Plantar Fasciitis – Causes & Management

Plantar fasciitis is a common condition causing heel pain. The pain is caused by inflammation of the plantar fascia at its insertion in the heel bone. The condition commonly affects athletes and nonathletes alike. The condition is associated with known risk factors but in some cases, there is no definite cause.

The plantar fascia is a tough band of tissue present just beneath the skin in the sole of the foot. The tissue originates from the heel bone and spreads to attach to the toes in the front. The plantar fascia is involved in the normal functioning of the foot in day to day activities.

The plantar fascia provides support to the arches of the foot while walking, standing, and running. The tissue is tough but flexible enough to absorb the stress and distribute it equally in the foot.

Symptoms

The commonest symptom of plantar fasciitis is heel pain with the first step on waking up. The pain decreases in intensity with activity. The pain may also occur on getting up after prolonged sitting.

Runners may experience pain after running but not during the activity. The pain is often described as a sharp pain but maybe dull aching in character.

The pain may be associated with mild swelling of the heel. The heel may be sore to touch and pressure. The patient may walk on their toes to avoid the pain of plantar fasciitis.

The patients may have numbness with pins and needles sensations along the inner side of the foot. It is due to the entrapment of the posterior tibial nerve in the tarsal canal, known as tarsal tunnel syndrome.

Causes & risk factors

Inflammation of the plantar fascia may be a result of injury or chronic overuse.

• The condition is more common in age groups of 30 – 60 years of age. Women are slightly more susceptible to develop plantar fasciitis.
• The amount of stress acting on the plantar fascia is related to body weight. Overweight and obese individuals are at a greater risk to develop plantar fasciitis.
• Flat foot also known as pes planus is a risk factor for the development of plantar fasciitis. The weakened medial arch increases the stress on the plantar fascia leading to inflammation and pain.
  Similarly, a high arch of the foot also known as pes cavus may increase the stress acting on the plantar fascia.
• Tight calf muscles increase the tension in the plantar fascia. The patients are unable to move the foot up during normal movements. The increased tension may cause tears of the plantar fascia.
• A sudden increase in training without stretching/strengthening may lead to plantar fasciitis.
• Chronic overuse is the cause of plantar fasciitis in runners and dancers. The repetitive activity may lead to the development of small tears and subsequent inflammation of the plantar fascia. Improper shoes and worn-out shoes may also lead to plantar fasciitis.
• In non-athletes, tight calf muscles and factors such as obesity play a greater role in plantar fasciitis. An occupation that requires long periods of standing such as teaching may cause overuse of the plantar fascia causing pain.
• Heel spurs are bone overgrowths on the undersurface of the heel bone (calcaneum). Previously thought to be the cause of plantar fasciitis, it is now known to be the result of plantar fasciitis.

Diagnosis

Diagnosing plantar fasciitis requires a physician consultation. The doctor’s office visit includes a detailed history of the events leading to heel pain. The physician will inquire about the level of physical activity and systemic diseases.

A detailed physical examination is done to locate the heel pain and rule out other causes of the pain. The patient’s foot is examined for tender points. The range of motion in all planes is assessed by the physician. Power and sensory examination are done to rule out any neurological cause of heel pain.

The radiological examination is done in the form of an X-ray. The physician will look for any fractures, bone spurs, alignment of the bones, and signs of arthritis.

A CT scan will normally provide a more detailed view compared to an X-ray. An MRI may be warranted to look for structures not visible on an X-ray. Structures such as plantar fascia ligaments are better visualized on MRI.

Management

The treatment of plantar fascia is generally conservative i.e non-surgical. Various treatment modalities include :

• Rest to the foot allows the healing of the injured fascia.
• Icing may help alleviate pain and inflammation when done at regular intervals multiple times a day.
• The doctor may recommend activity adjustment as it helps to reduce inflammation and decrease the future incidence of plantar fasciitis.
• Nonsteroidal anti-inflammatory drugs such as ibuprofen and naproxen aids in reducing inflammation. The medications also help reduce heel pain.
• Shoe inserts in the form of heel and arch support help to reduce tension in the plantar fascia. Specially designed supportive shoes may also be used.
• Night splints help to provide rest and allow the healing of the injured fascia. A boot cast may be applied to allow healing.
• Topical steroidal anti-inflammatory ointments may be used to reduce pain and inflammation.
• Corticosteroid injections may be given in the most tender part of the heel. Corticosteroid injections usually are able to control pain for a month and reduce inflammation for a longer period. Ultrasound imaging may be utilized to guide the injection.
• People with plantar fasciitis not responding to medications and therapy may benefit from extracorporeal shock wave therapy. The shock waves promote the healing of the inflamed fascia.
• Physical therapy and home exercise programs are aimed to stretch the tight calf muscles. Strengthening the calf and foot muscles helps to better stabilize the foot during movement and reduce tension on the plantar fascia.

Surgical management is done rarely to treat plantar fasciitis. Patients not experiencing relief after a prolonged period of conservative management are candidates for surgical treatment. The surgical treatment consists of the release of the gastrocnemius muscle to reduce the tightness of the calf muscles.

Another surgery that can be performed is a partial release of the plantar fascia from the heel. The complete release is not done as it could cause instability. The surgery can also be extended to release the entrapped posterior tibial nerve in the tarsal canal.

The above surgery can also be performed with an arthroscope. Arthroscopic surgery is a minimally invasive technique utilizing buttonhole incisions promising a faster recovery. A small camera with a mounted light source is inserted to look for the abnormality. Miniature instruments are then inserted to treat the condition.