Posted on 29 Apr 2009 15:00
By Robert Sheon
Clinical Professor Emeritus University of Toledo College of Medicine, Montgomery Village, MD, retired
What is the plantar fascia?
The plantar fascia is a dense fibrous tissue lining the bottom of the foot. (Picture 1)
Picture 1. The plantar fascia is a dense fibrous tissue lining the bottom of the foot. The fibers that attach to the heel can be injured simply during prolonged standing if you have flat feet.
The plantar fascia provides support when the foot rises up on the toes during walking, running, or climbing. It supports the long arch of the foot. Plantar fasciitis is caused by strain of the plantar fascia. The injured tissue causes pain at the bottom of the foot when starting to walk or when standing still for a long period of time. It is one of the most common causes of foot pain in adults [1,2].Jumping, running, or prolonged standing often causes strain on the plantar fascia. The outcome is generally good, with approximately 80 percent of people having no pain within one year. Flat feet can be a predisposing cause for plantar fasciitis as can a high arched foot (pes cavus) .
What are the symptoms of plantar fasciitis?
The major symptom of plantar fasciitis is pain beneath the heel and on the sole of the foot. The pain is often worse when stepping onto the foot, particularly when first getting out of bed or getting up after being seated for some time. Involvement of both feet occurs in about 30% of cases.
Some people are more prone to plantar fasciitis — Plantar fasciitis is more likely to occur in people whose lifestyle or occupation causes an abnormal amount of stretching of the plantar fascia.
Factors that increase the risk include:
* Long-distance running, especially during intensive training
* Poorly fitted shoes
* Standing for long periods of time
* Dancing, especially ballet and aerobic dance
* Repeated squatting or standing on the toes
* Use of a trampoline
Plantar fasciitis usually occurs in people without underlying medical problems, but it can be associated with other rheumatic disorders such as fibromyalgia, rheumatoid arthritis, or gout.
Heel spurs may be seen on x-ray but usually do not cause the problem. A heel spur, also called an osteophyte, is a ridge of extra bone that develops across the undersurface of the heel as the person ages. In one study 85 percent of 27 patients with plantar fasciitis had spurs; however, 46% of 79 asymptomatic controls also had spurs . In the past, surgery to eliminate the heel spur did not resolve the problem; now it is rarely done.
How is plantar fasciitis diagnosed?
To diagnose plantar fasciitis, a healthcare provider will examine the feet to locate painful areas (picture 2).
Picture 2. The toes are grasped and dorsiflexed with one hand, while the other hand palpates the plantar aspect of the foot. The point of maximum tenderness is usually located just forward of the heel bone.
Patients should let the provider know if there are other areas of tenderness or pain not found during the examination. Depending upon the duration of symptoms, the severity of pain, and other individual factors, the provider may also recommend x-rays to determine whether another disorder, such as a fracture, tumor, or infection is causing the pain. Magnetic resonance imaging (MRI) and technetium scintigraphy (a type of ultrasound using a radioisotope) can show the inflammation and is also used to rule out a stress fracture; these tests are performed only for cases resistant to treatment. A newer test, Doppler ultrasound, may be even more precise. [4,5].
What else can cause this pain?
More serious is a rupture of the plantar fascia. This occurs following or during activity, is sudden in onset, and upon standing, the involved arch of the foot may be more flattened. Swelling and bruising may become evident. Imaging tests are used for diagnosis and prognosis.
Other causes of foot pain at the bottom of the heel include bone diseases such as Paget’s disease; tendonitis; other inflammatory forms of arthritis; thinning (atrophy) of the heel pad in runners; diabetes; or sarcoidosis .
The following features suggest more serious problems:
* Numbness and tingling
* Pain or swelling in the toes
* Blue discoloration of the foot
* Pain at rest
* Pain that occurred suddenly
* Swelling in the bottom of the foot
* Loss of the normal arch of the foot when standing
* Pain that is constant
What is the treatment?
Plantar fasciitis is usually treated conservatively. Randomized controlled studies of these recommendations have been inconclusive, perhaps hampered by the high incidence of spontaneous improvement in the control groups [2,6].
Weight loss should be emphasized when obesity is present. Consultation with a dietitian, or referral to a community program should be considered.
Symptomatic flat feet should be treated with proper shoes and arch supporting shoe inserts. Wearing slippers or going in bare feet may aggravate the condition, even when the floor is carpeted. Having a slip-on at the bedside with a one-inch heel that provides some support for the arch is helpful when arising from bed.
Protective footwear — Athletic shoes, arch supporting shoes (particularly those with an extra-long counter, which is the firm part of the shoe that surrounds the heel), or shoes with rigid shanks (usually a metal insert into the sole of the shoe) are helpful. Cushion-soled shoes with silicone gel pad inserts or heel cups can provide temporary pain relief. Appropriate shoes and accessories can be found in stores featuring work shoes or "orthopedic shoes."
