Plantar Fasciitis

Description:

A very strong band of tissue, which extends from the medial process of the calcaneal tuberosity and divides into five digital slips at the toes. At the toes it blends with the deep transverse metatarsal ligaments creating a very strong bond. Conversely the medial attachment at the heel is very thin and can pull away from the bone if overstress occurs.

Causes:

Stress at the insertion of the plantar fascia from prolonged standing, walking, wrong shoes or sudden physical activity causes micro-tearing of the plantar fascia fibres. Hyper-pronation of the foot is one of the most common exacerbating factors. In the excessively pronated (flat) foot there is considerable lowering of the medial longitudinal arch, which increases stress on the plantar fascia.  Increasing age means the tendon is less adaptable to stress- this injury often happens around 50 years.  A significant leg length difference can also cause plantar fasciitis to occur.

In a cavus and rigid foot type (high arch) the foot is incapable of absorbing the stress of athletic endeavour. Consequently, any abnormal motion and further repetitive stress can sprain the plantar fascia.

Pathology:

Micro tearing of plantar fascia fibres with resultant pain and inflammation. In chronic and long term asymptomatic plantar fascial stress, a calcaneal spur may develop as the body attempts to strengthen the plantar fascia’s attachment to the calcaneus, but is not diagnostic.

Symptoms:           

Medial or central heel pain, usually 1st thing getting out of bed.  It may reduce with physical activity but often returns later in the day or after rest.  Referred pain up the lower leg or along the medial arch and into the great toe can also be present, the ankle and lower calf may become swollen.

Treatment Plan:

Short-term – Foot stabilisation using strapping tape to control over-pronation or reduce stress on the plantar fascia.  Anti-inflammatory medication if necessary.

Long-term – Alter functional alignment of feet using either customised off-the-shelf, or casted orthoses, for a minimum of 6 months and correct footwear.  The response to orthotics can be very individual and benefits do vary.

  • (1st) Sports strapping tape: Often gives relief for 2-3 days and is applied along the plantar fascia and around the foot to control hyper-pronation and reduce the strain on the fascia. This is used to confirm whether an orthotic will be of benefit, and is only used for 24h and any benefit is very temporary.
  • (2nd) Orthoses: Often footwear alone will not control or support the foot totally and a custom made orthoses will be needed. There are a number of different types available depending on the space in the shoe, patient’s activity and any additional factors such as over-pronation.
  • Rest: Reduce activity, especially sport and long periods of standing.
  • Anti-inflammatories: Non-Steroidal (i.e. Voltaren, Ibuprofen) in tablet form or gel locally to the heel, also natural based ‘Anti-flamme’ cream.
  • Ice and Massage: rolling foot over a frozen drinks bottle. Night splinting:  a loan moonboot.
  • Footwear: more stable shoes with a secure lace or other fastening are needed in over-pronated feet and increased cushioning in higher arched feet.
  • Cortisone: A steroid injected into the area, as a last resort, cortisone can relieve symptoms rapidly for approximately 6 months, with orthotics often being used in conjunction to prevent recurrence in the future. A side-effect can be degeneration of the tendon insertion, and failure to stop the pain long-term.
  • Surgery: for intractable pain, unresponsive to any treatment -can cause collapse of medial arch.