The plantar fascia (a connective tissue structure) stretches from the toes and ball of the foot, through the arch, and connects to the heel bone in three places: outside, center and inside. Normally it helps the foot spring as it rolls forward. It also provides support for the arch of the foot. The plantar fascia helps keep the foot on track, cutting down on oscillation. When the foot over-pronates (rolls to the inside) the plantar fascia tries to stabilize it and prevent excessive roll. In time, the inside and sometimes center connections are overstressed and pull away from their attachments. The first sign is usually heel pain as you rise in the morning. When you walk around, the pain may subside, only to return the next morning. Inflammation and increased soreness are the results of long-term neglect and continued abuse. A heel bone spur may develop after a long period of injury when there is no support for the heel. The plantar fascia attaches to the heel bone with small fibers. When these become irritated they become inflamed with blood containing white blood cells. Within the white blood cells are osteoblasts which calcify to form bone spurs and calcium deposits. The body is trying to reduce stress on that area by building a bone in the direction of stress. Unfortunately, these foreign substances cause pain and further irritation in the surrounding soft tissue.
It is common to see patients with Plantar Fasciitis who have been wearing shoes that are too soft and flexible. The lack of support can be stressful on the heel for those patients who’s feet aren’t particularly stable. If these ill fitting shoes are worn for long enough, the stress will lead to Heel Pain as the inflammation of the fascia persists. Footwear assessment and advice will be essential in order to get on top of the Plantar Fasciitis. It may surprise some people to learn that high heeled shoes are not the cause of Plantar Fasciitis, although they can cause tight calf muscles. High arches can lead to Plantar Fasciitis. This is due to the lack of contact under the sole of the foot. Even sports shoes which appear to have good arch support inside are often too soft and not high enough to make contact with the arch of the foot. Hence, the plantar fascia is unsupported. This can lead to Heel pain and Plantar Fasciitis. Flat feet can lead to Plantar Fasciitis. Flat feet is caused by ligament laxity and leads to foot instability. Other structures such as muscles, tendons and fascia work harder to compensate for this instability. Heel pain or Plantar Fasciitis arises when the instability is too great for these other structures to cope with. The strain on the fascia is too severe and the inflammation sets in. Over stretching can lead to Plantar Fasciitis. Certain calf stretches put the foot into a position that creates a pulling sensation through the sole of the foot. This can cause Plantar Fasciitis which can cause pain in the arch of the foot as well as Heel Pain.
The symptoms of plantar fasciitis are pain on the bottom of the heel, pain in the arch of the foot, pain that is usually worse upon arising, pain that increases over a period of months. People with plantar fasciitis often describe the pain as worse when they get up in the morning or after they’ve been sitting for long periods of time. After a few minutes of walking the pain decreases, because walking stretches the fascia. For some people the pain subsides but returns after spending long periods of time on their feet.
The health care provider will perform a physical exam. This may show tenderness on the bottom of your foot, flat feet or high arches, mild foot swelling or redness, stiffness or tightness of the arch in the bottom of your foot. X-rays may be taken to rule out other problems.
