Heel Pain Can Drive You Insane: Plantar Fasciitis, An Overview

Written By: Adam Gray, Chiropodist

Plantar fasciitis is one of the most common injuries seen within the clinic throughout the year, more so in early spring, or the fall.  Generally, one of the main reasons we see these conditions during these periods is that many clients are going from a sedentary lifestyle, to one of high activity, in a short amount of time.   

With that said, what is plantar fasciitis, and how do we treat it?

Plantar fasciitis has been considered an inflammatory condition in the past, but occasionally with limited to nil signs of inflammatory cells, we will consider it an enthosopathy here (which translates to an injury to, or abnormality at the attachment of a tendon to the bone [1]).

In general, plantar fasciitis is an overload injury of the tendon.  The plantar fascia is a band of tissue which inserts on the medial (inside) area of the heel, runs from here into the arch, and attaches to all the toes.  Thus, the plantar fascia can be thought of as essentially, an elastic band.  There are 3 bands of tissue from this tendon, with the inside band generally responsible for the discomfort felt.  Any time you pull the toes in an upward position (dorsiflexion: towards the body), the fascia becomes tight, pulling from the heel, towards the toes.  The plantar fascia is one of the most important structures in bringing the arch up during the gait cycle.        

SIGNS/SYMPTOMS:

The number one sign and most common reported symptom is pain with the initial few steps taken in the morning.  Usually, the pain will get better within a few minutes of weight-bearing; it improves throughout the day, and then increases at the end of the day.  Furthermore, any period of inactivity followed by activity will cause returning pain (i.e. sitting at a desk followed by weight-bearing).  Plantar fasciitis is the most common cause of heel pain, accounting for 11-15% of all foot symptoms [1]. 

CAUSES:

Several causes have been reported, but the most common include the following:  obesity, over-pronation (“flat feet”), high arches, footwear, single traumatic events (injury), tight calf muscles, and faulty biomechanics of the foot.  In general, we tend to see the condition resolved within a year, but with proper treatment this tends to decrease significantly. 

TREATMENTS:

If you were to “Google” plantar fasciitis, you would find 5000 different treatments.  When it comes to the condition, trying everything together tends to work the best.  It’s very rare that one single treatment out there will get rid of the condition on its own.  However, when it comes down to the best underlying treatment, it has been found that a daily focused stretching regimen has the best chances of improving your outcome of resolving the condition.  Nonetheless, we will outline some of the common treatments within the field.

Stretching:

In general, when it comes to plantar fasciitis, the tendon is generally tight to begin with, and once the injury occurs, this tightness increases.  The Achilles tendon, which inserts in the same general area as the plantar fascia also tends to tighten as well.  With a daily stretching regimen, the plantar fascia becomes more relaxed, and brings the tendon back to its original state of function, reducing the tightness at the insertion point of the tendon.  Studies have suggested that a stretching regimen is the utmost important and fundamental component of any treatment plan involving plantar fasciitis [2]. 

In addition, topical anti-inflammatories are often utilized, as well as a contrast bath method (alternating between hot and cold treatments). 

Laser Therapy: 

The idea behind laser therapy is that it kick starts the immune system to respond to the injury, increase wound healing, and affect the metabolism at a cellular level.  We currently use Laser Therapy within the clinic for several conditions, in addition to plantar fasciitis. 

Ultrasound:

Ultrasound involves placing a hand-held wand on the area of injury, which causes high-frequency sound waves to enter the area, causing increased heat within the tissues.  With increased heat, the body sends nutrients and proteins to the area to stimulate increased wound healing, also increasing the circulation to the area.  The treatment will take a bit longer than shockwave therapy, but needs to be conducted 2-3 times a week, for 2-3 weeks or more.  In addition, this treatments outcome is increased with addition to a topical NSAID (anti-inflammatory) during the treatment/visit.

