While Leonardo da Vinci once said that ‘the human foot is a masterpiece of engineering and a work of art’, maybe the sole of the foot could have done with a review. This area of the foot is the subject of one of the most debated points of pathology in musculoskeletal medicine – plantar fasciitis.
The plantar fascia, continued within the arch of the foot, is a pearly white flat sheet of connective tissue which acts as a broad thin tendon supporting the arch of the foot. It creates a mechanical linkage between the toes and the heal, or calcaneus. Plantar fasciitis is thought to be caused by overloading the region mechanically creating tension within the plantar connective tissue.
Inflammation of this structure affects 1 in 10 people at some time in their lives. The disease is associated with several different risk factors. There is a recognised relationship between increased activity and increased risk of inflammation in the plantar fascia. However, plantar fasciitis occurs more often in patients over the age of fifty and in nonathletic patients with a high BMI. This suggests two main patient groups typically presenting with plantar fascia pain. The athletic population gets inflammation which is thought to be due to bowing of the knees and high arching of the feet, which then reduce shock absorption. The non-exercising population tend to develop plantar fasciitis because their feet are pronated and lack flexibility due to their excess weight.
To diagnose plantar fasciitis you do not need to get any investigations- your doctor should be able to work this one out! Pain is worst with the first few steps of the day but then patients will often warm into it. As the day wears on the pain may then return and will not resolve when resting. Pain can be dependent on footwear and worsens the longer someone stands each day. Swellings and signs of inflammation are not seen on examination. X-rays may reveal a bony spur on the bottom of the calcaneas in about ~60% of patients but this is not necessary for the diagnosis and is not associated with symptom severity. It also does not usually impact the management of this condition. Of interest 20% of the population have a calcaneal spur and are completely asymptomatic.
Nonsurgical treatments for plantar fasciitis will be successful in most people
During diagnosis your doctor will identify which stage of inflammation your foot is going through: acute phase first 4-6 weeks; subacute phase next 6-12 weeks; and chronic plantar fasciitis pain for greater than 3 months. If plantar fasciitis continues beyond 6 months it is classified as a “recalcitrant chronic disease”.
Non steroid anti inflammatories don’t play a role in treating fascia pain with a number of studies showing no difference between placebos and NSAID treatment. A supportive shoe however is important in helping to reduce the mechanical forces involved in irritating the plantar fasciitis. Further to this, anything other mechanical treatments that support the foot can improve pain including strapping, taping, and orthotic insoles for shoes.
It is important to avoid soft unsupportive shoes such as ballet shoes or double pluggers.
Stretching is great for treating this condition. Stretching and strengthening of the intrinsic muscles of the foot will help to avoid inflammation of the fascia. Unfortunately there is no widespread consensus on the best type of stretching. One of the best exercises as recommended by the RACGP is to cross the affected foot over unaffected foot in a figure of four. Then pull the toes of the affected foot back towards the shin for 10 seconds.
It is not recommended to have more than 2-3 injections over a 12 months period
Some invasive treatments can be helpful in the short term. Injections of steroids around the fascia will reduce symptoms acutely however if used without additional interventions, the resolution of pain will likely last for one month after treatment. If these injections are used in conjunction with mechanical treatments such as taping, then effects of treatment are prolonged and resolution is more likely. Steroid injections should be used with caution however as risks include wasting of the fat in the heel as well as a risk of tearing of the plantar fascia. It is not recommended to have more than 2-3 injections over a 12 months period in order to reduce the risks of possible complications from this treatment method. Always seek advice from a qualified musculoskeletal GP when considering these invasive treatment options.
Extracorporeal shockwave therapy can be useful for some patients. In one study of subacute and chronic plantar fasciitis seventy percent of patients treated with this form of management experienced a decrease in pain after 6 weeks. It is important to note however that efficacy in the acute and recalcitrant populations was not studied and therefore cannot be determined for those populations
Experimental interventions include orthobiologics, botulinum toxin, or prolotherapy and have been used with some success in smaller studies however benefits and risks over the longer term have not yet been identified. (See upcoming article on PRP to be published soon)
Surgical procedures are always associated with significant risks and it is important discuss these options
Surgical intervention should be reserved for the recalcitrant chronic plantar fasciitis ie inflammation of the fascia that has been ongoing for 6 months or more. Surgeons will initially consider fasciotomy. This involves cutting the fascia to reduce tension through the arch of the foot. Alternately they may consider a procedure called a gastrocnemius recession. This procedure indirectly reduces tension on the plantar arch by reducing the pull of the achilles tendon. Surgical procedures are always associated with significant risks and it is important discuss these options with both your GP and an appropriately qualified surgeon before considering surgical treatments.
Interestingly there is a new study out in the Journal of American Podiatry Medical Association that has identified a link between bariatric surgery and successful management of plantar fasciitis. A survey of bariatric patients identified patients requiring significantly fewer treatment strategies for their plantar fasciitis after bariatric surgery. So dropping BMI would definitely help with heel pain.
In summary plantar fasciitis is associated with a number of different risk factors the most significant of which is obesity. While it is relatively easy to diagnose this disease treatment usually requires a number of different approach including non-invasive and invasive options. Mechanical treatments are often successful including stretching, splinting, appropriate shoes and weight loss. Steroid injection may be helpful if used in association with mechanical supports. PRP, prolotherapy or fasciotomy may also be considered depending on the patient’s individual needs and response to previous treatments. Overall it is important to work closely with you GP in order to monitor response and ensure progression of treatment modalities occurs in a timely manner. Referral to a doctor with experience in musculoskeletal medicine may be helpful in management of this sometimes difficult to treat disease.
GPearls on the GC
- cats do not get plantar fasciitis
- Stretch first, then cushion inject shock or splint
- One treatment does not fit all
Schneider HP, Baca JM, Carpenter BB, Dayton PD, Fleischer AE, Sachs BD.
J Foot Ankle Surg. 2018 Mar – Apr;57(2):370-381. doi: 10.1053/j.jfas.2017.10.018. Epub 2017 Dec 25. Review.