Plantar fasciitis is the most common cause of foot and heel pain. Plantar (not planter – people often mistake the spelling) means the “bottom of the foot” and “itis” means inflammation, so fasciitis means “inflammation of fascia”. The plantar fascia is the tough, fibrous arch part of the foot that provides strength, structure and support for the bottom of the foot.
Anatomy of the Plantar Fascia
The “distal” part of the foot is the part where the toes are and the “proximal” part of the foot is where the Achilles tendon attaches to the back of the foot. The proximal part of the plantar fascia attaches to the calcaneus on the plantar portion of the foot about two-thirds of the way proximally up the foot from the toes.
The “heel bone” is called the calcaneus. The distal part of the plantar fascia attaches to the bases of the toes.
What causes Plantar Fasciitis?
The point where the fascia attaches to the heel bone (calcaneus) is under the most stress when we walk and run; constantly being pulled on and stressed with each step we take causing microscopic tears every day. Our bodies are amazing healing machines and normally the body responds to the everyday stresses by healing these microtears. If the stress is built up over a gradual enough timeframe, the body will not only heal the fascia, but will also strengthen it so it can withstand the increasing demands.
However, if you have an injury or you do ‘too much too fast” and overstress the area, then the fascia and the fascial attachment breaks down faster than the body can heal itself. This results in ongoing (chronic) pain, inflammation and degeneration/break down. Prolonged standing starts to become more and more painful, eventually leading to pain with every step and often even pain at rest.
Who is at risk for Plantar Fasciitis?
Plantar fasciitis is very common in people who stress their feet a lot. Who is at risk? Athletes, workers who are their feet all day and/or work on hard surfaces, overweight/obese people, and people who wear ill fitting/non-supportive shoes. It is also more common as we age being most common between the ages of 40 and 60, but can effect all age categories. It can be associated with both pes planus (flat feet) and pes cavus (high arches).
Common Symptoms of Plantar Fasciitis
During an orthopedic exam, the most patients will feel pain directly to touch at the plantar fascia insertion site on the calcaneus. There can be tenderness along all or parts of the “arch”/plantar fascia. There may also be swelling, but if there is, it is usually subtle.
Patients with heel pain, often complain of “having a heel spur.” An x-ray may or may not show a heel spur. A heel spur is a calcium deposit that forms at the insertion site of the plantar fascia on the calcaneus. This is a result of chronic traction (pulling) stress of the arch attachment on the bone which responds by forming new bone/calcification.
A heel spur will appear on an X-Ray for about 50% of patients with heel pain/plantar fasciitis. The actual presence of a heel spur on the x-rays does not necessarily mean the it is the cause of the problem. Rather the heel spur is more the result of the problem.
Non-Surgical Treatment Options
- Stretches & Exercises – Plantar fasciitis treatment often starts with simple things. For example, certain types of stretches for the Achilles tendon have proven to be effective. If your Achilles tendon is tight (needs stretching), it can cause the rest of the foot to be “tight” because it attaches to the backside of the foot/heel. Our muscles are our main “shock absorbers” and so the stronger these “shock absorbers” are, the less force will go across the damaged/painful area providing a better chance of healing.
- Anti-inflammatory medication (Ibuprofen, Naproxen, etc.) can help with the inflammation and pain if O.K.ed by your doctor and appropriate for you.
- Ice is a very potent anti-inflammatory and is very effective for plantar fasciitis pain if used correctly. Ice massage such as freezing a bottled water and rolling the plantar part of the foot over the frozen bottle for 5-10 minutes after exercise/activity/standing on your feet all day and/or when in pain can be particularly effective.
- Arch supports, orthotics and especially proper fitting footwear and shoes that can provide a support under the arch/inflamed tissue is helpful for many patients with plantar fasciitis.
- Cortisone injections can help at times, especially for more acute (recent/new onset) pain where the inflammation is significant as cortisone is a natural hormone that our bodies make that is the most potent anti-inflammatory we know of.
- PRP (Platelet Rich Plasma) injections under ultrasonic guidance are an effective way to non-operatively treat and often cure plantar fasciitis.
- MLS Laser Therapy is the use of specific wavelengths of light to treat painful and debilitating conditions. It is a non-invasive, safe, and effective treatment modality where light is used to relieve pain, reduce inflammation, promote wound healing and soft tissue repair.
Surgical Treatment Options
When all else fails, there are surgical treatments for plantar fasciitis. Dr. Pietropaoli uses a minimally invasive technique called The Arthrocare Topaz Microtenotomy System as an effective treatment option plantar fasciitis. In addition, he also uses open surgical techniques such as partial and even complete release of the attachment of the plantar fascia.
Both PRP and surgical treatments require a mandatory period of rest and physical therapy in order to be successful. The surgical treatment is not as predictable as other types of surgery like knee arthroscopy for a torn meniscus cartilage or a carpal tunnel release, but as a last resort, definitely has a place in the treatment for plantar fasciitis. It will usually take, on average, 6-8 weeks to get back to “full duty” type activities, but it can sometimes take 3-6 months depending on what needs to be done.