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The ABCs of Plantar Fasciitis

Issue: August 2009

By: Alicia Knee, DPM

Plantar fasciitis, an inflammation of the plantar fascia of the foot, is one of the most common causes of heel pain. Since the plantar fascia runs across the bottom of the foot, connecting the heel bone to the toes, it causes pain when inflamed, and other symptoms can include flattening of the arch and tightening of the calf and hamstring muscles.

Plantar fasciitis can affect people of any age, and those for whom it’s chronic will find it more difficult to alleviate. It’s particularly common in runners, and others who are at higher risk of developing it include overweight people, pregnant women and those who wear shoes with inadequate support. It is a common problem without a known etiology.

In most cases, the pain associated with plantar fasciitis develops gradually and affects just one foot, although it can occur in both feet simultaneously. It’s often at its worst when people take their first steps after awakening, but it can also be triggered by long periods of standing or getting up from a seated position. Patients will complain about having a sharp pain in the heel of their foot.

The good news about plantar fasciitis is that more than 90 percent of all cases will go away without surgical intervention. The challenge for physicians is to rule out the other things that can be causing pain, such as stress fractures. The first thing I tell plantar fasciitis sufferers is that they need to wear shoes that offer good support—they should avoid going barefoot and wearing flip flops, slippers and flexible shoes—and they should begin a stretching program.

Assessing the Symptoms

There are three primary symptoms of plantar fasciitis; the appropriate treatment will be determined by which symptom your patient exhibits.

Symptom #1: Tight gastroc-soleus complex or hamstrings. When you dorsiflex the ankle with the subtalar joint held in a neutral position and the knee extended, the patient should have 10 to 15 degrees of dorsiflex available. If they have less ankle dorsiflexion than that, you know they need to be on a stretching program.

Symptom #2: Arches collapse in stance. This symptom may respond to orthotics and/or arch support as well as supportive shoes with a rigid heel counter an mid sole. A varus heel wedge with a four-degree incline may be appropriate to address pronation.

Symptom #3: First-step pain. When patients complain of heel pain when they take their first steps of the day, that’s caused by the plantar fascia shortening during sleep. The best way to alleviate this symptom is to prescribe a night splint, which will hold the foot at a 90-degree angle to the leg, keeping the plantar fascia on stretch. It may take one to two nights to get used to sleeping with the device. You should also recommend that these patients not go barefoot.

As noted previously, it’s important to rule out other potential causes of foot pain before starting to treat a patient for plantar fasciitis. If you have an elderly, osteoporotic female with new onset pain and pain with medial to lateral compress of the body of the calcaneus, you should consider a stress fracture in your differential. Also, if you palpate the calcaneus and find the fat pad has atrophied, your patient may have a bone bruise that can be treated with a Tully or silicone heel cup.

Treatment Considerations

When patients don’t fit nicely into one of those three symptom “buckets” noted above, or they have multiple symptoms, I always begin with the most conservative treatment, moving to more aggressive options only if the initial course of action doesn’t work. Most patients will get better with “Level 1” treatment:

Level 1: Stretching the calf and hamstring muscles; wearing an over-the-counter arch support and/or a night splint and a trial of NAIDs

Level 2: Receiving steroid injections, treating the symptoms but not the cause, so it’s important to continue with the Level 1 activities

Level 3: Wearing a well-molded fiberglass or plaster cast

Level 4: Undergoing a brief outpatient surgical procedure, endoscopic release, during which we cut the medial band of the fascia where it inserts into the heel, with the resultant scar tissue lengthening the ligament

Less than 10% of patients will require surgical intervention, and the success rate varies between 75-90%, depending on the study.

New and Sometimes Controversial Options

We’ve all experienced patients coming to us requesting treatments they’ve seen advertised as the “next big thing.” In my field, we’re hearing more and more about TOPAZ, minimally invasive radiofrequency treatments for tendons and fascia, and platelet-rich plasma injections.

The radiofrequency treatment, which claims to shorten recovery times and better preserve the anatomical structure of the tissue, has not generated any evidenced-based results to that effect. Exactly how it works is not completely understood. Theories include the formation of new blood vessels or destruction of sensory pain fibers. Since the jury is still out on the benefit of the procedure, insurance companies have not covered it.

Platelet-rich plasma injections with high platelet concentrations that contain growth factors, injected into the area in the hope of beginning a cascade of events that includes healing and tissue regeneration. Insurance coverage is also difficult.

While some people will be predisposed to develop plantar fasciitis based on their “biology,” there are a few things to suggest as preventive measures: maintain a healthy weight, choose supportive shoes, and don’t wear worn-out athletic shoes (replace them after about 500 miles of use).

Alicia Knee, DPM, is a podiatrist on-staff at Sutter Solano Medical Center.

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