WHAT IS PLANTAR FASCIITIS?

The plantar fascia is the large ligament located along the bottom of the foot,

extending from the heel bone to the forefoot. It functions to help support the arch of

the foot. When added stress is placed on the ligament, it can become inflamed, tear,

and cause pain. This is known as plantar fasciitis.

 

CAUSES OF PLANTAR FASCIITIS:

When the plantar fascia is stressed, overused, or traumatized, it becomes inflamed, 

causing pain and swelling. Often it is associated with increased activities, especially

higher impact ones (e.g. running, jumping), or prolonged activities (e.g. standing,

walking). Change in shoe gear or walking barefoot can also contribute to symptoms

of plantar fasciitis.

 

Certain foot types can also put a person at increased risk for developing plantar fasciitis. People with significantly high arches genetically have a shorter and tighter plantar fascia, so as this specific population ages and their soft tissues become less elastic, added stress to the ligament can cause it to tear, instead of stretch, with the body. This is why children rarely develop plantar fasciitis. On the other end of the foot type spectrum, people with flat feet also tend to get plantar fasciitis because as their arch flattens, the plantar fascia gets stretched, causing stress and pain along the plantar fascia.

 

When plantar fasciitis becomes chronic, it is termed fasciosis. Plantar fasciosis

refers to the degeneration, and sometimes calcification, of the ligament.  

 

SYMPTOMS:

Plantar fascial pain is often located along the bottom of the heel, where the plantar

fascia inserts, or along the plantar-medial arch; however, the pain can occur anywhere

along the course of the plantar fascia. 

 

The pain is noted with standing, walking, or other weight-bearing activities, and is

often improved with rest. One may also experience pain with first steps after periods

of rest. This is called post-static dyskinesia

TREATMENT OPTIONS:

Rest, Modification of activities, & Immobilization

Sometimes it takes a temporary modification of activities to help give the plantar fascial ligament a rest. This means, avoiding higher impact activities (e.g. walking, running, jumping) and switching to lower impact activities (e.g. swimming, biking) until the symptoms improve or resolve. If the pain persists, though, continued participation will only prolong, or inhibit, the healing process. Therefore, depending on the severity of the pain and when it occurs, helps determine how aggressive one needs to be with resting and/or immobilizing of the extremity. If modification of activities is not enough, sometimes a walking boot or walking cast is required for a period of time.

 

Icing 

Icing one to two times daily (especially after exercise) can help decrease inflammation. Ice should be avoided in persons with neuropathy/numbness or poor circulation. 

 

Anti-inflammatory medications

Anti-inflammatory medications can also help with inflammation and swelling, which, in turn, helps with pain; however, pain medications should not be used long-term.

 

Injections

  • For Plantar Fasciitis:   

       For acute plantar fasciitis pain, steroid injections are commonly used. Steroid injections help decrease the inflammation associated with      

       plantar fasciitis, thus helping improve pain. However, if the underlying reason for the development of the plantar fasciitis pain isn’t addressed          (e.g. poor shoe gear, lack of shoe gear, abnormal biomechanics, etc), the chances of developing the symptoms again is greater. It is

       important to know that the injections do not work for everyone and not all injections work the same each

       time administered. They also have their potential side effects and should only be performed 3-4 times

       per year.

  • For Plantar Fasciosis: 

       Most injections are saved for the more chronic stage of plantar fasciitis, plantar fasciosis. For

       plantar fasciosis, three injection therapy options are PRP injectionsProlotherapy, and Botox

      injections

                Blood is made up of plasma, red and white blood cells, and platelets. Platelets function to help with

                clotting of blood, but they also contain growth factors that aid in the healing process. Platelet-rich

                plasma, or PRP, is plasma that contains a higher concentration of platelets than normal. The purpose

                of PRP injections is to increase the number of growth factors into and around an area of soft tissue

                damage, thus stimulating and speeding up the healing process. The ultimate goal is decreased pain,

                improved function, and return to sports and activities.

                Prolotherapy (aka proliferation therapy) is a nonsurgical, serial injection of a dextrose solution that is

                injected into the affected area to stimulate an acute low-grade traumatic process, allowing the body

                to use its own inflammatory markers to aid in the body’s healing process naturally, thus regenerating

                and repairing damaged tissues, restoring joint stability, and improving pain. 

 

       Check out my blog to learn more about the roles PRP injections & prolotherapy play in treating chronic

       musculoskeletal pain.

  • Botox Injections

                The purpose of botox injections in plantar fasciosis is to reduce pain and inflammation, induce

                muscle relaxation, and decrease underlying muscle volume (1).

    

                In a 2005 study, the use of botox in plantar fasciosis was evaluated. Patients were randomized into

                either the botox group, which received the botox solution, or the placebo group, which received

                saline injections. The injections were done near the insertion of the plantar fascia on the heel and

                the most tender spot along the arch. At the 8-week follow-up, there was a significant improvement

                noted in all four pain-related variables for the botox group (1).

 

Shoe gear

Wearing proper shoe gear is always an important concept to think about when treating lower extremity pathologies. For plantar fasciitis pain, it is important to wear good, supportive tennis or walking shoes (e.g. New Balance, Brooks, ASICS, Saucony) as much as possible and avoid barefoot walking and the use of flat shoes and flip-flops. Wearing a shoe with a slight heel (temporarily) may also help because it will take tension off the tendon, allowing it to rest.

