treatments

What is plantar fasciitis?

The plantar fascia is a dense, fibrous band serving as a biomechanical stabilizer as well as a protector to the vulnerable neurovascular structures on the plantar aspect of the foot. The diagnosis “plantar fasciitis” encompasses disorders ranging from acute inflammation to chronic fibrotic degeneration, usually involving the calcaneal attachment. (1,2) Plantar fasciitis most commonly affects the medial portion of the band. (2)


The band’s proximal origin is the medial calcaneal tubercle, and its distal attachments are all five toes. The band functions, via the “windlass mechanism” to stabilize the foot during gait- i.e. at heel strike, the plantar fascia is slack to allow the foot to accommodate uneven surfaces. As the heel lifts and forefoot dorsiflexes toward toe off, the distal plantar fascia “winds” up and around the first MTP joint pulling the plantar fascia taut, shortening the distance between the heel and forefoot, raising the arch– creating a stiffer lever for propulsion. (3)


Although the term, “plantar fasciitis” implies inflammation, more recent studies suggest that plantar fascia pain results from a non-inflammatory, degenerative process. (4-12) Initial insults may generate an acute inflammatory reaction, but repetitive chronic overload results in a breakdown of the inflammatory process and a disorganized healing process that fails to regenerate “normal” tissue.


Plantar fasciitis is the most common cause of plantar heel pain, affecting approximately 10% of the population (14-18) The condition is present bilaterally in 20-30% of those affected. (19) The condition is common in young runners and middle-aged women, but the majority of plantar fascia patients are over the age of 40. (16-18)

How did I get it?

Like most cumulative trauma disorders, the etiology of plantar fasciitis is multi-factoral. (21) Problems typically arise when repetitive eccentric strain exceeds the tissues threshold for injury. Certain factors may increase the likelihood of developing the disorder. The leading biomechanical cause for plantar fasciitis is pes planus (fallen arch) which increases tension on the plantar fascia, leading to repetitive micro trauma at the band’s vulnerable attachment on the medial calcaneus. (22) Patients with pes cavus are likewise predisposed since a cavus foot is relatively immobile, and forces that would generally be dissipated by bony structures are now absorbed by the plantar fascia. (16,25)


Tightness or weakness in the gastroc and soleus directly contribute to plantar fasciitis by increasing tensile strain on the plantar fascia. (25-27) Gastroc and soleus hypertonicity limits dorsiflexion – meaning the plantar fascia must accommodate for this lost motion. (28) Gastroc and soleus weakness limits propulsion and increases loads on the plantar fascia and the intrinsic muscles of the foot. (28)


What are the risk factors?

Patients with plantar fasciitis are almost 9 times more likely to demonstrate hamstring hypertonicity. (29) Hamstring tightness may induce prolonged forefoot loading and increase strain to the plantar fascia. (30) Rapid weight gain and obesity are also recognized contributors to plantar fasciitis. (17,25) Patients with BMI’s greater than 35 are approximately 2.5 times more likely to experience plantar fasciitis as compared to those with BMI’s less than 35. (29)


Patients may be predisposed by occupations or activities that involve prolonged ambulation including: teachers, construction workers, cooks, nurses, distance runners, etc. Runners average 1200 steps per mile at a 6-minute per mile pace, and walkers average 2300 steps at a 20-minute/mile pace. The plantar fascia must absorb up to seven times body weight during the push off phase of running and biomechanical deficits are quickly amplified. Patients often present following an increase in training demand or change in running surface- i.e. concrete. (25)


What are the symptoms?

The most common presenting complaint of plantar fasciitis is a sharp pain with the first couple of steps in the morning or following any period of prolonged inactivity. (16,25) Symptoms are often noted during the push off phase when the band is at peak tension. (32) Symptoms are amplified by prolonged weight bearing, especially when compounded by inadequate foot support or walking barefoot. (25) Walking upstairs and sprinting or forefoot running tends to exacerbate symptoms by increasing plantar fascia strain. Patients report relief when unloading the foot by sitting or lying down. Symptomatic episodes are more frequent following periods of inactivity late in the day.

