Plantar Fasciitis (PF)? What is it?
On the foot of the average person there exists a very thick band of tissue that extends from the bottom of the heel bone (calcaneous) to the ball of the foot, inserting into the skin and tissues around each of the toes. This tissue spans the arch of the foot like a string on a bow. With each step, as weight is placed on the ball of the foot, the arch tends to flatten a little (or a lot depending on the person) tightening this band. Too much tension on the plantar fascia causes micro tears and a painful inflammatory response.
An increase in weight, change in activity such as a new running routine, long hours on your feet, poor shoe gear, tight calf muscles etc. can all contribute to the problem. Also, when you sleep, your feet tend to point downward, this allows the calf muscles and plantar fascia to tighten up during the night. This can also happen after sitting down for a few hours. When you begin walking the shortened tissues are stretched out causing that "first steps" pain.
When the plantar fascia is injured it can enter into a perpetual state of inflammation and degeneration. This process can be controlled but if the patient continues to walk through the pain the body never gets a chance to heal itself. The process repeats itself many times, scar tissue begins to build up and local nerves may become entrapped or permanently irritated and enlarged. This is the time when the patient should begin to contemplate surgery. If conservative treatments fail for several months with no improvement being appreciated, then more invasive measures should be taken. Thankfully, before this level of pathology is reached, the majority of patients find great relief with the conservative measures discussed below if diagnosed correctly in time.
Diagnoses of PF:
PF is normally diagnosed based on the patients story, an x-ray and quick physical exam. The patient's feet, specifically the heels, hurt with the first steps taken in the morning or after any prolonged period of rest. The pain gradually improves with activity but may persist throughout the day worsening after each period of prolonged rest. Pain is usually found if you press deeply into center of the bottom of the heel.
The plantar fascia can be visualized with ultrasound, x-ray and MRI. Thickening of the PF as well as evidence of inflammation are all pieces of evidence used in diagnoses of PF. Partial tears can sometimes be seen but are not normally appreciated.
I was told I have heel spurs...
Do heel spurs equal pain or a diagnoses of PF?? NO!! In the past it was once taught in medical schools that having heel spurs equated to heel pain. Studies have since demonstrated that many people have spurring at the heel without any symptoms whatsoever. The key is this: if it doesn't hurt don't fix it, even if you find a huge spur on x-ray.
How is PF Treated?
Conservative treatment is the first line of attack.
Stretching routines should focus on the plantar fascia, achilles tendon and calf muscles. A number of good studies have shown that sitting with your leg bent into your lap and stretching your toes backwards is the most effective stretch for PF (see picture below). Typical runner's stretches are best with the foot flat on the ground and the body leaning towards a wall alternating straight and bent knee positions (see pictures below). Hold the stretching position for greater than 40 seconds at each try and repeat for 10-15 minutes per day. An even better approach is one 15 min session in the morning and and one at night especially if calf muscle tightness is thought to be the culprit. There are several devices to help in your stretching routine: Thera-Band, Icing, heat packs, rest are also useful. Some patients swear by night splints. Night splints hold the foot at 90 degrees from the leg keeping the plantar fascia and calf muscles stretched out all through the night helping to prevent morning first steps pain and diminishing pain throughout the day.
Supportive shoes are the baseline of treatment. These should have a firm cup around the back of the heel, little give when the shoe is twisted lengthwise and only bend at the ball of the foot. No particular brand of shoe is always a slam dunk, find one that meets these criteria and wear them around the store to verify comfort. This being said, Asics, New Balance and Brooks have a fairly good track record. Your feet are more important than the cost of the shoes. However, more expensive shoes don't necessarily mean a better fit or function.
Orthotics have proven to be quite effect for some individuals (much discussion about orthotics in future posts to come). The current debate is whether $300+ custom orthotics or $30-50 over the counter orthotics are the better treatment. Recent research has shown that custom orthotics perform better in energy expenditure efficiency and pain relief. A good fitting orthotic supports the foot, reducing excessive movement such as pronation and supports the foot and plantar fascia allowing increased healing. Our experience shows better outcomes are had by having custom orthotics made for your specific arch shape compared with buying over the counter products that you may not fit well. Custom orthotics from our lab routinely last over 10 years while over the counter orthotics may only last a few months.