Non Surgical Treatment
More than 90% of patients with plantar fasciitis will improve within 10 months of starting simple treatment methods. Rest. Decreasing or even stopping the activities that make the pain worse is the first step in reducing the pain. You may need to stop athletic activities where your feet pound on hard surfaces (for example, running or step aerobics). Ice. Rolling your foot over a cold water bottle or ice for 20 minutes is effective. This can be done 3 to 4 times a day. Nonsteroidal anti-inflammatory medication. Drugs such as ibuprofen or naproxen reduce pain and inflammation. Using the medication for more than 1 month should be reviewed with your primary care doctor. Exercise. Plantar fasciitis is aggravated by tight muscles in your feet and calves. Stretching your calves and plantar fascia is the most effective way to relieve the pain that comes with this condition. Cortisone injections. Cortisone, a type of steroid, is a powerful anti-inflammatory medication. It can be injected into the plantar fascia to reduce inflammation and pain. Your doctor may limit your injections. Multiple steroid injections can cause the plantar fascia to rupture (tear), which can lead to a flat foot and chronic pain. Soft heel pads can provide extra support. Supportive shoes and orthotics. Shoes with thick soles and extra cushioning can reduce pain with standing and walking. As you step and your heel strikes the ground, a significant amount of tension is placed on the fascia, which causes microtrauma (tiny tears in the tissue). A cushioned shoe or insert reduces this tension and the microtrauma that occurs with every step. Soft silicone heel pads are inexpensive and work by elevating and cushioning your heel. Pre-made or custom orthotics (shoe inserts) are also helpful. Night splints. Most people sleep with their feet pointed down. This relaxes the plantar fascia and is one of the reasons for morning heel pain. A night splint stretches the plantar fascia while you sleep. Although it can be difficult to sleep with, a night splint is very effective and does not have to be used once the pain is gone. Physical therapy. Your doctor may suggest that you work with a physical therapist on an exercise program that focuses on stretching your calf muscles and plantar fascia. In addition to exercises like the ones mentioned above, a physical therapy program may involve specialized ice treatments, massage, and medication to decrease inflammation around the plantar fascia. Extracorporeal shockwave therapy (ESWT). During this procedure, high-energy shockwave impulses stimulate the healing process in damaged plantar fascia tissue. ESWT has not shown consistent results and, therefore, is not commonly performed. ESWT is noninvasive-it does not require a surgical incision. Because of the minimal risk involved, ESWT is sometimes tried before surgery is considered.
If treatment hasn’t worked and you still have painful symptoms after a year, your GP may refer you to either an orthopaedic surgeon, a surgeon who specialises in surgery that involves bones, muscles and joints, a podiatric surgeon, a podiatrist who specialises in foot surgery. Surgery is sometimes recommended for professional athletes and other sportspeople whose heel pain is adversely affecting their career. Plantar release surgery. Plantar release surgery is the most widely used type of surgery for heel pain. The surgeon will cut the fascia to release it from your heel bone and reduce the tension in your plantar fascia. This should reduce any inflammation and relieve your painful symptoms. Surgery can be performed either as, open surgery, where the section of the plantar fascia is released by making a cut into your heel, endoscopic or minimal incision surgery – where a smaller incision is made and special instruments are inserted through the incision to gain access to the plantar fascia. Endoscopic or minimal incision surgery has a quicker recovery time, so you will be able to walk normally much sooner (almost immediately), compared with two to three weeks for open surgery. A disadvantage of endoscopic surgery is that it requires both a specially trained surgical team and specialised equipment, so you may have to wait longer for treatment than if you were to choose open surgery. Endoscopic surgery also carries a higher risk of damaging nearby nerves, which could result in symptoms such as numbness, tingling or some loss of movement in your foot. As with all surgery, plantar release carries the risk of causing complications such as infection, nerve damage and a worsening of your symptoms after surgery (although this is rare). You should discuss the advantages and disadvantages of both techniques with your surgical team. Extracorporeal shockwave therapy (EST) is a fairly new type of non-invasive treatment. Non-invasive means it does not involve making cuts into your body. EST involves using a device to deliver high-energy soundwaves into your heel. The soundwaves can sometimes cause pain, so a local anaesthetic may be used to numb your heel. It is claimed that EST works in two ways. It is thought to, have a “numbing” effect on the nerves that transmit pain signals to your brain, help stimulate and speed up the healing process. However, these claims have not yet been definitively proven. The National Institute for Health and Care Excellence (NICE) has issued guidance about the use of EST for treating plantar fasciitis. NICE states there are no concerns over the safety of EST, but there are uncertainties about how effective the procedure is for treating heel pain. Some studies have reported that EST is more effective than surgery and other non-surgical treatments, while other studies found the procedure to be no better than a placebo (sham treatment).
Every time your foot strikes the ground, the plantar fascia is stretched. You can reduce the strain and stress on the plantar fascia by following these simple instructions: Avoid running on hard or uneven ground, lose any excess weight, and wear shoes and orthotics that support your arch to prevent over-stretching of the plantar fascia.