Will I need an x-ray?

Radiographs are typically not required for the diagnosis of plantar fasciitis. (51) Radiographs may, however, be useful in differentiating plantar fasciitis from other diagnoses, including neoplasm or fracture. Calcaneal stress fracture may appear on standard radiography as a radiopaque band traversing the trabecular pattern in the posterior calcaneus. Plain film radiographs commonly expose plantar calcaneal enthesopathy (heel spurs).. Studies demonstrate no correlation between spur size and the patient’s subjective complaints. (52) Calcaneal enthesophytes are considered coincidental and irrelevant radiographic findings. (53) They are a sequelae rather than a cause of the process. (54,55) Spurs are thought to develop when long-standing tension creates a traction apophysitis, via Wolf’s Law. The presence of a heel spur suggests abnormal stress in the region for at least six months. (56) Heel spurs are present in approximately 50% of symptomatic patients and 15-20% of asymptomatic patients. (54,57) Studies now suggest that heel spurs develop at the origin of the flexor digitorum brevis muscle as opposed to the plantar fascia attachment. (58)


Bone scans may be useful to rule out calcaneal stress fracture or neoplasm, although will not differentiate between the two. Advanced imaging, including MRI, may be appropriate for recalcitrant cases or to rule out differential diagnostic considerations, including Baxter’s neuritis. Sonographic studies demonstrate that while the average plantar fascia is approximately 2 mm thick, patients with plantar fasciitis symptoms demonstrate degenerative thickening of 4 mm or greater. (59) Diagnostic ultrasound evidence of decreasing plantar fascia thickness is associated with improvement. (60)

Will it get better on its own?

Eighty to ninety percent of plantar fasciitis patients foregoing treatment will report resolution of their complaints within 18 months. Conservative treatment, including manual therapy, stretching, myofascial release, exercise, orthotics, physical therapy modalities, and night splints may improve results. (61-63) The best treatment outcomes are achieved by combining multiple techniques- particularly mobilization and exercise. (63,97)

Will it get better on its own?

Eighty to ninety percent of plantar fasciitis patients foregoing treatment will report resolution of their complaints within 18 months. Conservative treatment, including manual therapy, stretching, myofascial release, exercise, orthotics, physical therapy modalities, and night splints may improve results. (61-63) The best treatment outcomes are achieved by combining multiple techniques- particularly mobilization and exercise. (63,97)

How can chiropractic help?

Ankle joint mobilization and manipulation can help restore normal motion, particularly dorsiflexion. (76,77,90) The addition of gastroc/ soleus and plantar fascia trigger point massage and soft tissue manipulation to traditional treatment programs produces superior short-term outcomes. (62) Myofascial release procedures, including transverse friction massage and IASTM are effective tools that may stimulate fibroblast proliferation and plantar fascia regeneration. (79,80,95) IASTM may be performed in a fanning fashion over the length of the plantar fascia in a strumming fashion near the medial calcaneal origin.


Stretching exercises are appropriate for the gastroc, soleus, hamstring, and plantar fascia. (81,91) The plantar fascia may be effectively stretched by sitting in a Figure 4 position, and fully dorsiflexing the great toe for 10 seconds repetitively throughout the day. Routinely stretching the plantar fascia in this fashion is associated with significantly improved outcomes. (81) Plantar fascia mobilization may be performed at home by rolling a golf ball or frozen water bottle beneath the plantar fascia. The use of a Prostretch may assist in stretching and mobilizing the plantar flexors.


