Plantar Fasciitis

Heel spurs, heel spur syndrome and plantar fasciitis are synonymous terms that refer to the same condition. Although hard to pronounce, plantar fasciitis is rapidly becoming the most commonly used term to describe this condition. Plantar is a geographic term that refers to the bottom of the foot (dorsal on top/plantar on bottom). Fascia is a tough, inelastic band. And 'itis' always refers to something that's inflamed (bronchitis, arthritis, etc.). When the root words are combined they describe is an inflammatory condition of a fascial band on the bottom of the foot; plantar fasciitis.

Fascia is a form of tissue that is found at many different locations in our bodies. Fascia plays a supporting role for the musculoskeletal system helping to guide motion while supporting bone and muscle. The plantar fascia originates on the bottom of the heel and travels across the arch to the toes. Although quit a complex structure, the primary function of the plantar fascia is to support the arch of the foot.

How do we develop plantar fasciitis? Plantar fasciitis is a form of overuse syndrome that is the result of excessive and repetitive loading of the plantar fascia. When we stand, load is applied to the arch of the foot causing the height of the arch to drop. This drop in the height of the arch places tension on the plantar fascia. If the tension (load) applied to the plantar fascia is greater than it can tolerate, the fascia will become inflamed.

Load that is applied to the foot can be divided into two types; intrinsic and extrinsic loading. Intrinsic load is the load that is applied to the fascia from the muscles of the leg, most importantly, the calf. It's important to recognize that the plantar fascia is actually part of a much larger structure called The CT Band. The CT Band (meaning calf to toes) consists of the calf, Achilles tendon and plantar fascia. Any one thing that make the CT Band tight will increase intrinsic load to the entire CT Band. It just so happen that the insertion of the plantar fascia on the bottom of the heel is the 'weakest link' in the CT Band. Extrinsic load consists of all the loading factors the effect the foot other than intrinsic load. Extrinsic load may include body weight, duration of standing, frequency of steps, etc. Plantar fasciitis results when the sum total of intrinsic and extrinsic loading surpasses what the body can heal in the course of a day. Essentially, when you get up out of bed in the morning and your heel hurts, what you're feeling are the loads applied to the foot yesterday that have yet to be healed by your body.

Plantar fasciitis can be describe in two forms;

• Primary plantar fasciitis - plantar fasciitis which is due to a mechanical overload of the plantar fascia by the sum of intrinsic and extrinsic loads. See the biomechanics tab below for a detailed description of mechanical factors that contribute to primary plantar fasciitis.

• Secondary plantar fasciitis - plantar fasciitis which is due to conditions other than mechanical loading of the fascia. These include direct trauma to the fascia and systemic diseases that may effect the attachment of the fascia to the calcaneus (heel bone) such as arthritis.

So if we know that a 'heel spur' is actually not a bone problem, are x-rays still a necessary tool in making a diagnosis? Absolutely. It's important to rule out many of the other conditions of the calcaneus (heel bone) that can mimic plantar fascial pain such as stress fractures and arthritis (see differential diagnosis tab for more information).

Treatment of Plantar Fasciitis

The first consideration in treating plantar fasciitis is determining whether the condition is primary or secondary plantar fasciitis. Primary plantar fasciitis is the most common form of and makes up at least 90% of all cases of plantar fasciitis.

Treatment Of Primary Plantar Fasciitis

Treatment of primary plantar fasciitis is based in four broad categories of care; biomechanical methods, anti-inflammatories methods, shock wave therapy and surgery. Let's take a closer look at each of these four categories and see how they can often work together.

