Plantar Fasciitis

Plantar fasciitis (Heel Spur Syndrome) is painful inflammation of a thick, fibrous ligament in the arch (bottom) of the foot. It is a common cause of heel pain and is sometimes called a heel spur. Plantar fasciitis is usually just on one foot, however, in about 30 percent of all cases, both feet are affected.

The ligament, plantar fascia, attaches into the heel bone and fans out toward the ball of the foot, attaching into the base of the toes. If this ligament is stretched excessively it will become inflamed and begin to cause pain. In severe instances the ligament can rupture resulting in immediate severe pain.

Sports such as tennis, racket ball, and aerobics can cause extreme tension on the plantar fascia resulting in small tears or rupture of the ligament. If the ligament ruptures the pain is so great no weight can be placed on the foot. Should this happen, the foot should be elevated and an ice pack applied.

Causes of Plantar Fasciitis

As you can imagine, when the foot is on the ground a tremendous amount of force (the full weight of the body) is concentrated on the plantar fascia. This force stretches the plantar fascia as the arch of the foot tries to flatten from the weight of your body. This is just how the string on a bow is stretched by the force of the bow trying to straighten. This leads to stress on the plantar fascia where it attaches to the heel bone. Small tears of the fascia can result. These tears are normally repaired by the body.

As this process of injury and repair repeats itself over and over again, a bone spur (a pointed outgrowth of the bone) sometimes forms as the body’s response to try to firmly attach the fascia to the heel bone. This appears on an X-ray of the foot as a heel spur. Bone spurs occur along with plantar fasciitis but they are not the cause of the problem.

As we age, the very important fat pad, or shock absorbers, that makes up the fleshy portion of the heel becomes thinner and starts to break down.
Other factors that may contribute to the development of plantar fasciitis include obesity, trauma, weak plantar flexor muscles, excessive flat foot or other alignment problems in the foot and/or ankle, and poor footwear.

Symptoms

The symptoms of plantar fasciitis include pain along the inside edge of the heel near the arch of the foot. The pain is worse when weight is placed on the foot especially after a long period of rest or inactivity. This is usually most pronounced in the morning when the foot is first placed on the floor. This symptom called first-step pain is typical of plantar fasciitis.
Prolonged standing can also increase the painful symptoms. It may feel better after activity but most patients report increased pain by the end of the day. Pressing on this part of the heel causes tenderness. Pulling the toes back toward the face can be very painful.

Treatment of Plantar Fasciitis

Nonsurgical Treatment

Most patients get better with the help of nonsurgical treatments. Stretches for the calf muscles on the back of the lower leg take tension off the plantar fascia.

The main emphasis of treatment is to reduce the forces that are causing the plantar fascia to stretch excessively. This includes calf muscle stretching, over the counter arch supports, and orthotics.

A night splint can be worn while you sleep. The night splint keeps your foot from bending downward. It places a mild stretch on the calf muscles and the plantar fascia. Some people seem to get better faster when using a night splint. They report having less heel pain when placing the sore foot on the ground in the morning.

Supporting the arch with a well fitted arch support, or orthotic, may also help reduce pressure on the plantar fascia. Placing a special type of insert into the shoe, called a heel cup, can reduce the pressure on the sore area. Wearing a silicone heel pad adds cushion to a heel that has lost some of the fat pad through degeneration.

Oral anti-inflammatory medications may be useful in controlling the pain and decreasing the inflammation in the fascia. Studies show that just as many people get better with anti-inflammatories as those who don’t have any improvement. Since these medications are rarely used alone, it’s difficult to judge their true effectiveness.

A cortisone injection into the area of the fascia may be used but has not been proven effective. Studies show better results when ultrasound is used to improve the accuracy of needle placement. Cortisone should be used sparingly since it may cause rupture of the plantar fascia and fat pad degeneration and atrophy, making the problem worse.

Surgery

Surgery is a last resort in the treatment of heel pain. Most procedures that are commonly used today focus on several areas:

• remove the bone spur (if one is present)
• release the plantar fascia (plantar fasciotomy)
• release pressure on the small nerves in the area

Usually the procedure is done through a small incision on the inside edge of the foot, although some surgeons now perform this type of surgery using an endoscope. An endoscope is a tiny TV camera that can be inserted into a joint or under the skin to allow the surgeon to see the structures involved in the surgery. By using the endoscope, a surgeon can complete the surgery with a smaller incision and presumably less damage to normal tissues. It is unclear whether an endoscopic procedure for this condition is better than the traditional small incision.

Surgery usually involves identifying the area where the plantar fascia attaches to the heel and releasing the fascia partially from the bone. If a small spur is present this is removed. The small nerves that travel under the plantar fascia are identified and released from anything that seems to be causing pressure on the nerves. This surgery can usually be done on an outpatient basis. This means you can leave the hospital the same day.