Plantar Fasciitis

close-up x-ray image of foot red pain

Plantar fasciitis is the most common cause of heel pain in adults; usually within the age range 40 years to 60 years. It results from repetitive micro-trauma and excessive strain of the plantar fascia. 

The plantar fascia is a thick  connective tissue structure which supports the arch on the bottom (plantar side) of the foot. It runs forward from the tuberosity of the heel bone( calcaneous) to the heads of the metatarsal bones. ( see the picture)

Anatomy of the Plantar Fascia

This condition is caused by any factor that increases tension to the plantar fascia which result in local inflammation mainly at the insertion of the fascia to the heel bone or along the fascia.

Most patients with plantar fasciitis feel severe heel pain , most noticeable with initial steps after a period of inactivity. Pain typically decreases during the next 30 to 45 minutes also worse following prolonged weight bearing.

In the physical examination, in patients with proximal plantar fasciitis, tenderness is localised above the plantar calcaneal tuberosity and proximal plantar fascia. In patients with distal plantar fasciitis (less common), maximal tenderness is localised above the distal and mid portion of the plantar fascia.

Any factor that increases the tension at the insertion of the fascia creates local inflammation; factors may include: running, walking, prolonged standing, walking barefoot, walking on uneven surfaces and obesity.

Plantar fasciitis can be diagnosed on the basis of medical history and physical examination. Radiography is appropriate when the diagnosis is uncertain; can be helpful in ruling out other potential causes of heel or foot pain.

Aims of treating these condition are

  • Relieve pain
  • Help the patient safely resume normal activities
  • Prevent recurrence

Among the patients diagnosed with plantar fasciitis, 90% to 95% of patients respond to nonoperative initial treatment with rest, ice, compression, and elevation, along with oral analgesics mainly NSAIDs for short-term pain relief.

Physiotherapy with stretch exercises would be helpful in relieving symptoms. Application of splints during the sleep may be beneficial to keep the foot in a neutral position while asleep and have particular benefit for first-step heel pain.

Corticosteroid injections are often considered in patients whose symptoms are not alleviated by at least 8 weeks of conservative treatment. Corticosteroid injections can be effective for short-term pain relief for 1 to 3 months.

Corticosteroid injections would be done in the clinic setup or a surgical theatre under aseptic conditions. The doctor would clean the heel area with antiseptics. Usually the steroids would be injected with local anaesthetic agents. The needle would be aimed towards the medial tubercle of the calcaneus or primary tender point. 

Additions to steroid injection, some centres used to inject platelet rich plasma(PRP) for this condition but no sufficient  data available for comment on its effectiveness. 

High-energy extracorporeal shock wave therapy may be considered in patients with plantar fasciitis who do not respond to conservative treatment. This option is not commonly practised in Sri Lanka at the moment. 

Surgical management is rarely necessary, uses only if  if conservative therapy has been unsuccessful in patients with persistent pain and significant disability. The surgical treatment includes open or laparoscopic plantar fasciotomy. Surgical managements are very rarely used in Sri Lankan set up.

Rupture of the plantar fascia is a rare ,but known complication of the disease. Sometimes it would be a complication of steroid injection. 

Plantar fasciitis typically is a self-limiting condition, with most cases spontaneously resolving within 12 months. Factors associated with a worse prognosis include bilateral symptoms, obesity, and failure to seek medical attention until the condition has become severe and chronic. Sportsmen who reject treatment and continue there work despite their pain are at risk for progressive symptoms and irreversible fascial degeneration

For the prevention of the disease, weight loss in obese patients, modifications to exercise regimens, running on a relatively soft surface, wearing proper footwear (shoes should fit properly, be well cushioned, and have ample toe room and arch support) would be helpful. 

If you having symptoms of plantar fasciitis you should consult a general surgeon or an orthopaedic surgeon. 

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