Plantar Fasciitis

Heel spurs, heel spur syndrome and plantar fasciitis refer to the same condition. Although hard to pronounce, plantar fasciitis is rapidly becoming the most commonly used term to describe this condition. Plantar is a geographic term that refers to the bottom of the foot (dorsal on top/plantar on bottom). Fascia is a tough, inelastic band. And 'itis' always refers to something that's inflamed (bronchitis, arthritis, etc.). When the root words are combined they describe is an inflammatory condition of a fascial band on the bottom of the foot; plantar fasciitis. Pain associated with plantar fasciitis is specific to the plantar heel as seen in red in the accompanying image.

How do we develop plantar fasciitis? Plantar fasciitis is an overuse syndrome that is the result of excessive and repetitive loading of the plantar fascia. When we stand, load is applied to the arch of the foot causing the height of the arch to drop. This drop in the height of the arch places tension on the plantar fascia. If the tension (load) applied to the plantar fascia is greater than what the fascia can tolerate, the fascia will become inflamed.

Treatment of Plantar Fasciitis

Treatment of plantar fasciitis is based on four broad categories of care; biomechanical methods, anti-inflammatories methods, surgery and other methods. Let's take a closer look at each of these four categories and see how they can often work together.

The leg, ankle and foot functions as a lever. This lever is called the CT band. Levers consist of three parts; an effort arm, a fulcrum and a resistance arm. In the CT band, the leg is the effort arm or source of force coming primarily from the calf muscles. The ankle is the fulcrum or hinge of the lever. And the foot is the resistance arm of the lever. The resistance arm of the lever is where the force creates action. The lever action of the leg, ankle and foot is to deliver force from the strongest muscle in our body (the calf) to the ball-of-the-foot. The action created is what we know as walking. Plantar fasciitis is the result of an imbalance in the lever mechanics of the leg ankle and foot. This imbalance results in force from the effort arm (calf) that overwhelms the resistance arm (the foot).

The first step in treating plantar fasciitis is to try and restore the balance between the effort arm and the resistance arm of the CT band. To do so, there are three simple steps;

• Avoid going barefoot or wearing a shoe with a low heel.

• Wear a heel lift or shoe with an elevated heel.

• Begin a program of calf stretches. If you are unable to complete 6 stretches/day, begin the use of a night stretching splint.

Taping the arch, stretching splints, heel cushions and a host of other 'devices' have been used successfully to treat plantar fasciitis. All of these devices focus on changing the biomechanical properties of the CT band. Remember, the key to treating plantar fasciitis is addressing the entire CT Band and not just the plantar fascia. Stretches and heel lifts are quite often all that is needed to change the biomechanical properties of the CT band and for complete resolution of symptoms of plantar fasciitis. Arch supports can be used on a daily basis to maintain good support of the arch and help to decrease recurrence of plantar fasciitis.

The second category of care is the use of anti-inflammatories. Anti-inflammatories include steroid injections, oral anti-inflammatory medications such as aspirin, prescription strength medications called NSAID's, ultrasound, massage, topical medications and a host of other methods to reduce inflammation. When using anti-inflammatories, bear in mind that we are treating a problem that we know is mechanical in nature. Plantar fasciitis is caused by mechanical overuse or overloading of the CT band. Anti-inflammatories help with the dull ache common in cases of plantar fasciitis. Anti-inflammatories typically do not help with the sharp tearing pain found with that first step out of bed or when initially standing during the day. That's why it's important to combine mechanical methods of care (above) with the use of an anti-inflammatory. The two methods work in conjunction with each other to address the two different types of pain that are common in cases of plantar fasciitis.

The third category of care includes surgery and what we describe as other methods (below). Surgery becomes indicated when a course of conservative care has failed. Endoscopic surgical methods have become the standard of care for the treatment of plantar fasciitis. The surgical procedure used today to treat plantar fasciitis is called an endoscopic plantar fasciotomy. The older methods of surgical correction included resection of the heel spur or partial resection of the heel bone. With an endoscopic plantar fasciotomy, we release, or make a cut through the fascia, leaving any spur in place. It's important to recognize that we are treating a soft tissue problem (plantar fasciitis) and not a bone problem (heel spur).

