Plantar Pain – Plantar Fascitis

E-ALGOS Co-Authors Team

Updated 19 September, 2011

Panos Symeonidis

Orthopaedic Surgeon Foot & Ankle Specialist

www.foot-ankle.gr

Introduction

Approximately one out of ten people will suffer from plantar heel pain at least once in their lives. Despite the fact that the symptom of plantar pain is so common, its exact cause cannot always be identified. In the majority of cases, plantar heel pain is the clinical presentation of a disease which is called plantar fasciitis. For many years, this condition has been by many (including medical doctors) defined as “heel spur”, a term which is gradually being abandoned. The following article is an attempt to discuss in simple terms the anatomy of the plantar fascia, clarify what a heel spur is, and describe the usual presentation of plantar fasciitis and its treatment.

What is the plantar fascia?

The plantar fascia resembles a natural sole consisting of dense fibers of connective tissue, extending from the base of the heel to the base of the toes. You can feel the plantar fascia as a tight cord underneath the middle of the plantar skin when stretching your toes. Although the plantar fascia is quiet elastic, it is also considerably strong and in certain areas its width reaches half a centimeter. As the string of a bow, it connects the front part of the foot to the hind part playing an important role in all foot functions, including stance, walking and running.

The plantar fascia is sensitive to direct load. Characteristically, if by mistake we step on an object directly to the mid part of our sole this would cause an immediate pain.  A similar discomfort is also elicited when walking barefoot on pebbles. All over the developed part of the world, people are accustomed to walk almost entirely in shoes. The sole of their feet is soft and underneath it lays a very useful but also vulnerable structure: the plantar fascia.

What causes plantar fasciitis?

In most cases, plantar fasciitis is caused by an either extended or increased load of the plantar fascia. The common pathway for the development of plantar fasciitis seems to be a repetitive microtrauma of the plantar fascia which initiates a inflammatory response in the region. Even common conditions such as fatigue from extended standing, long walking on uneven ground, a new pair of shoes with an improper sole, a long march (as characteristically is the case in new cadets), or even a sudden increase of our body weight may irritate or injure the plantar fascia causing persistent pain. However, it may as well be that the patient cannot attribute the pain in any of the above factors. In these patients it is hard to identify a specific contributing factor witch elicited the plantar fasciitis.

What is the usual presentation of plantar fasciitis?

As with every disease, the plantar fasciitis has certain clinical signs that characterize its difficult presentation. But be careful! The following list of symptoms is by no means a self-diagnosis guide, since similar clinical signs can be found in a number of other diseases as well. It is for the specialist doctor to confirm the diagnosis and also exclude other causes of plantar pain which can be more seldom, but sometimes also more serious. Keeping this in mind, in its typical presentation, plantar fasciitis is characterized by:

-          A deep dull ache, which is located around the attachment of the plantar fascia to the anterior / inner part of the heel bone (calcaneous) over the sole of the foot

-          Pain is typically worst when the patient wakes up, as well as in the end of a tiring day

-          The first steps after a long rest (or sleep) are particularly painful, whereas symptoms improve while the foot “warms up” with walking

-          Sympotms are more severe when walking barefoot in comparison with shoe wearing

-          Both feet may be painful, but as a rule the one side is much worse

My heel hurts. Do I suffer from plantar fasciitis?

Unfortunately this is not a yes or no answer. As mentioned before, there are many conditions that can cause heel pain. Some of them can be serious. These include not only diseases of the heel, but also spinal pathology, autoimmune diseases and even tumors. Therefore, it is important that the patient seeks medical attention on cases where plantar heel pain persists for longer tha a few days.

Plantar fasciitis is a diagnosis primarily based on careful history taking and clinical examination. The plain radiographs can assist in excluding other causes of pain, and in certain cases more advanced imaging modalities such as the magnetic resonance imaging of the area are required. Occasionally, the patient needs to have specific blood tests or a bone scan.

What is a heel’s spur?

A heel spur is a type of osteophyte in the anterior aspect of the heel, near the insertion of the plantar fascia. This has caused considerable relevant confusion to patients and doctors alike, as many identify the heel spur as being synonymous to plantar fasciitis and vice versa. It would be reasonable to consider the heel spur as the causing factor of plantar fasciitis, as the plantar pain is very often located in the region were the heel spear is found. However the relevant evidence is conflicting. Our current knowledge considering heel spurs is:

-    A heel spur can be identified in 13-27% of the general population (an average of one out of five people) without them necessarily suffering from any type of plantar pain.

