Typically, plantar fasciitis results from the repeated trauma to the tissue where it attaches to the calcaneus. Plantar fasciitis is common in middle-aged people. It also occurs in younger people who are on their feet a lot, like athletes or soldiers. It can occur in one foot or both feet.
Anatomy
The plantar fascia is a flat band of tissue - a ligament that connects heel bone to your toes. It supports the arch of your foot. It is attached to the heel bone and fans out to attach to the bottom of the metatarsal bones in the region of the ball of the foot. Since the normal foot has an arch, this tight band of tissue is at the base of it. In this position, the plantar fascia acts like a bowstring to maintain the arch of the foot.
Signs and symptoms of plantar fasciitis
Although plantar fasciitis usually develops gradually, it can also come on suddenly and be severe. Plantar fasciitis can affect both feet, but it usually occurs in only one foot at a time.
The most common symptoms are:
- Sharp pain in the inside part of the bottom of your heel, which may feel like a knife sticking in the bottom of your foot
- Heel pain that tends to be worse with the first few steps after awakening, when climbing stairs or when standing on tiptoe
- Heel pain after long periods of standing or after getting up from a seated position
- Heel pain after, but usually not during exercise
- Mild swelling in your heel
Possible causes of plantar fasciitis
It is proven that, as a person gets older, the plantar fascia becomes less like a rubber band and more like a rope that doesn't stretch at all. the result of this process is that the fat pad on the heel becomes thinner and can't absorb as much of the shock caused by walking.
The most common causes of plantar fasciitis are:
Physical activity overload
There is no doubt that activities such as long-distance running can place your plantar fascia under a lot of stress. Even activities such as jogging, walking or stair climbing can place too much stress on patient’s heel bone and the soft tissue attached to it.
Arthritis
Some types of arthritis can spread to surrounding tissue and cause inflammation in the tendons in the bottom of foot, which may lead to plantar fasciitis.
Diabetes
Although experts still don’t have an explanation for this, the fact is that plantar fasciitis occurs more often in people with diabetes.
Impaired foot mechanics
If a person is being flat-footed, having a high arch or even having an abnormal pattern of walking, he or she is definitely at a higher risk of developing plantar fasciitis. It can adversely affect the way weight is distributed when being on feet, adding stress to the plantar fascia.
Improper shoes
It is proven that shoes that are thin-soled and loose lack the arch support or the ability to absorb shock. If someone regularly wears shoes with high heels, Achilles tendon that is attached to your heel can contract and shorten, causing the strain on the tissue around heels.
Incidence of the condition
Plantar fasciitis accounts for about 10% of runner-related injuries and 11-15% of all foot symptoms which require professional care. It is thought to occur in 10% of the general population as well. It may present bilaterally in a third of cases. The condition occurs equally in both sexes in young people. Some studies show a peak incidence in women aged 40-60 years.
Risk factors for developing plantar fasciitis
A person is placed at a higher risk of developing plantar fasciitis if he or she is:
Pregnant
Several studies done in the past have proven that the weight gain and swelling that normally accompany pregnancy can cause ligaments in feet to relax. This can lead to mechanical problems and inflammatory conditions such as plantar fasciitis.
Wearing shoes with poor arch support or stiff soles
The fact is that poorly designed pumps, loafers and boots can cause plantar problems. People should therefore avoid them.
Active in sports
Activities that place a lot of stress on your heel bone and the attached tissue, such as running, ballet dancing and aerobics, are most likely to cause plantar fasciitis.
Workers on their feet
There is no doubt that people with occupations that require a lot of walking or standing on hard surfaces, including factory workers, teachers and waitresses, can damage their plantar fascia. That’s why they are placed at the highest risk for developing this condition!
Flat-footed or have high arches
It is proven that people with flat feet may have poor shock absorption, which increases the stretch and strain on the plantar fascia.
Middle-aged or older
Heel pain tends to be more common with aging as the arch of your foot begins to sag and relax more then it should, putting stress on the plantar fascia.