The human body has a remarkable capacity to heal. And in the case of plantar fasciitis, this couldn't be more true. We spoke earlier of load and how the change or increase in several loading factors contribute to the over loading or overuse of the plantar fascia. If we recognize then that plantar fasciitis is a mechanical condition it stands to reason that the most appropriate methods of treatment for plantar fasciitis are also mechanical. For instance, we speak of equinus (see biomechanics tab) and the CT Band. The pathological force that equinus applies to the foot through the CT Band can be neutralized by elevating the heel. This can be accomplished by using a firm 3/8" heel lift or wearing shoes with a wedged sole or higher heel. Calf stretches will also help to weaken the CT Band hence decreasing the power of the calf and tending to 're-balance' the normal biomechanics of the foot and leg. The most effective calf stretches are done by standing on the edge of a step or curb with just the toes and letting the heel drop below the level of the step. Drop the heels until you feel a tightness in the calf and hold that position for 60 seconds. Repeat this stretch 6 times each day. There are many ways to stretch the calf but this method is by far the most effective.

Taping the arch, stretching splints and slippers, heel cups and a host of other 'devices' have been used successfully to treat plantar fasciitis. All of these devices focus on changing the biomechanical properties of the CT Band. Remember, the key to treating plantar fasciitis is addressing the entire CT Band and not just the plantar fascia. Stretches and heel lifts are quite often all that is needed for complete resolution of symptoms. Arch supports can be used on a daily basis to maintain good support of the arch and help to decrease recurrence of plantar fasciitis.

We also spoke of anti-inflammatories. Anti-inflammatories include steroid injections, oral anti-inflammatory medications such as aspirin, prescription strength medications called NSAID's, ultrasound, massage, topical medications and a host of other methods to reduce inflammation. When using anti-inflammatory methods, bear in mind that we are treating a problem that we know is caused by overuse or overloading. We called this a mechanical problem and therefore realize that we always need to used our first category of treatment, biomechanical measures, to treat plantar fasciitis. Anti-inflammatories are helpful with one aspect of plantar fasciitis and that is the pain the develops as we spend more time on our feet. Anti-inflammatories will not typically address the sharp tearing pain we called post dystatic pain but rather address the pain we develop as the day progresses (see the symptoms tab for more information on symptoms of plantar fasciitis). That's why it's important to combine mechanical methods of care with an anti-inflammatory. The two methods of treatment work together to address the two different types of pain that are experienced with plantar fasciitis.

Extracorporeal shock wave therapy has been used recently as a tool to break the re-injury cycle associated with plantar fasciitis. The initial studies on shock wave therapy were performed on renal (kidney) and biliary (gall bladder) stone patients. Due to the initial success of treating renal and biliary stones, researchers began to look for new applications for shock wave therapy. Animal experiments began in 1986 to study the effects on bone growth when stimulated by shock wave therapy. In 1991, High Medical Technologies (HMT) of Switzerland developed and clinically tested the OssaTron®. The OssaTron® is the first shock wave therapy device designed for orthopedic/podiatric use. The OssaTron® received FDA approval for treating plantar fasciitis in 2000. Other applications for shock wave therapy, which are now under investigation, include tennis elbow, non-healing bone and tendonitis.

Shock wave therapy employs an acoustic wave that results in an explosion of energy at the point of focus. Shock waves differ in amplitude and are 'tuned' for a specific purpose based upon the desired amplitude and medium that is crossed to reach a target tissue. The effect of the shock wave in cases of plantar fasciitis is not fully understood. It is believed that the effect of the shock wave stimulates an intense focused inflammatory reaction that promotes healing at the insertion of the plantar fascia.

Shock wave therapy can be painful to perform and therefore requires that the procedure be performed in an outpatient setting with deep sedation. The procedure takes about 15 minutes to complete and does not require a local anesthetic (only sedation). Patients are able to walk on the foot the same day. Complication are minimal. Most doctors will require continued stretching and limited activity for 4 weeks following shock wave therapy. The long term success or failure of shock wave therapy is yet to be seen, but recent studies have had short term success rates of 48-77%. For additional information on shock wave therapy refer to The International Society for Musculoskeletal Shock Wave Therapy .

