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Plantar Fasciitis

Written by Dr.Mary

What is Plantar Fasciitis?

Plantar fasciitis is a medical condition in which the plantar fascia suffers from a change in structure, becoming inflamed and scarred. In the medical literature, this condition is also known as plantar fasciopathy or the jogger’s heel, being commonly encountered in those who practice jogging. This condition can be quite painful, affecting the heel and the underside part of the foot. As you will have the opportunity to read in the following paragraphs, the most common cause of plantar fasciitis is the excessive usage of the plantar fascia. Aging, excessive physical training and obesity are considered to be aggravating factors of plantar fasciitis, leading to a degenerative process and to the structural changes mentioned above.


Recent studies have demonstrated that plantar fasciitis is the number one cause in the world responsible for the heel pain. It is said that everyone goes at least through one episode of plantar fasciitis throughout the entire life. Certain factors, such as standing for prolonged hours and having flat feet are known to increase the prevalence for plantar fasciitis. This article will provide you with information on the symptoms and causes of this condition, the available methods for diagnosis and the treatment measures that can be taken (non-surgical and surgical). You will also be offered information on the different exercises that can be performed in order to improve this condition.

Anatomy

plantar fascia

Plantar Fasciitis Picture (1) showing the anatomy of Plantar fascia, heel bone, tearing and inflammation at the heel bone

The plantar fascia is a band or a ligament constituted from fibrous or connective tissue. The origin of the plantar fascia is at the medial tubercle, the thick band continuing to develop along the heel bone (anterior part). The fascia continues throughout the entire foot sole, until it reaches the base of the toes – this being the place of insertion. The main purpose of the plantar fascia is to support the arch of the foot – it is believed that the micro tears in the plantar fascia are actually responsible for the plantar fasciitis.

Symptoms of Plantar Fasciitis

These are the most common signs and symptoms of plantar fasciitis:

  • Pain is the most characteristic symptom of this condition, being quite intense
    • Patients describe the pain as ‘sharp’
    • The pain is felt in the heel
  • The unilateral involvement is more common than the bilateral one
  • If the person stands on the affected foot, the pain becomes even more intense (especially after a longer period of sitting)
  • The pain is more intense for the first steps that are taken after sitting for prolonged periods of time
  • By continuing walking, the patient often obtains relief from the pain
  • Other symptoms can be present in rare cases, including:
    • Numbness
    • Tingling
    • Inflammation
  • The pain can irradiate to other parts of the foot
  • In more severe cases, the plantar fascia can rupture, leading to the following symptoms:
    • Specific sound in the heel – patients describe it as ‘clicking’ or ‘snapping’
    • The inflammation is quite severe – visible with the naked eye
    • The pain is acute and intense – location: foot sole.

Causes

Speaking from a physiological point of view, plantar fasciitis is caused by the excessive usage of the plantar fascia. The repeated stress on the plantar fascia leads to the appearance of those micro tears that were mentioned above, affecting the structure of the fascia and leading to its degeneration. The more excessively the plantar fascia is used, the higher the risk for it to rupture.

This condition is presented as the jogger’s heel, because it is often encountered in those who are jogging or running on a regular basis. Standing for prolonged periods of time, especially on surfaces that are hard, can also lead to plantar fasciitis. Anatomical differences, such as having a high foot arch, a different length of the limbs or flat feet are responsible in some people for plantar fasciitis. A modified gait, with the tendency of rolling the feet inward, is also a risk factor for this condition. The risk is even higher if this occurs during running, as it places a lot of pressure on the plantar fascia. Obesity is commonly associated with the appearance of plantar fasciitis, as all of the excess weight presses on the plantar fascia, affecting its structure.

Studies have demonstrated that this condition is common in those who jog or run; however, it is just as common in those who do not perform such physical activities – this part of the population is the one that presents excess weight or has a rigid Achilles tendon. Some studies have also incriminated poor-fitting footwear as a cause of plantar fasciitis.

Diagnosis

These are the most common methods used for the diagnosis of plantar fasciitis:

  • Patient anamnesis
    • Medical history
    • Assessment of existing risk factors
  • Physical examination
    • Relevant for the identification of the symptoms exhibited by the patient
    • The patient can present tenderness to the touch in the sole or heel
    • The movements of the foot can be restricted, especially the dorsiflexion (constricted muscles of the calf or a rigid Achilles tendon)
    • Moving the foot – dorsiflexion – can cause a lot of pain (this movement stretches the plantar fascia)
  • Imaging studies – X-ray, ultrasound or MRI
    • Not commonly used for the diagnosis of plantar fasciitis
    • Often chosen to rule out other conditions that might cause similar symptoms
  • Blood tests
    • Recommended in patients who present bilateral involvement (suggestive of other conditions – often autoimmune diseases)
    • Used for the identification of markers encountered in autoimmune conditions
  • Electromyography
    • Investigation necessary for patients who present neurological deficits
    • Can determine whether there is additional damage to the nerves or muscles

Differential diagnosis can be made with the following conditions:

  • Bone fractures – stress fracture of the calcaneus
  • Bursitis
  • Arthritis
  • Spondylitis
  • Rupture of the plantar fascia
  • Tarsal tunnel syndrome
  • Medial calcaneal nerve impingement

Treatment

These are the most common measures of non-invasive treatment recommended for plantar fasciitis:

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Medication

  • Non-inflammatory medication
    • Recommended – acetaminophen, ibuprofen
    • Pain relief and reduction of inflammation

