Plantar Fasciitis

Michael W. Bowman M.D. FACS

Plantar fasciitis is a common condition affecting millions of American each year. this involves information or “itis” of the plantar fascia, which is a broad ligament on the bottom or plantar aspect of the foot.  The plantar fascia stretches from the toes along the arch back to its insertion at the heel. When you stand, the arch of the foot flattens slightly, putting a stretch or tension on the plantar fascia. when the attachment of the plantar fascia on the bottom of the heel becomes inflamed, this is known as insertional plantar fasciitis (the most common type).  Irritation along the broad surface of the plantar fascia in the arch is known as diffuse plantar fasciitis.

Causes for plantar fasciitis are many.  These include overuse injuries such as a sudden increase in exercise activities seen in runners or in people who started a new exercise program. obesity and the increased weight load on the plantar fascia can also be a common cause a plantar fasciitis.  Inflammatory conditions such as removed arthritis, lupus, ankylosing spondylitis and gallop can also be associated with irritation of the plantar fascia insertion.  Mechanical factors such as a tight Achilles' tendon, hallux rigidus or a stiff ankle cause U2 liftoff the foot prematurely and produced it increased force on the plantar fascia.  A flexible flatfoot with increased pronation or the opposite stiff cavovarus foot that resulted irritation the plantar fascia. direct trauma, such as stepping on a rock, male so-called plantar fasciitis.

Not all heel pain is plantar fasciitis.  Other conditions that may produce heel pain include a stress fracture of the heel (calcaneus), tibial nerve compression (tarsal tunnel syndrome) with irritation of the nerve to the ADQ muscle (factors nerve), atrophy or withering of the cushioning fat pad on the plantar heel. there may be also be pain referred to the heel from arthritis of the posterior ankle joint or subtalar joint.  Pain from the insertion of the Achilles' tendon may reach down around to the bottom of the heel.

 

Treatment of plantar fasciitis starts with a careful examination and history.  Symptoms of plantar fasciitis include both sharp and dull chronic pain on the plantar aspect of the heel, usually near the medial insertion of the plantar fascia, as seen in figure 1. usually this pain is worse with the very first steps in the morning or after sitting down for a while.  The plantar fascia has contracted and is painful with the first steps, producing stretching.  There can be a constant burning pain throughout the day, worse with increased weight-bearing and activities.  In runners the pain may actually decrease after the first couple miles, but return after stopping.

The examination reveals exquisite tenderness at the medial insertion of the plantar fascia as seen in figure 1.  Often the Achilles' tendon is tight to examination.  X-rays and/or an MRI may be ordered to rule out a calcaneal stress fracture or other cause for the discomfort.  A bone scan may also be used to distinguish between a calcaneal stress fracture and insertional plantar fasciitis.  Encases where the nerve to the ADQ (factors nerve) is compressed or irritated, pressure or tapping over the nerve (Tinel's test) may reproduce pain in the medial and plantar heel.

Treatment of plantar fasciitis begins with conservative treatment.  Multiple studies and my own personal experience revealed that 99% the patient's can be successfully treated without surgery.  we have enjoyed great success with our comprehensive conservative program to treat plantar fasciitis over the years.  It consists of anti-inflammatory, proper orthotic management, physical therapy and stretching by the patient. frequently patient's present to our office, having been treated elsewhere for plantar fasciitis, and have already tried one or two of the elements of the treatment plan.  It is important to combine them together for success. Mechanical problems that cause the plantar fasciitis must be addressed.  most importantly, A tight Achilles' tendon is addressed with stretching and physical therapy, frequent sessions of stretching during the day by the patient, and occasionally a night dorsiflexion and flow to hold the foot with the Achilles stretched. custom foot orthotics are usually prescribed with a good arch support to support the plantar fascia and the viscoelastic gel cushion built into the heel.  These orthotics may be different for the patient with a flexible flatfoot versus a high arch stiff cavovarus foot.  Physical therapy is prescribed to evaluate the overall gait, stance, muscle balance and tightness of the lower extremity.  Ice, massage and iontophoresis are used to decrease the inflammation at the plantar fascia. stretching exercises for the Achilles' tendon (with both the gastrocnemius and soleus muscles), plantar fascia and other tight muscles are initiated.  The patient will be instructed to perform frequent (several times per day) one to two minute stretching sessions.  Anti-inflammatories are also prescribed until the discomfort goes away.

Four patient with persistent resistant plantar fasciitis, the night dorsiflexion AFO may be prescribed when the Achilles' tendon is still very tight.  An injection of cortisone Xylocaine at the insertion of the plantar fascia may be performed to calm down the inflammation and allow therapy to continue. a cortisone injection is not a substitute for therapy, stretching or treatment.  Frequently patient's will discontinue their therapy for stretching after getting relief from a single injection, he going the mechanical factors that cause the plantar fasciitis and upset when it returns.  Multiple frequent cortisone injections are to be discouraged, since they may weaken the plantar fascia N. result in rupture of the plantar fascia.  Casting or placement in a protective boot to calm down the plantar fasciitis has also been used and cases of chronic plantar fasciitis.  Treatment of chronic resistant plantar fasciitis with electro- shock wave (ESW) therapy has been successful, but should be reserved for cases that did not respond to the above conservative treatment. reducing the amount or intensity of running may be required during treatment.  We tried to avoid this if possible.  Finally relief of plantar fascia may require reduction of the load on the plantar fascia and a controlled weight loss program.

We are currently pioneering a new treatment for plantar fasciitis involving the use of platelet rich plasma (PRP).  In this situation, approximately 30 cc of blood is drawn from the patient, prepared in the special centrifuge, and the buffy coat-part of the plasma containing platelets together with human growth factors is obtained.  That is been injected into the area of inflammation to promote healing.  This new in an exciting treatment may develop into the common method of treatment.

Finally surgery may be required for cases of plantar fasciitis that did not respond to the above nonsurgical treatment.  This approach should be utilized less than 1% of the time.  The surgery is performed as an outpatient with twilight local standby anesthesia.  A small incision is made on the plantar heel, just in front of the main weight-bearing area of the heel.  The medial one third of the plantar fascia is released and the skin is closed.  Patient's are placed in a protective boot with no weight-bearing for two weeks.  At the two-week visit the sutures are removed and progressive weight-bearing is begun together with initial therapy for range of motion.  At 6 weeks the patient is placed back in the shoes with orthotics.  Surgical risks with this condition and surgery include anesthesia related risks, wound healing problems infection, painful plantar incision and continued discomfort.  "Endoscopic" one or two incision variations for this procedure had been utilized.  Because of difficulty controlling the amount of plantar fascia release and permanent damage to the plantar nerves, we do not utilize this procedure. we have inherited patient's with both of these complications from elsewhere.