The following video shows the steps used to perform an endoscopic plantar fasciotomy. This procedure is performed at a surgery center or hospital and is completed with sedation and local anesthesia. The procedure takes approximately 15 minutes to complete. Patients are able to walk the very same day on the foot and return to most activities within 3-4 weeks.

Heel spur surgery, whether performed endoscopically or with a traditional method, is not without problems. While 90% of EPF cases are completed without complication, 10% do have problems that can vary in severity. One complication specific to plantar fasciotomies, regardless of how they are performed, is later column syndrome (LCS). LCS is sometimes a very difficult complication to understand, diagnose and treat. The complications of LCS occur not in the first week or two after surgery but rather 2-4 month after a plantar fasciotomy. As a patient reaches status 4 weeks post surgery, they start to feel more able to return to their normal activities. As they progressively increase their activities they begin to add an increase of load to the foot. Although the surgical site no longer is sore from the surgery, the biomechanical impact, or change to the joint structure of the foot is not complete for 4-6 months following the surgery. Early symptoms of LCS are a dull ache of the lateral (outside) of the foot and the top of the arch. This ache is a stiffness that if left untreated will result in small stress fractures if the lateral and dorsal aspects of the foot. LCS is a manageable complication of this procedure and should be thoroughly discussed before surgery so that patients are aware of the symptoms of LCS and can make their doctor aware should they experience problems.

Other non-conservative methods of care include shock wave therapy, Topaz surgery growth factor injections and neuroablation. These methods of treating plantar fasciitis focus on the difference between the terms plantar fasciitis and plantar fasciosis. Plantar fasciitis is an acute inflammatory condition of the plantar fascia. But after several months, the inflammatory nature of plantar fasciitis changes. Studies that have used tissue biopsy of long term plantar fasciitis show that over time, there become less of an inflammatory response by the body within the plantar fascia. So the acute inflammatory condition of plantar fasciitis changes to a non-inflamed case of plantar fasciosis. This finding is the basis for several other techniques used to treat plantar fasciitis.

Extracorporeal shock wave therapy is used as a tool to break the re-injury cycle associated with plantar fasciitis. Shock wave therapy employs an acoustic wave that results in an explosion of energy at the point of focus. Shock waves differ in amplitude and are 'tuned' for a specific purpose based upon the desired amplitude and medium that is crossed to reach a target tissue. The effect of the shock wave in cases of plantar fasciitis is not fully understood. It is believed that the effect of the shock wave stimulates an intense focused inflammatory reaction that promotes healing at the insertion of the plantar fascia. Shock wave therapy can be painful to perform and therefore requires that the procedure be performed in an outpatient setting with deep sedation. The procedure takes about 15 minutes to complete and does not require a local anesthetic (only sedation). Patients are able to walk on the foot the same day. Complication are minimal. Most doctors will require continued stretching and limited activity for 4 weeks following shock wave therapy. The long term success or failure of shock wave therapy is yet to be seen, but recent studies have had short term success rates of 65-95%. For additional information on shock wave therapy refer to The International Society for Musculoskeletal Shock Wave Therapy.

Topaz surgery is used to treat plantar fasciosis. To complete Topaz surgery, a patient is taken to surgery, sedated and anesthetized. A Topaz wand is used to place a series of small holes or defects within the fascia. The Topaz wan creates this defect by using radio frequency ablation. Patients are able to bear weight and walk immediately following surgery.

Growth factor injections are also used to treat cases of plantar fasciitis/plantar fasciosis that have failed conservative care. Growth factor is isolated from the platelets in a patient's blood. This technique can be completed in the doctor's office. A 50cc sample of blood is drawn from the patient and spun down in a centrifuge. The platelets are then re-injected into the most symptomatic area of heel pain. Patients are able to walk immediately following this procedure.