And lastly, we mentioned surgery. Surgical correction for plantar fasciitis has come a long way over the past several years. Although the actual procedure has remained the same, the methods of completing the surgery have changed dramatically. Endoscopic surgical methods have become the standard of care for plantar fasciitis. The procedure, called an endoscopic plantar fasciotomy, or EPF for short, was developed by Steve Barrett, DPM of Spring Texas. Dr. Barrett developed instrumentation that enabled the procedure to be performed through two small 1/4" incision. Most patients are able to return to their shoes in just a matter of days. Dr. Barrett deserves a lot of credit for making such improvements in not only the knowledge pertaining to plantar fasciitis but also revolutionizing the ways in which the procedure is performed. The older methods of surgical correction included resection of the heel spur or partial resection of the heel bone. We now merely release, or make a cut through the fascia, leaving any spur in place. Once again, it's important to realize that we are treating a soft tissue problem. Dr. Barrett's efforts have resulted in a vast improvement in surgical care, sparring many patients the complications and disability associated with the older surgical methods.

So what's the best method of care for you? That decision should be made by you and your doctor together. Essentially, the most important issue is time. How long has your plantar fasciitis been present? The use of the biomechanical methods of care and anti-inflammatories may help and are a necessary part of a complete treatment plan but do not always work. If your symptoms have been present for more than a year or if you've tried 4 months of conservative care with no change in your symptoms, you are probably a good candidate for an EPF. Consider the conservative measures of care as a means to help the body heal itself or make the necessary change to become pain free. Surgery on the other hand is the physical change.

Heel spur surgery, whether performed endoscopically or with a traditional method, is not without problems. 90% of EPF cases are completed without complication. 10% of cases do have problems that can vary in severity. One complication specific to plantar fasciotomies, regardless of how they are performed, is later column syndrome (LCS). LCS is sometimes a very difficult complication to understand, diagnose and treat. If we think of other endoscopic surgical procedures, such as a cholecystectomy (gall bladder) we tend to think of the first week or two as the time when we would have complications. The surgery is completed, we heal and move on. But consider the fact that you don't walk on your gall bladder surgery. The complications of LCS occur not in the first week or two after surgery but rather 2-4 month after a plantar fasciotomy.

Here's what happens in cases of LCS. As patients get 4 weeks or so out on their plantar fasciotomy, they start to feel more able to return to their normal activities. As they progressively increase their activities they begin to add an increase in load to the foot. Although the surgical site no longer is sore from the surgery, the biomechanical impact, or change to the joint structure of the foot is not complete for 4-6 months following the surgery. Early symptoms of LCS are a dull ache of the lateral (outside) of the foot and the top of the arch. This ache is a stiffness that if left untreated will result in small stress fractures if the lateral and dorsal aspects of the foot. LCS is a manageable complication of this procedure and should be thoroughly discussed before surgery so that patients are aware of the symptoms of LCS and can make their doctor aware should they experience problems.

Treatment of Secondary Plantar Fasciitis

Secondary plantar fasciitis encompasses all conditions that may cause inflammatory pain of the plantar fascia but are not due to repetitive loading of the fascia by the CT Band. Secondary plantar fasciitis may be due to direct trauma or arthritis.

Trauma to the fascia may be direct, such as a puncture wound of the foot or blunt trauma to the arch. Trauma to the fascia may also be indirect and secondary to other injuries. An example of indirect trauma to the plantar fascia would include swelling of the foot following an ankle fracture. In each case, whether direct or indirect, care of the trauma will be the goal. This discussion cannot fully discuss trauma care, but for sake of example, care may include rest, ice, elevation, immobilization or wound care.

Secondary plantar fasciitis due to arthritis is a symptom of a systemic disease. Treatment should focus on diagnosing and treating the systemic disease rather than on local care of plantar fasciitis. Occasionally local care, such as a shot of cortisone may be indicated.

On The Horizon... .

