Plantar Fasciitis

Age

As we age, the fat pad that makes up the fleshy portion of the heal shrinks, or becomes thinner. This is known as Fat Pad Atrophy, which leads to inadequate padding on the heel and chronic pain in this area and also results in the loss of the natural shock absorption of the heel resulting in increased stress being applied to the plantar fascia.

Gender

If women gain weight in their thighs and hips and men gain weight in their chest and belly, then a woman’s lowered center of gravity could help explain why women are 6 times more likely than men to have heel pain. The combination of women’s shoes and being overweight could have a combined negative effect on the plantar fascia.

Obesity

Being overweight places a lot of stress on this area and may be a causative factor. Obesity is a cause and initiator of heel pain and Plantar Fasciitis/calcaneal spur and that improper footwear aggravates the condition. Individuals who spend the majority of their workday on their feet and those whose body-mass index is >30 kg/m2 are also at increased risk for the development of Plantar Fasciitis .

Foot Structure

People who have problems with their arches – either overly flat feet or high-arched feet – are more likely to develop Plantar Fasciitis.

Flat foot is the leading cause of Plantar Fasciitis. When a person’s arch collapses, over-pronation occurs in the walking process, causing the plantar fascia to be stretched away from the heel bone. Pronated foot types are predisposed to increased stress on the plantar fascia with reduced ankle dorsiflexion appearing to be the most important risk factor.

Flooring

The harder the floor, the higher the force subjected to the feet.  Newton’s third law states that “for every action there is an equal and opposite reaction”.  When walking on a hard floor, the foot strikes the floor, but the floor also strikes back equally resulting in injury to the base of the foot.

Footwear

Poor cushioning can often be found in footwear with a high heel, hard sole, poor support, inadequate size, and inadequate width. Stiff shoes require more flexibility in the calf muscles by increasing the length of the foot which requires the foot to bend back further when walking.  If the foot cannot bend back that far it results in increased tension on the plantar fascia.

Prolonged Weight Bearing

Occupations requiring prolonged weight bearing have been considered a risk for Plantar Fasciitis due to the repetitive tensile load placed on the fascia (Riddle et al. 2003).

Other Conditions

Conditions such as reduced dorsiflexion, Equinus, shortened Achilles tendon, leg length discrepancies, tarsal coalition, weak plantar flexor muscles, rear foot varus, forefoot valgus weak intrinsic muscles of the foot, and excessive subtalar joint pronation can also contribute to the development of Plantar Fasciitis.  In addition, systemic inflammatory disorders, such as rheumatoid arthritis, lupus, Reiter’s syndrome and psoriasis, may produce Plantar Fasciitis.

NON-SURGICAL

Non-Surgical Treatment

Many patients get better with the help of non-medical treatments. Stretches for the calf muscles take tension off the plantar fascia and is one of the most effective treatments. A night splint may be worn while sleeping which keeps the foot from bending downward, and places a mild stretch on the calf muscles and the plantar fascia. Symptoms seem to get better faster when using a night splint. Supporting the arch with well fitted orthotics, may also help reduce pressure on the plantar fascia. Using a special type of insert into the shoe, called a heel cup, can also reduce the pressure on the area and add padding to a heel that has lost some of the fat pad through the ageing process. Shock wave therapy is a newer form of non-surgical treatment and applies shock wave pulses to the sore area. Patients receive the treatment once each week for up to three weeks.  Anti-inflammatory medications are also used to decrease the inflammation in the fascia. Cortisone injections into the area of the fascia has also been shown to be of benefit. Cortisone should be used carefully since it may contribute to the process of degeneration of the fat pad, making the problem worse.

Non-Surgical Rehabilitation

Patients with Plantar Fasciitis will often undergo physical therapy. Therapists design exercises to improve flexibility in the calf muscles and the plantar fascia. Treatments directed to the area help control pain and swelling (ultrasound, ice packs, and soft-tissue massage).  Therapy sessions sometimes include a mild electrical current to push anti-inflammatory medicine to the sore area. A customized foot orthotic may be designed to support the arch of the foot and to help cushion the heel or the therapist may recommend the use a heel cup. A night splint may also be required while sleeping.

SURGICAL

Surgical Treatment

Surgery should only be done as a last resort.

Possible surgeries can include:

• Removal of the bone spur (if present)
• Release of the plantar fascia (must be done)
• Release pressure on the small nerves in the area

Usually the procedure is done through a small incision on the inside edge of the foot often using an endoscope.  An endoscope is a small camera that can be inserted into a joint or under the skin to allow the surgeon to see the structures involved in the surgery.  This allows the surgeon to complete the process with a smaller incision. Surgery usually involves identifying the area where the plantar fascia attaches to the heel and partially releasing the fascia from the bone. If a bone spur is present this is removed. The small nerves that travel under the plantar fascia are identified and released from anything that seems to be causing pressure on the nerves.

Post-Surgery Rehabilitation

It will take several weeks before the tissues are well healed. The incision is protected with a bandage or dressing for about one week after surgery and crutches will likely be required.  The stitches are generally removed in 10 to 14 days. Physiotherapy may then be advised.