By Dr. Simon B. Small, DPM, FACFS, FAAPSM
Plantar fasciitis is a common foot-pain diagnosis. Also known as a heel-spur syndrome, plantar fasciitis causes heel pain and pain across the bottom of the foot due to the inflammation of the plantar fascia, a fibrous sheath just under the skin and traveling the length of the bottom of the foot from inside the heel bone across the sole to attach at the bottom of the toes.
With the active lever action of foot propulsion, the plantar fascia experiences over-usage. The painful complaints usually occur at the bottom, front portion of the heel bone. The occurrences appear more regularly in older, less flexible tennis players and individuals who do a lot of standing and walking, causing this overuse. The distribution is almost equal between men and women, although overweight patients seem to be more commonly affected.
Plantar fasciitis causes foot pain most typically with activity and upon arising in the morning. The reason the pain is more severe in the morning is that gravity and weight-bearing help massage and lengthen the foot muscles all day long. In bed (in the fetal position), the foot and the muscle in the sole shorten somewhat and when you get out of bed the muscle is forcefully re-stretched, causing the pain.
Since plantar fascial inflammation creates such discomfort and the inability to play, walk, and stand comfortably, attention needs to be focused on the cause. For most tennis players, the cause is usually overuse, worsened by poor biomechanics and foot structure. Therefore, most advice and attention are designed to reduce the stresses and promote healing and then prevention after recovery.
A foot specialist, podiatrist, or orthopedist usually will determine the faulty biomechanics of the foot and generally notice certain things. One is known as pronation or excessive flattening of the arch. Another is the exact opposite position, known as cavus, or excessively high-arched feet. Still, a third and most highly underappreciated portion of the diagnosis is the stretch, or rather lack of stretch (tightness), of the Achilles tendon and calf muscle (which are actually the same structure, but appear differently at different levels of the leg and attaches to the heel bone).
The tightness and then over-stretch of the Achilles tendon or plantar fascia have been shown clinically and in research to be the pain-causing factor. The use of an orthotic appliance, which is designed to balance and support the arch and heel, can be very effective. Orthotics can be custom-ordered by the doctor or obtained over-the-counter as a start to create a good balance and ease the overuse condition.
Treatment and Stretching
Conservative treatment, such as physiotherapy, aims to reduce local inflammation and address any biomechanical problems. While the plantar fascia is painful, it may be treated with ice application and anti-inflammatory medications. When the pain has subsided, stretching the plantar fascia in an organized exercise format is effective to encourage the tissue to regain normal alignment. Once the painful complaints are gone, stretching the plantar fascia (by moving the toes upward toward the front of the leg) is effective in encouraging the tissue to regain normal alignment and can relieve the symptoms of plantar fasciitis.
Splints worn at night have been shown to keep the plantar fascia muscle in a stretched position during sleep. This helps keep the muscles from retightening and shortening during the night, alleviating pain when you get out of bed.
Taping can also help players who suffer from plantar fasciitis by removing some of the strain that can aggravate the condition. A physiotherapist or athletic trainer can simply tape the ankle and foot in a position where the Achilles tendon and plantar fascia are under less stress by slightly angling the toes downward. They can also provide a small heel pad inside the taping and under the heel, which elevates the heel and reduces the pull of the muscle.
Plantar fasciitis resolves itself with conservative care in most cases. However, in severe cases, where heel pain is affecting normal walking, it is possible to have the doctor provide an injection, which involves a mixture of cortisone and local Novocain-type anesthetic. After the injection, the patient would rest for several days and then can resume normal activities on a gradual basis.
Is Surgery Necessary?
In persistent cases of plantar fasciitis that fail to respond in more than one year of conservative treatment, surgery can be considered. In the past, surgery included the removal of small bone spurs from the heel bone, known as a heel spur, and the cutting of the plantar fascia muscle which attaches to the inside of the heel spur at the heel bone on the bottom portion. This lack of tension is believed to reduce the pressure of the muscle pull that causes the pain initially. Some surgical results have been positive, but I feel that with the proper biomechanics and orthotic control, most cases of plantar fasciitis can be resolved without the use of the scalpel.
It is also important to note that stress fractures, tendinitis, arthritis, nerve entrapments, irritation to the nerves, trauma, bone cysts, and heel bursitis all are possible diagnoses that are related to plantar fasciitis, but are different in their cause and would be different in much of their treatment.
However, the concept of relieving the pain of the plantar fascia is tantamount to relieving the cause of the discomfort, therefore adequate orthotics or heel raises would be necessary for long-term conservative care. Also, inadequate footwear often is implicated in plantar fasciitis- shoes should provide adequate support for the foot, understanding though that the shoe is a housing for the foot and not a supporting device. However, unstable shoes can create the overuse of the plantar fascia and lead to the development of inflammation.
Overall, plantar fasciitis is a controllable malady, but often painful and limiting to athletics in general. Consult your health professional regarding heel pain and watch your efficiency increase.
Simon B. Small, DPM, FACFS, FAAPSM, is a board-certified Sports Medicine Specialist, Podiatrist, and President of Pro-Support Systems, Inc.