Custom orthotics fabricated on our office typically last over 10 years and quickly pay for themselves when compared with the cost of supplying yourself with over the counter orthotics for that period of time. We guarantee that our orthotics will bring you satisfactory pain relief or return them for a full refund. The cost of the orthotics includes fabrication, casting, fitting and modifications.
NSAIDS are a class of drug that moderate the inflammatory process of the body responsible for swelling and pain, both of which are part of the healing process. The danger with these drugs can be their affects on unhealthy kidneys, increased chance of bleeding and effects on the stomach and intestine contributing to ulcerations. NSAIDS should not be taken for periods longer than a few months and therefore are only an adjunct treatment option for PF pain.
Steroid injections into the plantar fascia are usually enough to knock out the pain for 2-3 months if not for years at time. Excessive steroid injections can lead to weakening (atrophy) of the tendons, skin, fat pads and capsules of the foot near the injection site. Most podiatrists will not inject a patient more than 3-4 times per year (this is a topic of great debate, and each podiatrist may give you a different story). I have seen many cases of patients that need an injection every few years and are "good to go" for quite a long time. Others don't experience as much success. When an injection is combined with supportive shoes, orthotics and stretching, pain will slowly start to diminish.
Surgery: When is surgery finally the answer? In the case of Plantar Fasciitis it is the last resort. The traditional surgical approach is either total or partial release of the plantar fascia from it's attachment to the calcaneous with possible removal of associated nerves. This is either done through a larger open incision or through smaller endoscopic portals using a camera and instruments. Results are quite encouraging with 80-95% of patients reporting successful outcomes. The remaining 5-20% of patients may not experience pain relief at all, may have new pain elsewhere in the foot as joints realign, may develop infection and/or may experience damaged or trapped nerves. Given that these risks happen fairly infrequently, surgical release of the plantar fascia is relatively safe. We are very much of the mind set that we should exhaust all conservative measures before heading to the operating room.
Tenex is a recently developed tool that involves an ultrasound debridement wand that is used to break up scar tissue and increase healing. Recent results are very encouraging and very few side effects are being reported.
Other Options: There are more treatment options for PF than there are Podiatrists. Theses include but are not limited to:
- Graston Techniques (http://www.grastontechnique.com/) or Astym Technique (http://www.astym.com/) where a specially trained therapist performs deep tissue massage with rigid instruments.
- Extracorporeal Shockwave Therapy (http://orthopedics.about.com/od/footankle/i/shockwave.htm), a fancy name for zapping the plantar fascia with shock waves to cause minute damage and encourage to the body to increase it's efforts in healing the damaged area. The evidence is not overwhelming for this option.
- Topaz Micro-debridement (http://www.topazinfo.com/content/other/Fascia.pdf) where a small probe is introduced into the tissue causing micro-damage encouraging increased healing to soft tissues.
The list goes on and on and on. You get the idea, the silver bullet has yet to be found and many attempts will be tried until that happens. Common themes are to control the inflammatory process or to create micro trauma to incite the inflammatory process and create a new phase of healing speeding up the process.
Plantar Fasciitis can be aggravating, life changing, and downright painful. You don't have to put up with the pain, please see a qualified Podiatrist and follow his advise to the "T". The worst thing you can do is to only carry out the advise given by your Doctor when the pain hits you. Plantar fasciitis can come and go each day, week or month. Don't wait around for it to come back, do the stretches, always wear your orthotics, always wear good shoes, the pain is possibly lurking around the corner, beat it too the punch!!
I have pages more to say about this topic, if I've been unclear or left you wondering about something, pop me a line, I'd love to be of assistance.
Dan Preece, DPM
Dan Preece, DPM & Darren Groberg, DPM