What is Plantar Fasciitis? (fashee-EYE-tiss)
Plantar fasciitis is a common painful foot condition located mostly at the heel. Although originally thought of as an inflammatory process, plantar fasciitis is a disorder of degenerative changes in the plantar fascia leading to thickening of the fibre and may be more accurately termed plantar fasciosis (Lemont et al 2003). Plantar means the bottom of the foot, and fascia is the fibrous tissues that connect the heel bone (calcaneus) to the heads of the metatarsal bones found at the base of your toes. It is an overuse injury where the plantar fascia becomes strained due to levels of stress that exceed how much the plantar fascia can tolerate. The level of stress the plantar fascia can tolerate varies from person to person. Plantar fasciitis is the most common cause of heel pain affecting up to 10% of the population. Approximately 90% of heel pain is caused by plantar fasciitis. It is most often seen in middle-aged men and women (between the ages 40-60), but can be found in all age groups and is also common in the athletic population (Rome et al 2001). In these athletes, it is thought that the repetitive nature of the sports causes the damage to the plantar fascia.
What causes it?
The cause of plantar fasciitis is multi-factorial meaning that it is caused by a combination of individual factors. There is no one single cause of the condition. Proposed causative factors in the medical literature can be split into two types:
· feet that roll inwards too much when walking (increased pronation)
· feet with very low arches (flat feet)
· feet with very high arches
· tight Achilles tendons or calf muscles
· tight hamstrings
· limited ankle joint flexibility
· being overweight
· Occupations that keep you on your feet. Factory workers, teachers, chefs, nurses, cleaners and others who spend most of their work hours walking or standing on hard surfaces can damage their plantar fascia.
· Improper shoes – shoes that are not supportive or worn out.
What are the symptoms of plantar fasciitis?
Plantar fasciitis is diagnosed clinically with the classic symptoms of "sharp/stabbing" pain well localized over the heel area of the bottom of the foot as this is where the plantar fascia attaches to the heel bone. Often the pain from plantar fasciitis is most severe when you first stand on your feet in the morning. Pain often subsides after a while, but then returns after prolonged standing or walking. Typically pain is noticeable when standing after a long period of rest, this is known as post-static dyskinesia. The pain is often described as a sharp, stabbing pain and can feel like walking on a marble. In some cases, pain may also extend along the sole of the foot where the plantar fascia continues to attach to the metatarsal heads.
How is plantar fasciitis diagnosed?
The diagnosis of plantar fasciitis is usually made by a patient history that matches the classical symptoms of plantar fasciitis, along with a clinical assessment by a podiatrist or suitably qualified health professional. Diagnostic imaging such as ultrasound and MRI are not routinely used to confirm a diagnosis but can be helpful when one is unsure of the diagnosis. Diagnostic imaging is also useful to rule out differential diagnoses such as radiculopathy (referred back pain), bone oedema (swelling), plantar fascia tear, stress fracture, inflammatory disorders etc.
Why did I get plantar fasciitis?
Plantar fasciitis occurs because of irritation to the thick ligamentous connective tissue that runs from the heel bone to the ball of the foot. This strong and tight tissue contributes to maintaining the arch of the foot. It is also one of the major transmitters of weight across the foot as you walk or run. Therefore, the stress placed on this tissue is tremendous. When the amount of stress placed on the plantar fascia exceeds the amount it can tolerate it becomes damaged causing the connective tissue that forms the arch of the foot to become thickened and degenerative. The reason one may have placed too much stress on their plantar fascia varies greatly from person to person. For some, it may be a combination of tight calf muscles and feet that pronate (roll in). For others, it may be standing for long periods in unsuitable footwear. All of these individual factors contribute to the loading stress on the plantar fascia.
Is it treatable?
Of course, it is! But no single treatment works best for everyone with plantar fasciitis. The most important thing is to identify and eliminate the causative factor(s), which again differs from person to person. Fortunately, there are many things you can try to help your foot get better:
· A short period of rest – cut back on activities that make the pain worse
· Ice treatment to reduce pain
· Massage which often provides a therapeutic effect
· Wearing a night splint
· Following a prescribed stretching and strengthening programme
· Wearing appropriate shoes
· Wearing functional foot orthoses (insoles)
This list is not exhaustive.
How long will it take for the pain to go away?
This is a tough question as there are many factors that can influence one's healing such as their overall medical health, certain medical conditions are known to delay one's capacity to heal from injury such as diabetes, immune deficiencies, poor blood supply etc. Plantar fasciitis most often occurs because of repetitive micro-trauma injuries that have happened over time. The length of time you have had the condition also influences how well it will respond to treatment. What we know is that chronic conditions (over 6 months) are more difficult to heal and less respondent to conventional treatment. Therefore the quicker you receive treatment the better chance you have in curing the problem.
What causes treatment to fail?
Nonsurgical treatments almost always improve the pain. It is commonly reported that 90% of cases will get better from nonsurgical treatment. If the underlying causes of plantar fasciitis are properly addressed patients usually respond very well to treatment. Reasons for treatment failing are most commonly due to inappropriate treatment recommended, and poor patient compliance i.e. not wearing appropriate footwear or not performing prescribed treatments correctly. Treatment may also fail in chronic plantar fasciitis (having the condition for over 6 months). In chronic cases, the plantar fascia may become very degenerative with a build up of scar tissue. This makes the condition more difficult to treat and less responsive to conventional treatment. In chronic cases, one may benefit from treatments aiming to promote and restart the healing cascade such as extra-corporeal shockwave therapy. We will cover this treatment option in more detail in another article. Another cause for treatment to fail is misdiagnosis where the cause of the pain is in fact not plantar fasciitis but instead a different type of heel pain.
How do I prevent the pain recurring?
One of the most important things is to maintain your improved flexibility since muscular tightness is one of the leading causes of plantar fasciitis. This can be achieved by performing stretching exercises once every few days or as often as you start to notice any tightening of your muscles. Maintaining the improved flexibility reduces your chances of going back to square one.
It is equally important to wear appropriate shoes. This does not mean you have to spend all of the time in supportive footwear. It simply means that spending all of your time in bad footwear will increase the likelihood of the condition recurring.