Massage:

Massage therapy is one of the many treatments I will recommend the client seek if they are already seeking out treatment for other concerns.  Massage therapy works somewhat similar to ultrasound, with the exception that it is more manual treatment.  Massage tends to increase the circulation in the area of discomfort, bringing nutrient-rich blood supply into the foot, flushing out all of the bad toxins which have become stagnant around the site of injury.  Lastly, massage aims to increase the elasticity of the tendon, while decreasing the tightness it is experiencing.    

Orthotics:

The general idea behind an orthotic is to bring the ground up, fill the arch in, and relieve stress/pressure on the forefoot, and hence the heel/rear foot.  This, in turn, reduces the stress on the plantar fascia.  In addition, they decrease the amount of excessive shock absorbed in the foot.  Studies suggest that custom-made orthotics provided significant relief in all measures of outcome, and tend to provide the best results when combined with the stretching regimen [4].  Moreover, orthotics tend to provide the best long-term results when it comes to resolving the condition, as well as preventing the condition from returning once it’s resolved.  Nonetheless, if orthotic therapy is implemented, 100% of the cases are still implementing a basic stretching regimen, to treat the underlying condition.  Orthotic therapy is never an “end all” treatment when it comes to heel pain.      

Night Splints:

The general idea behind a night splint is that it prevents the foot from plantarflexion (moving the foot downwards, away from the leg) during sleep. With plantarflexion, the fascia will attempt to heal in a shortened position, along with being relaxed, which leads to a non-functional state.  This is why stretching is so fundamental: the fascia is most likely tight prior to the injury, and it most certainly tightens after the injury.  The goal is to lengthen the tendon to a more functional state, preventing constant over-stress on the heel bone.  Studies have revealed the night splints tend to provide significant relief in the discomfort felt first thing in the morning, and are a great option are chronic cases.

Shockwave Therapy

Shockwave therapy involves placing a wand on the area of treatment, in which single pulse acoustic waves are driven into the area of concern.  Due to its large amplitude, the effects on the tissues stimulate tissue regeneration, and these treatments show good results for breaking up bone spurs.  In general, if I have been treating a client for a couple weeks using stretching, topical anti-inflammatories, and insoles/orthotic techniques, and the condition is unresponsive, an x-ray will be conducted if no improvement is noted.  With chronic cases (i.e. 2-3 months or more), there is also a possibility that a bone spur has formed.  If this is the case, the client is usually started on our shockwave treatment regimen, enduring 1 treatment a week, for 2-4 treatments in total.      

CONCLUSION:

The standard treatment within the clinic for plantar fasciitis begins with an initial exam, followed by a focused stretching regimen to the individual case.  In addition, topical anti-inflammatories are implemented, along with orthotics or over the counter insoles if short to mid-term treatments plans seem to be ineffective.  From there, each individual case will be catered to the person’s needs, as observed within the clinic.

When it comes to heel pain, always get it assessed sooner than later.  The earlier the treatment is initiated, the quicker we can get you back on your feet, pain free.  Come see us today for all of your foot care needs, and keep your best foot forward!

Adam D. Gray, B.A, D.Ch   

Chiropodist/ “Foot Guy”

Bibliography:

1. Stuber, K.  Kristmanson, K.  Conservative therapy for plantar fasciitis: a narrative review of randomized controlled trials.  J Can Chiropr Assoc 2006; 50 (2). 
2. Pfeffer, G et al.  Comparison of custom and prefabricated orthoses in the initial treatment of proximal plantar fasciitis.  Foot Ankle Int 1999; 20 (4): 214-221. 
3. Basford, J et al.  A randomized controlled evaluation of low-intensity laser therapy: plantar fasciitis.  Arch Phys Med Rehabil 1998; 79 (3); 249-254. 
4. Dimou E., Brantingham, J., Wood, T.  A randomized controlled trial of chiropractic manipulation and Achilles stretching vs. orthotics for the treatment of plantar fasciitis.  J Am Chiro Assoc 2004; 41(9): 32-42.