 

Orthotics

These are devices that go into many different types of shoes to help cushion, support, and control abnormal motions of your feet. They can also help with the realignment of the lower extremity more proximally, including your knees, hips, and back. They can be purchased off-the-shelf or be custom-made to fit your feet.

 

  • Over-the-counter (OTC) orthotics

       These are pre-constructed devices that can be purchased off the shelf. There are several brands and  

       variations to these shoe inserts. The benefit of OTC orthotics is that they are cheaper (will likely note

       cost you more than $65-70) and they are ready to wear immediately. The downfall of OTC orthotics is

       that they are not made for your specific foot so they have limitations as far as how much they may help

       with your foot pain or other lower extremity-related issues.

 

  • Custom-molded orthotics (CMOs)

       These are specially-made devices that are made specific for your feet, foot deformities, and related

       biomechanical issues. Scans, impressions, or molds of your feet are taken and then sent to a lab

       for manufacturing. Within a couple weeks, the custom orthotics are returned and fitted for your

       shoes. They are more expensive, starting at around $400; however, they should last significantly

       longer than OTC orthotics. Whereas, OTC orthotics may wear out in about a year, you may get 5 or

       more years out of one pair of custom orthotics.

 

       Check out my blog to learn more about the differences between OTC and custom orthotics.

 

Stretching

Stretching is important because many people that develop plantar fasciitis and fasciosis may have ligaments, as well as tight calf muscles. Also, as people age, their soft tissues (e.g. tendons, ligaments) become less elastic and often tighten. This puts them at increased risk for developing injuries. Therefore, routine stretching can help regain flexibility and length back in these structures, as well as help prevent injuries from occurring.

 

  • When to stretch

       In my patients that experience post-static dyskinesia (pain with first steps after periods of rest, such after sleeping or sitting at a desk for a  

       long period of time), I usually recommend moving their feet and ankles around first, as well as massaging each calf muscle, and then carefully

       try doing the exercises. For those that are still exercising, or are involved in sports/athletics, it is also important to stretch after your activities.

 

       The timing of the exercises is crucial for proper rehabilitation, so it is important to get clearance from your doctor before starting any exercise

       program, especially if you are injured. The stretching exercises can either be done on your own or under the guidance of a trained physical

       therapist. ​

 

  • Exercises

       1. Wall stretches: ​​These are done while leaning against a wall. Place one foot in front of the other, keeping your heels on the ground and your

        feet pointing straight ahead. For the first exercise, bend your front knee and keep your back leg and knee straight (see Wall Stretch #1 below).

        Lean into the wall by bringing your hips forward. You should feel a mild pulling (not painful) sensation along the back of the back leg. Hold  

        this for 30 sec. Repeat 3 times and then switch legs. ​​For the second exercise, keeping the same position (feet straight ahead, heels down, and

        front knee bent), now bend the back knee (see Wall Stretch #2 below). Lean forward and hold this position for 30 sec. Repeat 3 times and

        then switch legs. 

       

       2. Step Stretches: ​​Find a staircase or small step, where you can hold onto a railing for ​​balance. Using both feet, place your heels off the step

       and slowly lower them, keeping your knees straight, until you feel a mild pulling (not painful) sensation along the back of the legs. Hold this  

       for 30 sec. Repeat 3 times. Then, like the above exercise, you can bend your knees slightly and hold this position on the step for 30 sec,

       repeating 3 times. Once you are comfortable with the above exercise, you can try doing single heel drops (see Stair Stretch below).

 

       3Towel Stretches: These exercises are done while seated on the ground (or while in bed). For the first exercise, place a towel around your

       forefoot and while keeping your knee straight (see Towel Stretch #1 below), slowly pull the towel​​towards your body until you feel a mild pulling

       (not painful sensation) along the back of your leg. Hold this for 30 sec. Repeat 3 times and switch legs to stretch the opposite calf muscles.

       For the second exercise, bend the involved knee slightly (like you did with the wall & step stretches), then pull the towel towards you again  

       and hold for 30 sec. Repeat 3 times and switch legs to stretch the opposite calf muscles. 

 

       Check out my blog on “Why Stretching Your Calf Muscles Daily Is Important” to learn more about the importance of stretching daily.

 

 

 

 

Night splint

This is a device that is worn on the lower extremity while you sleep. It holds the foot in a position that keeps the plantar fascia and the Achilles tendon out to length and prevents them from shortening while you sleep. This is often helpful for those that get “first steps of the morning” pain along the plantar fascia. The night splints can be easily purchased online. From my patients that have used them, their biggest complaint is that they can be uncomfortable to sleep with.

 

Surgery 

Surgery is considered if pain persists after several months of failed conservative treatment. The surgery involves cutting part of the ligament. Recovery after surgery may last weeks to months. It is important to wear good supportive shoes and orthotics after surgery to prevent recurrence.

 

 

Reference:

1. Babcock, M. S., Foster, L., Pasquina, P., & Jabbari, B. (2005). Treatment of pain attributed to plantar fasciitis with botulinum toxin a: a short-term, randomized, placebo-controlled, double-blind study. 

Wall Stretch #1
Stair Stretch
Wall Stretch #2
Towel Stretch

Disclaimer: The above information is meant for educational purposes only and should not be construed as medical advice. Should you feel that you are suffering from Plantar fasciitis or another foot-related issue, please schedule an appointment to see the doctor.

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