Neuroablation is a technique used to treat heel pain that doesn't focus on treating inflammation, but instead focuses on deadening nerve pain in the plantar heel. Neuroablation doesn't actually treat the mechanical component of heel spur syndrome, but instead destroys nerve that supplies sensation to the bottom of the heel. Neuroablation can be performed with a cold probe (cryoablation, thermoablation) with a hot probe (radiofrequency surgery) or with injectable chemicals (alcohol, phenol). Neuroablation is an appropriate procedure for select patients who have not responded to conservative care.

What's the best method of care for you? That decision should be made by you and your doctor as a team. Consider conservative measures of care as a means to help your body heal itself. Surgery on the other hand is the physical change. The first consideration in determining a treatment plan is the duration of your symptoms of plantar fasciitis. How long has your plantar fasciitis been present? If your symptoms have been present for more than a year or if you've tried 4 months of conservative care with no change in your symptoms, you are probably a good candidate for surgery or other care.

Plantar Fascial Tears

Plantar fascial tears are a relatively uncommon injury. There are no precipitating factors (age, weight, smoker, etc) that would tend to make one patient more susceptible to a plantar fascial tears. Plantar fascial tears occur in men within the 20-50 year age range who are engaged in aggressive activities such as sports or physical labor. The onset of a plantar fascial tear is abrupt and typically secondary to a fall or sports injury. Sharp pain with weight bearing, along with bruising specific to the plantar heel and arch are found. Treatment include, rest, ice, compression and partial weight bearing to tolerance. Surgical repair of a torn plantar fascia is unnecessary. The fascia will heal over the course of 4-6 weeks to be fully functional. Plantar fascial tears should be evaluated with an x-ray to rule out a stress fracture of the heel.

The terms heel spur syndrome and plantar fasciitis are used interchangeably to describe a set of symptoms which include pain in the bottom of the heel. Heel spur syndrome is the older of the two terms but has remained as a common description of these symptoms. Plantar fasciitis is a relatively newer term that is more descriptive of the condition and is becoming the definition used by most medical professionals.

‘Plantar’ refers to the bottom of the foot. ‘Fascia’ is a component of the musculoskeletal system that is found through-out the body. Fascia helps to support the function of the bones and joints and often acts as an anchor for structures such as muscles. ‘Itis’ refers to the inflammation found in a structure and is used in other familiar words such as arthritis (inflammation in a joint).

The combination of plantar + fascia + itis results in the descriptive term, plantar fasciitis, or inflammation of the plantar fascia.

Enthesiopathy - pain that results from a ligament or tendon pulling away from its' insertion on a bone

EPF - endoscopic plantar fasciotomy

Lateral column - All osseus and soft tissues of the foot including the calcaneus, cuboid, 4th and 5th metatarsals.

Lateral Column Syndrome - a complication post EPF surgery due to abrupt loading of the lateral column of the foot

The plantar fascia is a strong, inelastic ban that originates on the bottom of the heel and spans the length of the foot, inserting into the toes. The plantar fascia can easily be felt in the bottom of the foot, particularly when the toes are dorsiflexed (towards the shin). The plantar fascia consists of three slips; a medial, a central and a lateral slip. The medial slip of the plantar fascia is the band that most commonly becomes symptomatic in cases of plantar fasciitis.

When we stand and apply load to the foot, the arch drops and the plantar fascia becomes tight. Plantar fasciitis occurs when the load that is applied to the foot is so great that the plantar fascia begins to pull away from the heel bone. The painful symptoms of plantar fasciitis do not result from standing on a sharp heel spur, but rather from the result of the overwhelming tension that occurs in the plantar fascia as we stand (apply load). The plantar fascia becomes so tight that it is literally being torn from the bottom of the heel.

When discussing biomechanical properties of heel spur syndrome, it’s important to understand the mechanical definition of load. The amount of load, the frequency of load and the duration of load are just a few of the different loading issues that can contribute to plantar fasciitis. Loading issues will vary in each person affected by plantar fasciitis. For instance, for a long distance runner, the frequency of loading may be the primary issue that contributes to the onset of plantar fasciitis. For a factory worker who stands for long periods of time, the duration of load may be the primary issue. Typically, those who suffer from plantar fasciitis don’t have just one of these loading issues but a number of them combined.

