Plantar fasciitis is a common cause of heel pain, which frustrates the patients and practitioners alike because of its disabling nature and resistance to treatment. The plantar fascia is an extremely tough sheet of tissue that extends out from the base of the calcaneous (heel bone) to attach onto the bases of the toes. This tissue is very inelastic and helps maintain the foot's arch during activity. Although the term "plantar fasciitis" implies and inflammatory process, pathologic studies demonstrate micro-tears and changes that are consistent with a chronic degenerative process secondary to repetitive stress. Normally functioning feet are able to tolerate the stress placed on them with daily activity; however, a point is ultimately reached where the stress sustained by the fascia become symptomatic.
The history of plantar fasciitis usually reveals a slow but gradual onset of pain along the inside of the heel. Occasionally the pain may be associated with the twisting injury of the foot producing an abrupt onset of pain. The location of the pain is generally described as along the medial (inner side) of the foot at the bottom of the heel. The pain is worse upon first arising in the morning and then decrease with increased activity. It may increase, however, after prolonged activity. Periods of inactivity are generally followed by an increase in pain as activity is started again. Numbness of the foot is not present. When severe pain is present, the patient is unable to bear weight on the heel and will instead bear weight on the forepart of the foot.
Specific risk factors associated with plantar fasciitis include repetitive stress in athletes, obesity, and middle age (the most common age for presentation). Abnormal anatomy such as a flat foot or high arched foot may predispose to this condition as well by placing a greater amount of burden and stress on the fascia. A tight heel cord also contributes to excessive stress in plantar fascia and can cause a painful bursitis.
Sometimes radiograph (x-rays) of painful heels may reveal calcaneal heel spurs. However, no relationship has definitely established between these heel spurs and sub calcaneal pain. In fact, 15% of normal asymptomatic adult feet have sub calcaneal spurs, whereas about 50% of adult feet with plantar heel pain have spurs. So, the mere presence of heel spurs does not mandate pain.
The good news with this condition is that it almost always gets better without the need of surgery. The bad news is that it usually does not get better quickly. A patient suffering from plantar fasciitis can expect it to take at least 6 to 9 months to resolve completely, and sometimes up to a year.
The mainstay of treatment is to stretch the tight achilles tendon and plantar fascia. Physical therapy consisting of stretching, strengthening, ultrasound, and other modalities may be used. In addition, a daily home program of stretching is essential. If the condition is not responsive to this regimen within the first 6 weeks, or has been present for more than 3 months, a night splint with the foot maintained in dorsiflexion (flexed up) is prescribed. If this does not suffice after a period of approximately 3 months, then a walker boot can be considered.
In my practice, I try to avoid steroid injections around the heel to prevent any subsequent loss of the fat pad that provides natural cushioning to the foot. This fat loss process is irreversible. If symptoms do not respond to this non-operative regimen, and the injury or impairment is sufficient to prevent desired activity levels, then I might consider surgical intervention after 9 to 12 months of treatment. Fortunately, less than 10% of patients suffering from this condition will go on to require any surgery. Once symptoms improve and are maintained for 4 to 6 weeks, a gradual increase in activity may be allowed and return to sports can be expected, if symptoms remain under adequate control.