People who work or reside in buildings with concrete floors should use cushion-soled or crepe-soled shoes.
A number of studies using various combinations of treatment options revealed a slight statistical proof of benefit. For example, prefabricated silicone heel inserts combined with stretching exercises was helpful in one randomized controlled study . Felt or rubber heel cups were less helpful than silicone inserts; magnets were not helpful [8,9].
Rest — Limiting athletic activities and getting extra rest for up to two weeks can help the inflammation to subside. Excessive heel impact from jumping, walking, and use of a trampoline should be avoided. A padded heel cup can be helpful. A complete lack of physical activity, though, can lead to stiffening and recurrence of pain.
Icing — If pain is of very recent onset, applying ice to the area for 20 minutes up to four times daily can be helpful. Ice may also be used prior to exercise.
Exercise is an important part of therapy. Home exercises include the calf-plantar fascia stretch (picture 3),
Picture 3. Sitting with the knees extended, loop the Theraband around the foot of the leg to be stretched and pull the forefoot toward the knee. You could also use a jumprope or towel. Hold the stretched position for 10 to 30 seconds. Repeat five times per session, two sessions per day. The foot may also be pushed against the Theraband in order to activate/strengthen the plantarflexor muscles (mainly the gastrocnemius).
Picture 4. Circle the foot at the ankle, moving the foot up and down by flexing and extending the ankle. Travel one direction for 30 seconds, then reverse. Repeat 3 times twice daily.
Picture 5. The toes are curled around a book as pictured. The toes should be alternately curled and straightened. This exercise is performed for one to two minutes, twice daily.
Be sure to perform these exercises with care so as not to overexert the painful area. A number of randomized controlled studies comparing various exercises with sham controls were inconclusive. Nevertheless, exercises that stretch the calf muscles, Achilles tendon, and the plantar fascia remain key elements in therapy. Most clinicians continue to recommend exercise in an effort to reduce pain more quickly. Local tenderness should be diminished before sport activities are resumed.
Nonsteroidal analgesics — A clinician may recommend a two to three week course of a non-steroidal anti-inflammatory drug (NSAID) such as ibuprofen or naproxen to reduce swelling and relieve pain. Prescription strength dosing may be necessary if systemic inflammation is present.
Some practitioners and therapists use ultrasound, deep friction massage, ice massage, or taping. In one study, taping (often performed by a podiatrist) relieved first step pain when arising from bed or a chair .
What else can be done?
If these noninvasive measures fail to improve the pain within two to three weeks, a healthcare provider may recommend one of the following treatments:
Steroid (cortisone) injection —
A steroid medication may be injected into the affected tissue. These painful sites for injection are determined by palpation (picture 6).
Picture 6. Intralesional injections are performed in the areas of point tenderness noted on physical examination. After proper cleansing, a coldspray or local anesthetic can be used to reduce the discomfort of injection. Ice application after injection often reduces the residual pain following injection. A local anesthetic and corticosteroid mixture is commonly used.
Another method employs a single injection from the side of the foot. In two studies, a single injection provided relief for up to 3 months [11,12]. Many clinicians limit the number of times they will give this type of injection because repeated injections may weaken the tissues of the sole of the foot. In addition, each injection carries a small risk of causing infection.
Short walking cast — This begins at the calf and covers the ankle and foot up to the toes. This type of cast has a rocker-shaped bottom that allows a person to continue walking while wearing it.
Shock wave therapy — Shock wave therapy is a form of ultrasound that provides a burst of energy to the sole of the foot. The treatment is initially painful. Although not supported by randomized controlled studies , some clinicians still recommend it.
Botulinum toxin injection – Injection of Botox has been tried in a small randomized trial in which two injections were used. Although effective in pain relief, the magnitude of the relief was not considered . Although promising, use of Botox must await further study.
Surgery — Surgery is done for only 2 to 5 percent of people with plantar fasciitis. Surgery would only be recommended if all other treatments fail. A number of different procedures have been advocated but no randomized studies have been reported. Most surgeons would consider surgery only if symptoms have persisted at least six months despite conservative treatment.
Where can you learn more?
Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
A number of Web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies, and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable.
National Library of Medicine (www.nlm.nih.gov/medlineplus/healthtopics.html]
American Academy of Orthopedic Surgeons (http://orthoinfo.aaos.org/)
American Podiatric Medical Association (www.apma.org/)
American Academy of Family Physicians (http://familydoctor.org/140.xml)
UpToDate patient information (http://www.patients.uptodate.com/topic.asp?file=bone_joi/10174&title=Plantar+fasciitis)
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10. Radford JA, Landorf KB, Buchbinder R, Cook C. Effectiveness of low-Dye taping for the short-term treatment of plantar heel pain: a randomised trial. BMC Musculoskelet Disord 2006; 7:64.
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This page created 29 Apr 2009 15:00
Last updated 03 Jun 2016 22:53