Two additional biomechanical issues to consider when treating plantar fasciitis are equinus and CT Band Syndrome.

The symptoms of plantar fasciitis classic. The symptoms develop slowly and insidiously over the period of a week or two. As the pain becomes progressively worse, the pain becomes focused in the bottom of the heel. People describe significant pain in the bottom of the heel when they try to get up out of bed in the morning or try to stand after a period of rest. This post rest pain is a sharp pain that seems to subside after being on the feet for 5-10 minutes.

People will also describe a second kind of pain that becomes worse as the day progresses. This pain is described as dull and achy. It's often on the bottom of the heel but also seems to radiate to the inside of the heel.

This picture shows the location of pain found in patients with plantar fasciitis. The red area on the bottom of the heel is where the plantar fascia inserts into the medial tubercle of the calcaneus. This is the location where patients with plantar fasciitis feel pain upon standing after a period of rest or when getting out of bed in the mornings.

Also shown in this picture are the areas where pain is felt with several different nerve entrapments of the heel. The line of red dots symbolizes the path of the posterior tibial nerve. As the posterior tibial nerve descends into the foot, it divides into several different nerves that supply motor function to the muscles of the foot and sensory function to the bottom of the foot. Entrapment of the posterior tibial nerve can result in tarsal tunnel syndrome or Baxter's nerve entrapment.

Baxter's nerve entrapment - entrapment of the 1st branch of the lateral plantar nerve of the posterior tibial nerve

Gout - deposition of monosodium urate crystals (hyperuricemia)

Retrocalcaneal bursitis (Albert's Disease) - this is the formation and inflammation of a bursa at the back of the heel between the heel bone and Achilles tendon

Rheumatoid arthritis

Rheumatic Fever

Septic Arthritis

Sero-negative arthropathies such as Reiter's Syndrome

Sever's Disease - and inflammatory condition typically found in young over weight boys age 10 to 15 years old

Stress fracture of the calcaneus - Achilles tendonitis pain is characteristically different from that of fractures of the calcaneus. Fracture pain begins with the onset of activity and remains painful through the activity.

Tarsal Tunnel Syndrome - also known as posterior tibial nerve neuralgia. Tarsal Tunnel Syn. characteristically has pain that does not decrease with rest. Also has numbness or 'tingling' of the toes

• Achilles Tendonitis

• Tarsal Tunnel Syndrome

• Posterior Tibial Tendon Dysfunction

• Baxters Nerve Entrapment

• Sinus Tarsi Syndrome

This article was written by Jeffrey A. Oster, DPM and last updated 2/8/13.

Additional references include;

Brekke MK, Green DR: A retrospective analysis of minimal incision, endoscopic and open procedures for heel spur syndrome. JAPMA 88: 64, 1998

Boike AM, Snyder AJ, Roberto PD, et al: Heel spur surgery: a transverse plantar approach. JAPMA 83:39, 1993

Kitaoka HB, Luo ZP An KN: Mechanical behavior of the foot and ankle after plantar fascial release in the unstable foot. Foot Ankle Int 18: 8, 1997

Barrett SL, Day SV: Endoscopic plantar fasciotomy: two portal endoscopic surgical techniques-clinical results of 65 procedures. J Foot Ankle Surg 32: 248, 1993

Goecker, R.M., Banks, A.S. Analysis of release of the first branch of the lateral plantar nerve J. Am. Podiatric Assoc. 90:6 281-286 June, 2000

Baxter, D.E., Pfeffer, G.B. Treatment of chronic heel pain by surgical release of the first branch of the lateral plantar nerve. Clin Orthop 279:229, 1992

Thordarson, D.B., Kumar, K.J., Hedman, T.P., et al: Effect of partial vs complete fasciotomy on the windlass mechanism. FootAnkle 18: 16, 1997

Anderson, D., Fallat, L., Savoy-Moore, R. Computer assisted assessment of lateral column movement following plantar fascial release: A cadaveric study. J. Foot Surg 40:2, 62-70 2001