By Erik Adams MD, PhD
Midwest Institute of Sports Medicine

Plantar fasciitis is a condition in which the plantar aponeurosis in the foot, sometimes referred to as the plantar fascia, is inflamed. This structure is on the sole of the foot and stretches from the heel to the toes. It is a tough, flat band of tissue which serves to not only toughen the sole of the foot, but it maintains the longitudinal arch of the foot. It can be likened to the bowstring in an archery bow. The curve of an archery bow is maintained by the presence of the bowstring, and when the bowstring is removed, the bow straightens. Figure 1 shows a lateral view x-ray of a foot, and the position of the plantar fascia is drawn in blue on the x-ray. The red line on the film shows the shape of the medial longitudinal arch of the foot, which is the arch that lowers when someone is flat-footed.


Figure 1. Diagram of medial longitudinal arch
(blue) and plantar fascia position (red)

Those suffering from plantar fasciitis will tell you that they have pain at the heel, slightly medial to its midline. Most patients will also say that the first steps in the morning are especially painful, but this is not universal. Some experience increased pain toward the end of the day. In more severe and chronic cases, nodules can form within the plantar fascia, in the area under the medial longitudinal arch of the foot.

Table 1 shows the range of treatment in general use for plantar fasciitis. This has been divided into recommended treatments, which are those used at the Midwest Institute of Sports Medicine, and those we do not recommend.

Table 1. Range of treatment available for plantar fasciitis

Pedorthotics
Pedorthotics refers in this case to replacement insoles. For milder cases, and when there is little to no flat-footedness, over the counter inserts are adequate. Recommended brands include Superfeet and Shock Doctor.  I have found both to be superior to Spenco.  For those with higher arches, custom Superfeet are also available.  Inquire at your local Superfeet dealer.  This service is available at the REI in Madison, Wisconsin.

When plantar fasciitis is more chronic in its duration, the pes planus (flat footedness) is more severe, or if the patient is larger, custom pedorthotics are recommended. These should never be the rigid type, which are usually made out of plastic or graphite, and they should be full-length. At the Midwest Sports Medicine Institute, we have established a good relationship with a local firm which makes their own pedorthotics and does an outstanding job. Theirs are full-length and semi-rigid, and we notice that our patients do much better with these than with the rigid variety.  A prescription is required, which necessitates an evaluation by a knowledgeable physician.


Inflexibility
Tightness of the calf muscles and hip flexors is often seen in plantar fasciitis and can be the ultimate cause of this disorder. The calf muscles involved are the gastrocnemius and soleus, which connect through the Achilles tendon to the heel. These are the two muscles which are used to stand on your toes. The gastrocnemius is the two-headed muscle easily seen on the posterior calf in athletes, and the soleus is deep to this. Tightness of these muscles alters the gait, causing the person to land in heel strike with the ankle in less dorsiflexion. Dorsiflexion is the ankle motion in which the forefoot is brought upwards towards the knee and the Achilles is stretched. The result of this footstrike pattern is that impact occurs more on the origin of the plantar fascia at the heel, instead of posterior to it. As the stride continues through stance phase and into toe-off (heel lift), those with this muscular tightness pattern tend to pull their heel off prematurely. This leads to earlier stretching of the plantar fascia than usual with each step. Thus, each stride ends up impacting the origin of the plantar fascia and stretching it prematurely.

Hip flexors are the muscles which cause you to lift your thigh up towards your chest, and when they are tight, this also leads to early toe-off with each stride. In patients with plantar fasciitis seen at the Midwest Sports Medicine Institute, hip flexor tightness is almost universal.

Stretching technique must be taught on an individual basis. At our clinic, we have found that many patients require coaching in technique. Some patients have such severe hip flexor tightness that they require customized stretches.

With the combination of proper pedorthotics and meticulous attention to stretching, the overwhelming majority of patients with plantar fasciitis experience relief.

Night Splinting

The night splint is a device which holds the ankle at 90° while you sleep, providing increased stretching of the gastrocnemius and soleus. It should be utilized if stretching and pedorthotics do not provide sufficient relief but is not appropriate as primary therapy. A poorly fitting night splint can cause pressure injury to a variety of ankle and foot structures.

Cortisone injection

This treatment is rarely required and represents a last resort. However, when done properly, it is helpful. There is a risk that the cortisone could become deposited within the fat pad of the heel, causing necrosis (wasting away) of the fat pad in a localized area. This is a disaster for anyone with plantar fasciitis, since the fat pad is providing cushioning over the irritated area. The cortisone must be deposited between the site of origin of the plantar fascia and the calcaneus bone.

Some practitioners attempt to avoid incorrect placement by approaching with the needle through the sole of the foot. It is true that, if the needle is not placed too far towards the heel, when the needle hits bone, it is likely to be in the proper location. However, without careful measurements made off of the patient’s x-rays, this cannot be assured. The greatest problem with this approach, however, is that the sole of the foot is intensely sensitive. In my practice, I have found that patients who express concern about the painfulness of a cortisone injection have either had one through the sole of their foot or know someone who has.

This injection need not be so painful. A medial approach is much more comfortable, although technically a little more demanding for the doctor. Because of the danger of fat pad necrosis, this injection should only be attempted by someone who is very familiar with the technique. It should also only be offered as an option after at least six months of conservative therapy.

Therapies Which Are Not Recommended

It should be pointed out that these treatments are in wide use elsewhere and may be considered acceptable in the medical or podiatric literature, but we do not recommend them at our clinic. The reasons for this are outlined below.

Heel spur excision

Surgery to remove a heel spur is quite common, but the problem is that the heel spur only represents the body’s normal reaction to chronic inflammation, which is to deposit calcium at that site. With a heel spur, the calcium is laid down along the plantar fascia, and the longer the plantar fasciitis has been present or the more rapid the calcification, the longer will be the heel spur. Also, some people are more prone to calcification at sites of inflammation than others.

Although the heel spur is quite prominently seen on an x-ray (see Fig 2), it should not be regarded as a cause of the pain. The presence of a heel spur helps to confirm the diagnosis, but the treatment does not change because of it.


Figure 2. Lateral foot x-ray showing
small heel spur

Heel lifts

This does give some symptomatic relief for a short while, but it does the opposite of what you really need to do, which is stretch the gastrocnemius/soleus/Achilles complex. Lifting the heel allows relaxation of these structures. The only possible use of a heel lift might be to provide symptomatic relief in severe cases, to allow physical therapy to begin. However, the heel lift should be removed after one week. Heel cups are sometimes helpful, as they gather together the fat pad on the bottom of the heel and thus allow more cushioning of the origin of the plantar fascia. However, if a patient has a severe enough case of plantar fasciitis to need a heel cup, they also need custom pedorthotics, which themselves do incorporate a heel cup. Thus, a heel cup may have utility until the pedorthotics are completed.

Summary

The overwhelming majority of patients find relief from plantar fasciitis with a program of stretching and pedorthotics. It should be emphasized, however, that a complete exam is mandatory. Only occasionally are night splints found to be necessary, and injection is used even less often. Those with plantar fasciitis should realize that this problem will resurface in the future, so a maintenance program of stretching and continued proper attention to effective arch support is needed.

copyright 2005 Midwest Sports Medicine Institute

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