-    In many cases the heel spur is found bilaterally (ie in both feet) while only the one foot hurts.

-    It is a fact that in patients with plantar pain heel spurs are more common (approximately one out of two cases)

-    Plantar fasciitis treatment seems to be irrelevant with the occurrence or the excision of a heel spur.

These are some of the reasons that the term “heel spur” is now days considered not appropriate as a causative diagnosis for plantar heel pain and is gradually being abandoned.

Plantar fascitis treatment

In the majority of cases plantar fasciitis will subside even without any type of treatment since it belongs to the so called self-limiting diseases. These means that, as in other parts of the human body, the plantar fascia has the ability to gradually cure itself, albeit after a considerable period of time, during witch the patient can experience significant pain. This natural course may last for months and not infrequently the disease can relpase, witch means it will affect the patient again. This is the reason why as a rule, plantar fasciitis needs treatment with a variety of modalities.

The treatment modality with the strongest evidence is the stretching of the plantar fascia following a specific program under the supervision of a specialist. These stretching exercises need to be followed for weeks. When performed on a regular basis, indeed they have been shown to offer significant pain relief to the majority of the patients. Stretching is also useful in limiting the number and severity of reccurring episodes of plantar fasciitis. According to the same principle of stretching, a variety of night splints have been introduced. These night splints work by maintaining tension along the plantar fascia during the night. The clinical results from the use of night splints have been encouraging, however their effectiveness is not superior to the stretching exercises.

Ice therapy and oral analgesia also offer significant pain relief to the patient. On the other hand, anti-inflammatory drugs have not been shown to add significantly to either the pain relief or to the healing process.

A useful supplement in the treatment of plantar fasciitis are the cushion orthotics, such as the silicon heel pads which are used widely.

In certain cases with acute and severe pain, a local steroid injection has been proposed. This treatment modality however has been the subject of considerable debate, regarding its long term effectiveness and also potenital side effects. This is especially true in the case of repetitive injections, which certainly are to be avoided as they carry the risk of causing rupture of the plantar fascia (a potentially devastating complication). A wide variety of other substanses has also been injected locally in patients with plantar fasciitis in an effort to offer pain relief and expedite the healing process. These include among others enzymes, growth factors, concentrated factors derived from the patient’s blood or even plain autologous blood, and finally injections without any inflitration, the so called dry-needling. These modalities have been used with or without the aid of some type of imaging of the plantar fascia, such as ultrasonography, in an effort to accurately place the needle over the affected area. Despite a number of entusiastic reports from the advocates of each method, none of these has as yet managed to accumulate strong evidence for its effectiveness in the treatment of plantar fasciitis. It may so be that in the future one of these modalities will prove its superioirty and become the gold standard in treating the condition. For the time being however, this is not the case.

Another promissing alternative  treatment of plantar fasciitis, especially in recalcitant cases, is the use of the so called “shock waves”,  or Extacorporeal Shock Wave Therapy (ESWT). The technology used is based on previous experience with lithothripsy for the treatment of kidney stones. It requires specific equipment and training and is being implemmented by specialised physiotherapists and doctors alike. The waves are being introduced to the plantar fascia through the skin with the use of the head of a targeting device over the area of maximum tenderness. According to the different protocols, treatment takes place in one or more sessions, with or without the use of anaesthesia. The method has a satisfactory success rate and it may prove effective in accelerating the heeling process.

Finally, in rare cases where all these modalities have failed, allthough they were used appropriately for an extended period of time (more than 6 months), the patient is treated surgically. The relevant procedure is an open surgical release of the plantar fascia, by resecting a part of its insertion to the heel. Although plantar fascia release may offer significant pain relief in persistent cases, essentially it is a compromise with potential side effects, since it involves the partial sacrifice of a significant structure from the sole of the foot, namely the plantar fascia.

In conclusion, the fast –simple -quick and effective treatment of plantar fasciitis is yet  to be found. There is still a lot to learn about the causes of the condition and how it evolves in time. According to current knowledge, the most effective treatment seems to be the stretching of the plantar fascia in combination with ice therapy, oral analgesics and a type of insole orthotic such as the heel pad. One way or another, in the large majority of patients the pain will finally subside.