, instability of the medial longitudinal arch of the foot, fracture of the calcaneus, prolonged recovery time, infection, rupture of the plantar fascia, and failure to improve the pain. Coblation (TOPAZ) surgery has recently been proposed as alternative surgical approaches for the treatment of recalcitrant plantar fasciitis.
An important part of prevention is to perform a gait analysis to determine any biomechanical problems with the foot which may be causing the injury. This can be corrected with orthotic inserts into the shoes. If symptoms do not resolve then surgery is an option, however this is more common for patients with a rigid high arch where the plantar fascia has shortened.