What is Plantar Fasciitis
Plantar fasciitis presents as heel pain usually in one heel though both can be affected. Pain is usually worst first thing in the morning or standing after a prolonged period of rest. In the past it was thought to involve inflammation of the plantar fascia especially where it attaches to the calcaneus, hence it has the name itis. However recent research has shown no inflammation occurs except in extreme or prolonged cases, building a case to change the name to plantar fasciosis or chronic heel pain.
Anatomy and role of the Plantar Fascia
Pleas see blog post Plantar fascia and the Windlass Mechanism
Policeman heel, joggers heel, sub calcaneal pain, heel spur syndrome and stone bruise.
How Common is Plantar Fasciitis?
Plantar fasciitis accounts for up to 15% of all adult foot complaints and effects 10% of the population. With in the USA plantar fasciitis accounts for 1 million patient visits per year making only trauma injuries more prevalent.
If you are suffering with heel pain please contact Ayres Podiatry.
Who’s at Risk
With plantar fasciitis having such a strong prevalence there are many groups of people at risk. However they can be categorised in 2 main populations each group having similar and different risk factors:
- Mostly affects those who are stood for long periods of time such as factory workers, hair dressers and nurses.
- 65% of suffers who are in the non-athletic population are over weight.
- Most common in those who are 40+.
- Decreased 1st MPJ (big toe) dorsiflexion.
- Plantar fasciitis affects 10% of all running athletes.
- Mostly affects distance runners.
- Also seen frequently in basketball, tennis, football and dance.
Plantar fasciitis is often caused by multiple factors which lead to degeneration and weakness of the plantar fascia. As the degeneration occurs there is little inflammation, although pain will be present. Eventually degeneration weakens the plantar fascia enough to allow mechanical overloading, which does cause inflammation. Below are the 5 main reasons that lead to plantar fascia degeneration:
Lack of Ankle Dorsiflexion
As ankle dorsiflexion is reduced, greater doriflexion moments occur across the midfoot, which in turn increases tension in the plantar fascia and its heel attachment point.
Increased body weight leads to increased load on the plantar fascia and increased stresses on the heel fat pads.
Alterations to heel fat pad properties
The plantar fat pad is great at absorbing shock due to its elasticity. Elasticity is lost during the natural aging process and from repetitive impacts on hard surfaces. As a result the magnitude of impact on the bone is increased, which in turn decreases the bones ability to with stand traction from the plantar fascia.
Calcification of the heel fat pad
This usually occurs due to systemic diseases such as diabetes, gout and thyroid problems. The same as above, this decreases elasticity and shock absorption.
There is a strong link between plantar fasciitis and inflammatory disesases such as arthritis, ankylosing spondylitis and reiters syndrome.
Signs and Symptoms
- Gradual onset – Pain gradually increases over a period of weeks or months.
- Pain first thing in the morning – Pain is greatest during the first few steps in the morning or after prolonged periods of non-weight bearing activity.
- Pain at the start of activity – pain improves after a warm-up but increases after physical activity.
- Local tenderness – Pain is usually over a small area over the proximal insertion of the plantar fasciia. In severe cases there can be diffuse tenderness along the sides of the calcaneus.
- No swelling – swelling is usually only seen in more severe cases and can indicate fractures or muscle injury.
- Nodular changes to the fascia – these can develop to become the size of golf balls and occur due to repeated injury, healing and scaring.
- Pain with passive ankle dorsiflexion – Due to the close relationship between the tricep surae (calf muscles) and the plantar fascia dorsiflexion at the ankle will can cause pain.
There are many different treatments for plantar fasciitis. Each has its own pros and cons and some are more successful than others. The main aims are to reduce pain, restore movement, reduce stress on the plantar fascia and it s attachment points (both tension and compression from impacts) and allow the damaged tissue to recover. The main treatments are listed below:
Extracorporeal shock wave therapy
A type of ultra-sound that has shown to be more effective than placebo but only has a small reduction in heel pain.
Low dye taping
A great short-term therapy that provides an indication for longer term orthotic use.
Custom Foot Orthoses
A very effective short and long term treatment that improves foot function, reduces pain and has great patient compliance.
This is a vital part of any plantar fasciitis treatment. Stretching the plantar fascia alone has been show to be more effective than stretches of the tricep surae. However stretching both the tricep surae and plantar fascia has been shown to be even more effective than stretching the plantar fascia alone.
NSAIDS (Non-steroid anti-inflammatory drugs)
As plantar fasciitis has little inflammation NSAIDS are of very little use except in more severe cases.
A good short term relief if the night splint can be tolerated. However plantar fasciitis often return within a 2 year period.
Steroids are an anti inflammatory therefore little use in plantar fasciitis except in more severe cases.
Differential Diagnosis (mistaken for)
- Achilles Tendonitis
- Subcalcaneal bursitis
- Tarsal tunnel syndrome
- Severs disease
- Calcaneal stress fracture
- Tibialis posterior dystfunction
Plantar fasciitis is a very common foot problem that usually presents as heel pain. It has a gradual onset that slowly intensifies over time. Usually presents as localised heel pain first thing in the morning, in the early stages of exercise and after exercise. There are many factors that lead to plantar fasciitis, many of which cause degeneration of the plantar fascia and its bony attachment, lowering its ability to with stand mechanical loading. There are many different treatments for plantar fasciitis. The most successful of which address the underlying biomechanical cause rather than provide short term pain relief.
Bartold, S. (2004). The Plantar fascia as a source of pain – biomechanics, presentation and treatment. J. of Bodyworks and Movement Therapies. 8, 214-226. Elsevier
Frowen, P. O’Donnell, M. Lorimer, D. Burrow, G. (2010). Neal’s Disorders of the Foot Clinical Companion. Elsevier
Hyland, M. Webber-Gaffney, A. Cohen, L. Lichtman, S. (2006). Randomised Controlled Trial of Calcaneal taping, Sham Taping and Plantar fascia Stretching for the Short-term Management of Plantar Heel Pain. J of Orthopaedic and Sports Physical Therapy. 63;6 364-371.
Nicholl, D. (2008). Plantar fasciitis: part 1. A grading system for plantar fasciitis; with critical review of the aetiologies of plantar fasciitis. Podiatry Now, Dec 2008
Wearing, S. Smeathers, J. Urry, S. Hennig, E. Hills, A. The Pathomechanics Of Plantar (Review Article) Fasciitis. Sports Medicine 36 (7) 586-611