Drs. Barrett and Erredge in Texas have taken a novel approach to treating plantar fasciitis. They have put forth a hypothesis that plantar fasciitis is not the result of repetitive loading and inflammation but rather the result of degenerative change in the fascia unrelated to mechanical load. Their study, published in the November 2004 edition of Podiatry Today advocates the use of autologous platelet concentrate (APC+) injected directly into the portion of the fascia that is painful. This technique stimulates healing.

Autologous (meaning derived from the patient) platelets are obtained by drawing the patients blood and processing it to obtain a concentrated mix of platelets. Platelets are known to have 4-6 times the normal level of human growth factor. Introduction of growth factor into a wound stimulates the influx of fibrocytes and new vascular ingrowth. This technique has been used for some time in the treatment of chronic wounds but is a new way of addressing chronic inflammatory problems such as fasciitis and tendonitis.

We applaud these doctors for their innovative thinking and look forward to more studies using this technique.

The terms heel spur syndrome and plantar fasciitis are used interchangeably to describe a set of symptoms which include pain in the bottom of the heel. Heel spur syndrome is the older of the two terms but has remained as a common description of these symptoms. Plantar fasciitis is a relatively newer term that is more descriptive of the condition and is becoming the definition used by most medical professionals.

‘Plantar' refers to the bottom of the foot. ‘Fascia' is a component of the musculoskeletal system that is found through-out the body. Fascia helps to support the function of the bones and joints and often acts as an anchor for structures such as muscles. ‘Itis' refers to the inflammation found in a structure and is used in other familiar words such as arthritis (inflammation in a joint).

CT Band - The calf to toe band is a band of structures that combines the calf muscle, Achilles tendon and plantar fascia.

The combination of plantar + fascia + itis results in the descriptive term, plantar fasciitis, or inflammation of the plantar fascia.

Enthesiopathy - pain that results from a ligament or tendon pulling away from its' insertion on a bone

EPF - endoscopic plantar fasciotomy

Lateral column - All osseus and soft tissues of the foot including the calcaneus, cuboid, 4th and 5th metatarsals and toes

Lateral Column Syndrome - a common complication post EPF surgery due to abrupt loading of the lateral column of the foot

Plantar Fascia - The plantar fascia extends from the bottom of the heel to the toes and can easily be felt in the bottom of most feet. It originates from two small bumps of bone, referred to as tubercles, on the bottom or plantar surface of the heel bone. It is a very strong structure when placed under tension and does not stretch. The plantar fascia typically consists of two distinct bands; a larger medial (inside of the heel) band and a smaller lateral (outside of the heel) band. The vast majority of cases of plantar fasciitis will originate at the medial tubercle and medial band.

CT Band - The calf to toes band is a band of tissue that's actually composed of three distinctly separate structures; the calf muscle(s), the Achilles tendon and the plantar fascia. The calf and Achilles tendon work together to act as the body's single most powerful muscle/tendon complex. The plantar fascia can be considered a continuation of the Achilles tendon wrapping around the back of the heel to continue to the bottom of the heel to the toes. Anatomists have argued the presence of absence of fibers that actually connect the Achilles tendon and the plantar fascia. For sake of definition of The CT Band, we will speak of a continuous 'biomechanical' band and not a true anatomical band of tissue.

The foot is a remarkable structure designed to carry load. With every step, load is absorbed by the structures of the foot including bone, fascia, ligaments and joints. The ‘normal' foot is one that is able to accommodate these loads and allow us to remain on our feet free of pain. But when the foot is loaded to a degree greater than what it can physically tolerate, problems, such as plantar fasciitis begin to occur.

When discussing biomechanics, it's important to understand the mechanical definition of load. Load, when defined in mechanical engineering, is a very broad term and includes a number of different types of load. The amount of load, the frequency of load and the duration of load are just a few of the different loading issues that can contribute to plantar fasciitis. Loading issues will vary in each person effected by plantar fasciitis. For instance, for a long distance runner, the frequency of loading may be the primary issue. For a factory worker who stands for long periods of time, the duration of load may be the primary issue. Typically, those who suffer from plantar fasciitis don't have just one of these loading issues but a number of them combined.