Overweight
Carrying some extra pounds around can break down the fatty tissue under the heel bone and cause heel pain. That’s why weight loss is one of the principles of good therapy!
Other anatomic risks include overpronation, discrepancy in leg length, excessive lateral tibial torsion and excessive femoral anteversion. Functional risk factors include tightness and weakness in the gastrocnemius and soleus muscles, Achilles tendon and intrinsic foot muscles.
Diagnosis of plantar fasciitis
Patient’s history
Patient’s history is very important in making the right diagnosis of plantar fasciitis. Doctor should ask about symptoms and look for points of tenderness in patient’s foot. This can help rule out other causes of heel pain, such as tendinitis, arthritis, nerve irritation or a cyst.
X-ray imaging or MRI
Some doctor believe that X-ray or MRI could be very important in diagnosis because these diagnostic tools can rule out the stress fracture which is also a common condition. Sometimes, an X-ray shows a spur of the bone projecting forward from the heel bone, which can be corrected surgically.
Treatment of plantar fasciitis
There are several types of treatment which proved beneficial in treating plantar fasciitis:
- Conservative treatment
- Exercises
- Anti-inflammatory agents
- Surgical procedures
Conservative treatment
Night splints have shown to be very helpful to the patients. Doctor may recommend wearing a splint fitted to patient’s calf and foot while he or she is sleeping. This holds the plantar fascia and Achilles tendon in a lengthened position overnight so that they can be stretched more effectively.
For a long time now doctors have been prescribing these custom-fitted shoe inserts called orthotics. They are molded to fit each patient’s feet, to help distribute the pressure on the feet more evenly. Custom orthotics are usually made by taking a plaster cast or an impression of the individual's foot and then constructing an insert specifically designed to control biomechanical risk factors.
Exercises
A physical therapist can devise a series of exercises to stretch the plantar fascia and Achilles tendon and to strengthen lower leg muscles, which stabilize ankle and heel. A therapist may also teach the patient to apply athletic taping to support the bottom of the foot.
- Stretching and strengthening programs play an important role in the treatment of plantar fasciitis and can correct functional risk factors such as tightness of the gastrocsoleus complex and weakness of the intrinsic foot muscles.
- Other effective techniques include use of a slant board (Figure 3) or placing a two-inch 3 four-inch piece of wood.
Strengthening programs should focus on intrinsic muscles of the foot.
Exercises used include towel curls and toe taps.
- Exercises such as picking up marbles and coins with the toes are also useful.
Anti-inflammatory agents
Anti-inflammatory agents used in the treatment of plantar fasciitis include:
- Ice - it is applied in the treatment of plantar fasciitis by ice massage, ice bath or in an ice pack. To use an ice bath, a shallow pan is filled with water and ice, and the heel is allowed to soak for 10 to 15 minutes.
- NSAIDs – They seem to cause an improvement in great majority of the patients. Advantages of NSAIDs are the acceptability of the use of an oral medication and the acceptance by medical insurance. Disadvantages of NSAIDs are many, including the risk of gastrointestinal bleeding, gastric pain and renal damage.
- Iontophoresis - Iontophoresis is the use of electric impulses from a low-voltage galvanic current stimulation unit to drive topical corticosteroids into soft tissue structures.
- Cortisone injections – They have the greatest benefit if administered early in the course of the disease. Steroids can be injected via plantar or medial approaches with or without the ultrasound guidance.
Surgical procedure
In cases when the condition does not respond to any conservative treatment, surgical release of the plantar fascia may be considered. The operation is called plantar fasciotomy. It may be performed using open, endoscopic or radiofrequency techniques. What makes this operation good? Overall, the success rate of surgical release is 70 to 90 percent in patients with plantar fasciitis. Of course, there are some potential risk factors and the most common include flattening of the longitudinal arch and heel hypoesthesia as well as the potential complications associated with rupture of the plantar fascia and complications related to anesthesia.