Strengthening exercises are appropriate for the gastroc, soleus, posterior tibialis, and intrinsic muscles of the foot. (82) Examples include marble and towel gripping exercises. Strengthening exercises for the posterior tibialis should be implemented to help arch support. Strengthening of the flexor digitorum brevis is an important component of treatment and may be accomplished by performing toe flexion with an exercise band. (36) Eccentric heel raises with the great toe positioned in passive dorsiflexion (i.e. great toe propped up with a towel) have shown benefit for plantar fasciitis patients. (98)


Nearly two-thirds of foot and ankle orthopedic specialists prefer stretching and manual therapy over anti-inflammatories or corticoid steroid injections for chronic plantar fasciitis patients. (83) Medical management of recalcitrant plantar fasciitis includes extracorporeal shock-wave therapy (ESWT), cortisone injections, and surgery. ESWT has shown to help some patients. (63,85) ESWT (originally developed as lithotripsy) is thought to break up calcific deposits and stimulate fibro blast activity to encourage healing. Corticoid steroids may provide an anti-inflammatory effect in cases where inflammation is present but carry the risk of spontaneous plantar fascia rupture or damage to the heel pad. (62,87) Surgical management includes fasciotomy.

References

1. Kendrick Alan Whitney Plantar Fasciosis Copyright 2010-2013 Merck Sharp & Dohme Corp accessed 4/16/14

2. Thomas Michaud, Differential Diagnosis of Heel Pain Dynamic Chiropractic – January 15, 2013, Vol. 31, Issue 02

3. Michaud T. Foot Orthoses and Other Forms of Conservative Foot Care. 1st ed. Newton, MA: Thomas C Michaud; 1997.

4. Martin J, Hosch J, Goforth WP, Murff R, Lynch DM, Odom R. Mechanical Treatment of Plantar Fasciitis. Journal of the American Podiatric Association 2001; 91(2):55-62.

5. Aldridge T. Diagnosing Heel Pain in Adults. American Family Physician 2004; 70(2):332-8.

6. Fillipou D, Kalliakmanis A, Triga A, Rizos A, Grigoriadis E. Sport Related Plantar Fasciitis. Current Diagnostic and Therapeutic Advances. Folia Medica 2004; 46(3):56-60.

7. Wearing S, Smeathers J, Yates B, Sullivan P, Urry S, Dubois P. Sagittal Movement of the Medial Longitudinal Arch is Unchanged in Plantar Fasciitis. Medicine & Science in Sports & Exercise 2004; 36(10):1761-67.

8. Lemont H, Ammirati K, Usen N. Plantar Fasciitis:A Degenerative Process Without Inflammation. Journal of the American Podiatric Association 2003; 93(3):234-37.

9. Huang YC, Wang LY, Wang HC, Chang KL, Leong CP. The Relationship Between the Flexible Flatfoot and Plantar Fasciitis:Ultrasonographic Evaluation. Chang Gung Medical Journal 2004; 27(6):443-8.

10. Dyck D, Boyajian-O’Neill L. Plantar Fasciitis. Clinical Journal of Sports Medicine 2004; 14(5):305-309.

11. Cole C, Seto C, Gazewood J. Plantar Fasciitis: Evidence-Based Review of Diagnosis and Therapy. American Family Physician 2005; 72(11):2237-42.

12. Roxas M. Plantar Fasciitis:diagnosis and therapeutic considerations. Alternative Medicine Review 2005; 10(2):83-93.

14. DeMaio M, Paine R, Mangine RE, Drez DJr. Plantar fasciitis. Orthopedics 1993; 16:1153-1163.

15. Neufeld SK. Plantar Fasciitis: Evaluation and Treatment J Am Acad Orthop Surg June 2008 vol. 16 no. 6 338-346

16. Singh D, Angel J, Bentley G, Trevino SG. Fortnightly review. plantar fasciitis.

BMJ. 1997;315:172-175.