As we stand and apply load to the foot, the arch drops and the plantar fascia becomes taught. Plantar fasciitis occurs when the load that is applied to the foot is so great that the plantar fascia begins to pull away from the heel bone. This is a very important concept to understand and is probably why plantar fasciitis is such a misunderstood medical condition. The painful symptoms of plantar fasciitis do not result from compression, or standing on the heel, but rather from the result of the overwhelming tension that occurs in the plantar fascia as we stand (apply load). The plantar fascia becomes so tight that it is literally being torn from the bottom of the heel.

Another important biomechanical issues to consider when treating plantar fasciitis is equinus. Equinus is the single most important most contributing factor to plantar fasciitis. Equinus, derived from the term equine or horse, refers to one who walks on their toes. Equinus can determined by measuring the range of motion of the ankle with the knee flexed and extended. When the knee is flexed, the amount of equinus of the soleus muscle is measured. With the knee extended, both the soleus and gastrocnemius muscles are measured. Imaginary lines are established on the long axis of the leg and the foot. By dorsiflexing the foot (toward the body) an angular measurement is established between these two lines. Normal range of motion of the ankle, to complete a normal gait cycle, is 10 to 15 degrees beyond 90 degrees. This means that the normal range requires the ankle to dorsiflex to 90 degrees plus an additional 10 to 15 degrees. An inability to complete this range of motion is termed equinus.

Other factors may contribute to an inability to reach 90 degrees, such as a bony block on the front of the ankle.

Consider the fact that the calf, Achilles tendon, heel and plantar fascia all work as one continuous unit called The CT Band. Think about the implication of equinus in this way. Let's use a string to represent the CT Band Run that string from the back of the knee, around the back of the heel, along the bottom of the foot to the toes. Now point the toes down (plantarflexing the ankle). The string becomes slack. Now move the toes towards the shin (dorsiflexing the ankle) and the string becomes taught. Raise the heel, the string becomes slack, lower the heel and the string is taught.

This simple lesson can be used to treat the biomechanical issues associated with The CT Band and plantar fasciitis. The simple use of a heel lift (not a soft heel pad) raises the heel and weakens the pull on the entire length of the "string" weakening The CT Band, hence decreasing the strain on the plantar fascia at it's painful insertion on the bottom of the heel. Lower the heel, such as wearing flat shoes or going barefoot, and you tighten the string placing more load on the plantar fascia.

The symptoms of plantar fasciitis are classic. They seem to develop slowly and insidiously over the period of a week or two. Often there is one event that seems to precipitate the onset of symptoms. A lot of people will say that they were wearing flat shoes, such as moccasins, on a day when they were particularly active. As the pain becomes progressively worse, it becomes more and more focused in the bottom of the heel. People describe significant pain in the bottom of the heel when they try to get up out of bed in the morning or try to stand after a period of rest. This post rest pain is a sharp pain that seems to subside after being on the feet for 5-10 minutes.

People will also describe a second kind of pain that becomes worse as the day progresses. This pain is described as dull and achy. It's often on the bottom of the heel but also seems to radiate to the inside of the heel. This pain is secondary to the post rest pain earlier described. This secondary pain is actually inflammation from the plantar fascia ripping away from the bone. This secondary pain responds to anti-inflammatory medications where the post rest pain does not.

Plantar fasciitis can present with two types of pain

A. Post rest pain- Post rest pain occurs when standing after a period of being off the feet. This could be upon rising out of bed in the morning or taking a break at work. Post rest pain is a sharp tearing pain specific to the bottom of the heel. Post rest pain will subside somewhat after being up on the feet for 10 minutes.

B. Overuse pain- Overuse pain is somewhat different from post rest pain in that it seems to become worse with the more time that one spends on their feet. It is a dull achy pain that is described on both the bottom and the inside of the heel.

