Plantar Fasciitis: What It Is and How We Treat It!
By E. Pepper Toomey, MD

Condition: Plantar fasciitis is the most common problem found in the foot. In fact, it occurs so frequently that I refer to it as the 'common cold' of the foot.

Plantar Fasciitis has no particular known etiology; however obesity, high impact activities, and age seem to be common elements in many patients who have this problem. Rarely is it seen in patients under 30 and it appears to be far more common in runners and those doing high impact aerobics.

The plantar fascia is a broad ligament that stretches from the plantar surface of the heel and fans out across the arch all the way to the toes.

In addition to the term plantar fasciitis, this condition is also called 'heel spur syndrome'. This is very much a misnomer as patients develop a heel spur because of the inflammation and pulling of the plantar fascia at the heel and the osteophyte that develops is not the cause of pain.

However, once a patient is told they have heel spur syndrome and see one on x-ray, they oftentimes think they need surgery and will not be well until the spur is removed. It has been demonstrated that the osteophyte seen in this condition bears very little weight in the heel strike portion of gait and is not the cause of the problem. Therefore, I try to avoid this confusing term.

Studies conducted look at how the plantar fascia contributes to the longitudinal arch. It gives approximately 50% of the ligamentous support to the arch. This is a very important point to remember when considering surgery for this condition. In very refractory cases, surgery is done with release of the plantar fascia and removal of the heel spur. In one series, patients who had this procedure were found to develop more of a flatfoot three years out than those who had not. Because of the secondary problems from flat footedness, surgery for this condition should be approached with great caution.

Diagnosis: Most patients do not recall any particular incident or mechanism of injury, instead they first complain of pain in the morning when taking the first few steps out of bed. Often, once they start walking they can "walk it off" and start to notice improvement as they stretch the plantar fascia and Achilles tendon. After awhile however, they no longer can walk the condition off and seek medical treatment.

Many times, I find that if this condition has become really chronic, patients experience the morning pain that goes away and then, about midday, they develop progressive heel pain. Furthermore, each time they sit and rest and then start walking again they get increasing pain.

Treatment: When I see a patient for this condition, the first thing I ask is how much they go barefoot. It seems that no matter how padded the carpets are, and all the other arguments I have heard for not wearing shoes, not going barefoot is a must for successful treatment; I have yet to see anyone with this condition who goes barefoot for most of the day.

The next thing that I review is how tight the patient's gastrocsoleus Achilles tendon complex is. Through computerized gait pressure analyses on many of plantar fasciitis patients, I have found they have less heel strike pressure than the average patient. Therefore, they are spending 70-80% of their gait cycle on their arch and on the push-off phases of their gait. This leads to continued tension on the plantar fascia exacerbating the pull at the heel. Consequently, stretching of the Achilles is an extremely important part of correcting this condition. The clinician must remember that there are two muscles, the gastrocnemius and the soleus, that insert into the Achilles tendon. Two separate stretching exercises are therefore required. Since the gastrocnemius crosses both the knee and the ankle, this muscle must be stretched by keeping the knee straight. The soleus, on the other hand, is stretched with the knee bent. For patients, I use the analogy of positioning the leg in a squatted position like the mogul skier for the soleus and the knee straight and stretched out over the skis like the ski jumper for the gastrocnemius. As you are trying to stretch the gastrocsoleus complex and not the plantar fascia, the heel should always remain flat on the floor.

Interesting, I have not found heel cups to be beneficial. I have been much more pleased with a three-quarter length arch support made out of medical grade silicone. These insoles can be obtained from the Silipos Corporation and I have found them very beneficial.

I tend to start my patients on a nonsteroidal anti-inflammatory drug and favor a Cox 1 sparing drugs such as Mobic that are once a day dosing and again have good patient compliance.

If patients do not improve with a stretching program, nonsteroidal anti-inflammatory drugs, and three-quarter silicone insoles I will add night splints. There are many vendors that sell these and I have not found one that is much more comfortable and effective than the others. Patient compliance can be poor with these splints as they sometimes disturb the patient's sleep. It does appear however, that not letting the plantar fascia and Achilles contract during the night is very helpful in getting rid of this problem.

Lastly, if patients do not improve with the above regimen, I will consider injecting the plantar fascia. This is done from the medial side of the heel and not through the bottom. This is much less painful and no less effective. I place the needle all the way down to the bone where the plantar fascia originates and inject 1 cc of lidocaine and 1/2 cc of depomedrol into the area. I stay close to the bone and do not put any of the steroid preparation superficially into the fat of the heel pad. This avoids the terrible complication of fat atrophy from a steroid ejection.

In the very refractory cases, surgery can be considered. Extracorporeal shockwave therapy is a new modality that also shows some promise and probably should be given consideration before surgery. However, many insurance carriers do not cover this as yet, even though there are studies showing it to be effective for this condition.

In summary, plantar fasciitis is a very common problem of the foot. It is a significant nuisance for the patient but usually does not pose any significant long-term problems for the foot or lower extremity. In treating this, three-quarter length silicone insoles, nonsteroidal anti-inflammatory medication, Achilles stretching exercises, and night splints all appear to give significant benefit for this condition. In those patients that do not to improve within three to four weeks, consider a steroid ejection. The patient must be warned about possible rupture of the plantar fascia and fat atrophy they can result from the injection. In the very refractory cases extracorporeal shockwave therapy and surgery can be done to help the patient. With a surgical release of the plantar fascia and removal of the osteophyte from the calcaneus, the patient will develop a flatter arch over time.