17. DeMaio M, Paine R, Mangine RE, Drez D,Jr. Plantar fasciitis. Orthopedics. 1993;16:1153-1163.

18. Barrett SJ, O’Malley R. Plantar fasciitis and other causes of heel pain. Am Fam Physician. 1999;59:2200-2206.

19. Charles LM. Plantar fasciitis. Lippincotts Prim Care Pract. 1999;3:404-407

21. Gross MT, Byers JM, Krafft JL, Lackey EJ, Melton KM. The impact of custom semirigid foot orthotics on pain and disability for individuals with plantar fasciitis. J Orthop Sports Phys Ther. 2002;32:149-157.

22. Abreu M, Chung C, Mendes L, et al. Plan¬tar calcaneal enthesophytes: new obser¬vations regarding sites of origin based on radiographic, MR imaging, anatomic, and paleopathologic analysis. Skeletal Radiol. 2003;32:13-21.

25. Young CC, Rutherford DS, Niedfeldt MW. Treatment of plantar fasciitis. Am Fam Physician. 2001;63:467-74, 477-8.

26. Schepsis AA, Leach RE, Gorzyca J. Plantar fasciitis. etiology, treatment, surgical results, and review of the literature. Clin Orthop. 1991;(266):185-196.

27. Bolivar YA, Munuera PV, Padillo JP. Relationship between tightness of the posterior muscles of the lower limb and plantar fasciitis. Foot Ankle Int. Jan 2013;34(1):42-8.

28. Bedi HS, Love BR. Differences in impulse distribution in patients with plantar fasciitis. Foot Ankle Int. 1998;19:153-156.

29. Labovitz JM, Yu J, Kim C. The role of hamstring tightness in plantar fasciitis. Foot Ankle Spec. 2011 Jun;4(3):141-4.

30. (Harty J, Soffe K, O’Toole G, and Stevens NM. The role of hamstring tightness in plantar fasciitis. Foot, ankle, int. 2005, December; 26 (12): 1089-92)

32. Michaud T, New Techniques For Treating Plantar Fasciitis Competitor Group Published Mar. 6, 2014

33. Boberg J, Dauphinee D. Plantar Heel. In: Banks AM, Downey D, Martin S, Miller. McGlamry’s Comprehensive Textbook of Foot and Ankle Surgery. 1. 3. Philadelphia: Lippincott Williams & Wilkins; 2001:471.

34. DeGarceau D, Dean D, Requejo SM, Thordarson DB. The association between plantar fasciitis and Windlass test results. Foot & Ankle International 2004; 25(9):687-8

35. De Garceau D, Dean D, Requejo SM, Thordarson DB. The association between diagnosis of plantar fasciitis and Windlass test results. Foot Ankle Int. Mar 2003;24(3):251-5.

36. Michaud T, New Techniques For Treating Plantar Fasciitis Competitor Group Published Mar. 6, 2014

37. Wearing S, Smeathers J, Yates B, et al. Sagittal movement of the medial longitudi¬nal arch is unchanged in plantar fasciitis. Med Sci Sports Exerc. 2004;36:1761- 1767.

38. Menz H, Zammit G, Munteanu S, Scott G. Plantarflexion strength of the toes: age and gender differences and evaluation of a clinical screening test. Foot Ankle Int. 2006; 27:1103-1108.

39. Dirim B, Resnick D, Ozenler, N.K. Bilateral Baxter’s Neuropathy secondary to plantar fasciitis, Med Sci Monitor, 2010 April; 16 (4): CS 50-53.)

40. Delfaut EM, Demondion X, Bieganski A, Thiron MC, Mestdagh H, Cotten A. Imaging of foot and ankle nerve entrapment syndromes: from well-demonstrated to unfamiliar sites. Radiographics. 2003; 23:613-623.

41. Oztuna V, Ozge A, Eskandari MM, Colak M, Golpinar A, Kuyurtar F. Nerve entrapment in painful heel syndrome. Foot Ankle Int 2002; 23: 208-211.

42. Chundru U, Liebeskind A, Seidelmann F, Fogel J, Franklin P, Beltran J. Plantar fasciitis and calcaneal spur formation are associated with abductor digiti minimi atrophy on MRI of the foot. Skeletal Radiol. 2008; 37:505-10.