This picture shows the location of pain found in patients with plantar fasciitis. The red area on the bottom of the heel is where the plantar fascia inserts into the medial tubercle of the calcaneus. This is the location where patients with plantar fasciitis feel pain upon standing after a period of rest or when getting out of bed in the mornings.

Also shown in this picture are the areas where pain is felt with several different nerve entrapments of the heel. The line of red dots symbolizes the path of the posterior tibial nerve. As the posterior tibial nerve descends into the foot, it divides into several different nerves that supply motor function to the muscles of the foot and sensory function to the bottom of the foot.

One entrapment that causes heel pain is an entrapment of the calcaneal branch of the posterior tibial nerve. The blue circle shows an area where the calcaneal branch of the posterior tibial nerve may be entraped as it passes beneath the abductor hallucis muscle.

Another entrapment that may cause heel pain is called tarsal tunnel syndrome. The black dot area is the area where tarsal tunnel pain may be felt. Tarsal tunnel syndrome may present with many different types of pain. For additional information on nerve entrapments of the foot, including tarsal tunnel syndrome, please refer to tarsal tunnel syndrome in our knowledge base.

Baxter's nerve entrapment - entrapment of the 1st branch of the lateral plantar nerve of the posterior tibial nerve

Gout - deposition of monosodium urate crystals (hyperuricemia)

Retrocalcaneal bursitis (Albert's Disease) - this is the formation and inflammation of a bursa at the back of the heel between the heel bone and Achilles tendon

Rheumatoid arthritis

Rheumatic Fever

Septic Arthritis

Sero-negative arthropathies such as Reiter's Syndrome

Sever's Disease - and inflammatory condition typically found in young over weight boys age 10 to 15 years old

Stress fracture of the calcaneus - Achilles tendonitis pain is characteristically different from that of fractures of the calcaneus. Fracture pain begins with the onset of activity and remains painful through the activity.

Tarsal Tunnel Syndrome - also known as posterior tibial nerve neuralgia. Tarsal Tunnel Syn. characteristically has pain that does not decrease with rest. Also has numbness or 'tingling' of the toes

This article was written by Jeffrey A. Oster, DPM, C.Ped and last updated 3/24/05.

Additional references include;

Brekke MK, Green DR: A retrospective analysis of minimal incision, endoscopic and open procedures for heel spur syndrome. JAPMA 88: 64, 1998

Boike AM, Snyder AJ, Roberto PD, et al: Heel spur surgery: a transverse plantar approach. JAPMA 83:39, 1993

Kitaoka HB, Luo ZP An KN: Mechanical behavior of the foot and ankle after plantar fascial release in the unstable foot. Foot Ankle Int 18: 8, 1997

Barrett SL, Day SV: Endoscopic plantar fasciotomy: two portal endoscopic surgical techniques-clinical results of 65 procedures. J Foot Ankle Surg 32: 248, 1993

Goecker, R.M., Banks, A.S. Analysis of release of the first branch of the lateral plantar nerve J. Am. Podiatric Assoc. 90:6 281-286 June, 2000

Baxter, D.E., Pfeffer, G.B. Treatment of chronic heel pain by surgical release of the first branch of the lateral plantar nerve. Clin Orthop 279:229, 1992

Thordarson, D.B., Kumar, K.J., Hedman, T.P., et al: Effect of partial vs complete fasciotomy on the windlass mechanism. FootAnkle 18: 16, 1997

Anderson, D., Fallat, L., Savoy-Moore, R. Computer assisted assessment of lateral column movement following plantar fascial release: A cadaveric study. J. Foot Surg 40:2, 62-70 2001

Wang, C, Chen H, Huang T: Shockwave therapy for patients with plantar fasciitis: a one year follow-up study. Foot And Ankle International 23(3):204-207, 2002

Alvarez R: Preliminary results on the safety and efficacy of the Ossatron for treatment of plantar fasciitis. Foot And Ankle Internationall 23(3):197-203, 2002

Barrett, S, Erredge, S, Growth Factors For Chronic Plantar Fascitis? Podiatry Today November 2004.