Plantar fasciitis
The most common reason patients seek our care is for heel pain. This condition can be
caused by a variety of factors. Including, entrapped nerves, metabolic disorders, arthritis
and infections. By far the most common cause, accounting for 95% of all cases, is
abnormal, repetitive stresses placed on the anatomic structures of the foot and leg
resulting in injury and inflammation. This condition is known as plantar fasciitis.
The plantar fascia has several functions. It helps keep the small muscles of the foot in a
compact and efficient package beneath the foot when full weight is bore. More
importantly, it helps maintain the bones of the foot in an "arch" orientation.
As body weight is transmitted down through the leg and ankle, the foot tries to maintain
a triangle shape. The base of the triangle is the plantar fascia. The fascia must resist the
force of the heel and arch bones to flatten out. The extent to which the arch flattens is
dependent on how much the plantar fascia can support. Thus, during the normal course
of walking, our plantar fascia is subjected to tremendous, repetitive forces.
To understand what is causing heel pain, an examination of the anatomy is necessary. The plantar fascia is a dense thin layer of tissue just beneath the skin on the sole of the foot. It is shaped like a triangle (blue lines), with the apex oriented towards the back of the foot.
The plantar fascia has several functions. It helps keep the small muscles of the foot in a compact and efficient package beneath the foot when full weight is bore. More importantly, it helps maintain the bones of the foot in an "arch" orientation.
As body weight is transmitted down through the leg and ankle, the foot tries to maintain a triangle shape. The base of the triangle is the plantar fascia (blue line). The fascia must resist the force of the heel and arch bones to flatten out(red lines). The extent to which the arch flattens is dependent on how much the plantar fascia can support. Thus, during the normal course of walking, our plantar fascia is subjected to tremendous, repetitive forces.
Since the plantar fascia is shaped like a triangle, a great deal of force is concentrated at the heel. When too much strain is placed on the fascia, the area of greatest strain becomes inflamed. This inflammatory process leads to pain and swelling. This is often termed plantar fasciitis or heel spur syndrome. Over time, this condition may produce bone projections off the heel known as spurs. Often times, patients will come to the office with heel pain wishing their "spurs" be removed. They believe the heel pain is caused by these bony growths, when in fact, the true reason for the pain is from inflammation of their plantar fascia. The heel spur has developed in response to the chronic irritation of the plantar fascia on the calcaneus (heel bone).
Treatment targets the plantar fascia, not the heel spur, since it is the true source of the
pain.
Signs and symptoms
Patients present with chronic pain to the bottom of the heel. Usually, this pain has been
present for weeks to months and they have delayed seeking treatment hoping the
symptoms would subside. Terms such as a stone bruise or deep ache are usually used
to describe the discomfort. The onset is usually gradual, with no recollection of an injury
or accident.
Classically, the pain is worse when arising from rest. For example, the first few steps
taken after waking in the morning or after a prolonged period of sitting can generate the
most pain. Once the foot warms up, the heel pain may lessen. Swelling or puffiness on
the inside of the heel may also be noticed.
Treatment
For the vast majority of patients (95%), conservative treatment can eliminate their pain.
We tailor our treatment to the individual patient, taking into account health, lifestyle and
their work environment. A cookie cutter approach will not be as effective, as there are
many factors which must be considered. In general, the steps outlines below are utilized
in different combinations and varying degrees of emphasis.
Anti-inflammatory medication:
Also known as NSAID's, this class of drugs helps to decrease the inflammatory process
within the plantar fascia. We frequently use these drugs for a period of several months.
Stretching:
By stretching the plantar fascia, the abnormal pressure can be alleviated and resolution
of the problem obtained. Many times night splints can achieve this goal with minimal
pain and inconvenience.
Injections:
Cortisone injections carry potent anti-inflammatory action. They are used for moderate
to severe cases of plantar fasciitis. Plantar fasciitis which does not respond to other
forms of treatment are also an indication for their use.
Orthoses:
These devices help to support the arch and take pressure off the plantar fascia . They
are placed in shoe gear and can help prevent recurrence of the condition. Both custom
molded orthotics and over-the-counter devices can be effective.
Footwear:
Proper fitting and supporting shoe gear is critical is alleviating heel pain. Many times we
place our patients in athletic shoes for prolonged periods. These styles allow more
support to the arch and heel, creating a favorable environment for recovery.
NewBalance shoes are our preferred manufacturer.
Rest:
In severe cases of heel pain, we ask our patient to take time off work to rest their foot.
This is especially true for people who spend a great deal of time on their feet. This may
be combined with immobilization in a short leg cast.
Surgery:
Surgery maybe needed for those cases of plantar fasciitis which have failed all forms of conservative treatment. There are many different forms of surgery for plantar fasciitis, each of our physicians has his preferred method.
Typical appearance of an instep plantar fasciotomy 4 days after surgery. Click here to watch a video of this surgery being performed.
Extracorporeal shock wave treatment (ESWT)
This technology represent the latest innovation in the treatment of resistant plantar
fasciitis. We have been utilizing this modality since January of 2000 with excellent
results. Learn more about Shock Wave Therapy