Plantar fasciitis is a common cause of heel pain in adults. The pain is usually caused by collagen degeneration (which is sometimes misnamed âchronic inflammationâ) at the origin of the plantar
fascia at the medial tubercle of the calcaneus. This degeneration is similar to the chronic necrosis of tendonosis, which features loss of collagen continuity, increases in ground substance (matrix
of connective tissue) and vascularity, and the presence of fibro-blasts rather than the inflammatory cells usually seen with the acute inflammation of tendonitis. The cause of the degeneration is
repetitive microtears of the plantar fascia that overcome the body's ability to repair itself.
The cause of plantar fasciitis is poorly understood and is thought to likely have several contributing factors. The plantar fascia is a thick fibrous band of connective tissue that originates from
the medial tubercle and anterior aspect of the heel bone. From there, the fascia extends along the sole of the foot before inserting at the base of the toes, and supports the arch of the foot.
Originally, plantar fasciitis was believed to be an inflammatory condition of the plantar fascia. However, within the last decade, studies have observed microscopic anatomical changes indicating that
plantar fasciitis is actually due to a non-inflammatory structural breakdown of the plantar fascia rather than an inflammatory process. Due to this shift in thought about the underlying mechanisms in
plantar fasciitis, many in the academic community have stated the condition should be renamed plantar fasciosis. The structural breakdown of the plantar fascia is believed to be the result of
repetitive microtrauma (small tears). Microscopic examination of the plantar fascia often shows myxomatous degeneration, connective tissue calcium deposits, and disorganized collagen fibers.
Disruptions in the plantar fasciaâs normal mechanical movement during standing and walking (known as the Windlass mechanism) are thought to contribute to the development of plantar fasciitis by
placing excess strain on the calcaneal tuberosity.
People with this condition sometimes describe the feeling as a hot, sharp sensation in the heel. You usually notice the pain first thing in the morning when you stand. After walking for a period of
time, the pain usually lessens or even disappears. However, sharp pain in the center of the heel may return after resting for a period of time and then resuming activity.
Plantar fasciitis is usually diagnosed by a health care provider after consideration of a personâs presenting history, risk factors, and clinical examination. Tenderness to palpation along the
inner aspect of the heel bone on the sole of the foot may be elicited during the physical examination. The foot may have limited dorsiflexion due to tightness of the calf muscles or the Achilles
tendon. Dorsiflexion of the foot may elicit the pain due to stretching of the plantar fascia with this motion. Diagnostic imaging studies are not usually needed to diagnose plantar fasciitis.
However, in certain cases a physician may decide imaging studies (such as X-rays, diagnostic ultrasound or MRI) are warranted to rule out other serious causes of foot pain. Bilateral heel pain or
heel pain in the context of a systemic illness may indicate a need for a more in-depth diagnostic investigation. Lateral view x-rays of the ankle are the recommended first-line imaging modality to
assess for other causes of heel pain such as stress fractures or bone spur development. Plantar fascia aponeurosis thickening at the heel greater than 5 millimeters as demonstrated by ultrasound is
consistent with a diagnosis of plantar fasciitis. An incidental finding associated with this condition is a heel spur, a small bony calcification on the calcaneus (heel bone), which can be found in
up to 50% of those with plantar fasciitis. In such cases, it is the underlying plantar fasciitis that produces the heel pain, and not the spur itself. The condition is responsible for the creation of
the spur though the clinical significance of heel spurs in plantar fasciitis remains unclear.
Non Surgical Treatment
A doctor may prescribe anti-inflammatory medication such as ibuprofen to help reduce pain and inflammation. Electrotherapy such as ultrasound or laser may also help with symptoms. An X-ray may be
taken to see if there is any bone growth or calcification, known as a heel spur but this is not necessarily a cause of pain. Deep tissue sports massage techniques can reduce the tension in and
stretch the plantar fascia and the calf muscles. Extracorporeal shock wave therapy has been known to be successful and a corticosteroid injection is also an option.
The majority of patients, about 90%, will respond to appropriate non-operative treatment measures over a period of 3-6 months. Surgery is a treatment option for patients with persistent symptoms, but
is NOT recommended unless a patient has failed a minimum of 6-9 months of appropriate non-operative treatment. There are a number of reasons why surgery is not immediately entertained including.
Non-operative treatment when performed appropriately has a high rate of success. Recovery from any foot surgery often takes longer than patients expect. Complications following this type of surgery
can and DO occur! The surgery often does not fully address the underlying reason why the condition occurred therefore the surgery may not be completely effective. Prior to surgical intervention, it
is important that the treating physician ensure that the correct diagnosis has been made. This seems self-evident, but there are other potential causes of heel pain. Surgical intervention may include
extracorporeal shock wave therapy or endoscopic or open partial plantar fasciectomy.
The following exercises are commonly prescribed to patients with this condition. You should discuss the suitability of these exercises with your physiotherapist prior to beginning them. Generally,
they should be performed 2 - 3 times daily and only provided they do not cause or increase symptoms. Your physiotherapist can advise when it is appropriate to begin the initial exercises and
eventually progress to the intermediate and advanced exercises. As a general rule, addition of exercises or progression to more advanced exercises should take place provided there is no increase in
symptoms. Calf Stretch with Towel. Begin this stretch in long sitting with your leg to be stretched in front of you. Your knee and back should be straight and a towel or rigid band placed around your
foot as demonstrated. Using your foot, ankle and the towel, bring your toes towards your head until you feel a stretch in the back of your calf, Achilles tendon, plantar fascia or leg. Hold for 5
seconds and repeat 10 times at a mild to moderate stretch provided the exercise is pain free. Resistance Band Calf Strengthening. Begin this exercise with a resistance band around your foot as
demonstrated and your foot and ankle held up towards your head. Slowly move your foot and ankle down against the resistance band as far as possible and comfortable without pain, tightening your calf
muscle. Very slowly return back to the starting position. Repeat 10 - 20 times provided the exercise is pain free.