Home treatments

  • The R.I.C.E protocol is the recommended home treatment for plantar fasciitis, consisting of: rest, ice, compression and elevation

Extracorporeal shockwave therapy

  • Recommended in patients who have followed other non-invasive treatment measures for a period of three months, with no improvement in the symptoms presented
  • Most important advantage – significant pain relief
  • Can be performed with or without anesthesia (more effective without, studies have shown)
  • The area of treatment can remain red for a short period of time after the procedure

Physical therapy

  • The exercise program will bring pain relief and will allow the patient to maintain the normal range of motion in the feet
  • The physical therapist can also teach you how to walk in a correct manner and what kind of movements you should avoid

Corticosteroid injection

  • Recommended to patients who have failed to obtain improvement through other treatment methods
  • Short-term solution – not effect on a long term basis
  • The injections present a series of risks, the most important one being the one of the plantar fascia rupturing
  • Can cause nerve or muscle injury

Night splints

  • The night splints have the purpose of stretching the calf muscles and maintaining the foot in a non-painful position during sleep
  • Basically, the plantar fascia is maintained in a lengthened position throughout the entire night
  • Often recommended as the same time with physical therapy – the plantar fascia that has been stretched during the night with the splints, can be easier mobilized by the physical therapist

Orthotics/arch supports

  • The main purpose of the orthotics or arch supports is to help with the even distribution of the weight
  • These are custom fitted, being prescribed by the doctor
  • Most commonly recommended – heel cup, cushion or arch support.

Surgery

The surgical intervention is recommended in the patients who are diagnosed with plantar fasciitis and who suffer from intense pain. The procedure is known as plantar fasciotomy and it represents the last resort – no doctor will perform this surgery, without trying all of the above mentioned non-invasive treatments. The most efficient and minimally invasive surgery is the one performed through the endoscopic approach but this equipment is not so readily available in all hospitals and clinics. During the surgery, the doctor might also decide to remove the heel spurs, thus improving the outcome of the intervention. In some patients, the pain comes from a nerve being entrapped by the inflamed fascia – the surgeon will perform the plantar fasciotomy at the same time with the release of the entrapped nerve.

Recovery time

First of all, you need to understand that the recovery time depends on the approach that was used for the intervention. It is a known fact that the endoscopic approach guarantees a faster recovery and thus less down time.

If the surgery was performed through a traditional approach, you will probably need to wear a cast for two or three weeks. During this period, you will not be allowed to put your foot down and you will need to learn how to use crutches. You will probably need to take two months of time off from work. After the cast is off, you need to wear shoes with adequate support – you will feel like new in approximately one and a half months.

In case the endoscopic approach was used, after the intervention, you will need to wear a cast for three to seven days. You will also need to avoid placing weight on the operated foot for the first week – however, you can go to the bathroom on your own. For the next weeks, you will need to wear the orthotics recommended by the doctor. Depending on the type of work that you do, you can return to work in one-three weeks. Excessive physical effort, including running and jumping, is forbidden for the next three months.

Cost

The cost of the plantar fasciitis surgery depends on the clinic, the fees and the approach used. Depending on your health insurance policy, you can expect to pay about 10-50% of the overall costs for the surgery. You will also need to consider the costs for the medication, physical therapy, orthotics, cortisone shots and other treatments.

Success rate

According to recent studies, the endoscopic approach has an approximate success rate of 87%. The success rate for recalcitrant cases of plantar fasciitis is of 86%.

Complications

These are the most common complications that can occur with the plantar fasciitis injury:

  • Postoperative infection
  • Hemorrhage
  • Scarring
  • Blood clots
  • Nerve and muscle injury
  • Modification of foot structure (foot arch)
  • Complications related to anesthesia

Exercises and Stretches

These are several exercises and stretches that you can perform in order to improve your symptoms:

  • Toe curls – place a towel on the floor and try to bunch it up while curling your toes
  • Calf stretch – stand in front of a wall, with your body inclined in a forward direction; place your hands on the walls and transfer your weight to the feet, stretching the calf muscles
  • Heel raise – stand with the tip of your toes on a flight of stairs; raise your heels, maintaining the position for a couple of seconds
  • Heel stretch – while standing, raise on of your feet and place your hand on the heel; stretch your heel, maintaining the position and repeat
  • Belt stretch – sit in a comfortable position, with your feet stretched; use a belt to place it on the middle of the foot and stretch your feet by drawing the belt towards you
  • Hamstring stretch – sit on a mattress, with your knees extended; reach for the tip of your toes with your hands and draw them towards you, maintaining the position for a couple of seconds
  • Towel stretch – this exercise is similar to the belt stretch; the difference lies in the fact that you will need to use a towel instead of a belt
  • Sitting toe raise – stand on a chair, with your feet resting comfortably on the floor; raise your toes, maintaining the position for a short period of time and repeat
  • Towel pickup – place a towel on the floor and try to pick it up using your toes
  • Achilles tendon stretch – while standing, place one foot forward and bend it slightly; bend the other one more, stretching the Achilles tendon
  • Pencil pickup – this exercise is similar to the towel pickup one; the difference is given by the fact that you will have to use your toes in order to pickup a pencil
  • Stretching on a step – recommended for the stretching of the plantar fascia but also for reducing the rigidity experience in the Achilles tendon and in the calf muscles.

Plantar Fasciitis Pictures

plantar fasciitis pictures

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