43. Donovan A, Rosenberg ZS, Cavalcanti CF. MR imaging of entrapment neuropathies of the lower extremity. Part 2. The knee, leg, ankle, and foot. Radiographics. 2010; 30:1001-1019.

45. Baxter DE. Release of the nerve to the abductor digiti minimi. In: Kitaoka HB, ed. Master techniques in orthopaedic surgery of the foot and ankle. Philadelphia, PA: Lippincott Williams and Wilkins; 2002: 359.

46. Lui, TH. Endoscopic decompression of the first branch of the lateral plantar nerve. Arch Orthop Trauma Surg 2007; 127:859-61.

48. Charles LM. Plantar fasciitis. Lippincotts Prim Care Pract. 1999;3:404-407.

49. Thordarson DB. The Foot and Ankle. 2004 Lippincott Williams and Wilkins p. 190

51. McMillan AM, Landorf KB, Barrett JT, Menz HB, Bird AR. Diagnostic imaging for chronic plantar heel pain: a systematic review and meta-analysis. J Foot Ankle Res. Nov 13 2009;2:32.

52. Gulick DT, Bouton K, Detering K, Racioppi E, Shafferman M. Effects of acetic acid iontophoresis on heel spur reabsorption. Phys Ther Case Rep. 2000;3:64-70.

53. Banks AS, Downey MS, Martin DE, Miller SJ. Foot and Ankle Surgery. Philadelphia: Lipincott Williams & Wilkins, 2001

54. Barrett SL, Day SV, Pignetti TT, Egly BR. Endoscopic heel anatomy: analysis of 200 fresh frozen specimens. J Foot Ankle Surg. Jan-Feb 1995;34(1):51-6

55. Saidoff D, McDonough AL. Medial calcaneal heel pain upon weight bearing in an intrinsic foot deformity. In: Critical Pathways in Therapeutic Interventions – Extremities and Spines. 1st ed. St. Louis, MO: Mosby; 2002:319-338.

56. The diagnosis and treatment of heel pain. J Foot Ankle Surg. Sep-Oct 2001;40(5):329-40.

57. Tisdel CL, Donley BG, Sferra JJ. Diagnosing and treating plantar fasciitis: A conservative approach to plantar heel pain. Cleve Clin J Med. 1999;66:231-235.

58. Abreu M, Chung C, Mendes L, et al. Plan¬tar calcaneal enthesophytes: new obser¬vations regarding sites of origin based on radiographic, MR imaging, anatomic, and paleopathologic analysis. Skeletal Radiol. 2003;32:13-21.

59. Dubin J. Evidence Based Treatment for Plantar Fasciitis: Review of the Literature. March 2007 www.dubinchiro.com/plantar.pdf accessed 5/1/14

60. Mahowald S, Legge BS, Grady JF. The correlation between plantar fascia thickness and symptoms of plantar fasciitis. J Am Podiatr Med Assoc. Sep 2011;101(5):385-9.

61. Buchbinder R. Clinical practice. plantar fasciitis. N Engl J Med. 2004;350:2159-2166.

62. Renan-Ordine R, Alburquerque-Sendin F, Rodrigues De Souza D, et al. Effectiveness of myofascial trigger point manual therapy combined with a self-stretching protocol for the management of plantar heel pain: a randomized controlled trial. J Orthop Sports Phys Ther. 2011;41:43.

63. Díaz López AM, Guzmán Carrasco P. Effectiveness of different physical therapy in conservative treatment of plantar fasciitis: systematic review. Rev Esp Salud Publica. 2014 Feb;88(1):157-78.

64. Quillen WS, Magee DJ, Zachazewski JE. The process of athletic injury and rehabilitation. Athletic Injuries and Rehabilitation. Philadelphia, Pa: WB Saunders Co; 1996:3-8.

Share by: