Plantar Fasciitis

Plantar Fasciitis

Plantar fasciitis is the catchall term that is commonly used to describe pain on the plantar aspect of the proximal arch and heel. The plantar fascia is an aporneurosis that runs the length of the sole of the foot and is a broad dense band of connective tissue. It is attached proximally to the medial surface of the calcaneus and fans out distally, attaching to the metatarsophalangeal articulations and merges into the capsular ligaments. The plantar aponeurosis assists in maintaining the stability of the foot and secures or braces the longitudinal arch.

Plantar fasciitis is caused by a straining of the fascia near its origin. The plantar fascia is under tension with toe extension and depression of the longitudinal arch. During normal standing (weight bearing principally on the heel), the fascia is under minimal stress, however, when the weight is shifted to the balls of the feet (running) the fascia is put under stress and strain. Often planar fasciitis is a result of chronic running with poor technique, poor footwear, or because of lordosis, a condition in which the increased forward tilt of the pelvis produces an unfavorable angle of foot-strike when there is considerable force exerted on the ball of the foot. 14

Patients more prone to plantar fasciitis include: those with a pes cavus foot; excessive pronation; overweight; walking , running or standing for long periods of time, especially on hard surfaces; old, worn shoes (insufficient arch support); and tight Achilles tendon. 14 The patient will present with pain in the anterior medial heel, usually at the attachment of the plantar fascia to the calcaneus. The pain is particularly noticeable during the first couple of steps in the morning or after sitting for a long time. Often the pain will lessen as the patient moves more, however the pain will increase if the athlete is on his/her feet excessively or on his/her toes often. Upon inspection, the plantar fascia may or may not be swollen with crepitus. The patient’s pain will increase with forefoot and toe dorsiflexion.

Rehabilitation expectations

Depending on patient compliance, plantar fasciitis can be a very treatable minor injury with symptoms lasting days. However, without proper treatment and patient compliance, plantar fasciitis can linger for months or even years.

Initial treatment of plantar fasciitis starts with pain control. Rest is extremely important at this time, patients should not being performing any unnecessary weight bearing. Patients should also be wearing comfortable supportive shoes when walking is necessary. Adding a heel cup or custom foot orthosis to a patient’s shoe may relieve some of the pain at the plantar fascia insertion. During this time, regaining full dorsiflexion range of motion of the foot as well as of the big toe is vital. Towel stretches, slant board stretches, and joint mobilizations administered by a rehabilitation clinician will aid in the return of dorsiflexion range of motion.

After pain is reduced strengthening exercises can be incorporated into rehabilitatoin. The focus should be in strengthening some of the smaller extrinsic and intrinsic muscles of the foot. Towel crutches, big toe-little toes raises, short foot exercises are good examples of strengthening exercises ( Fig 3). Throughout the treatment and rehabilitation process, soft tissue work such as cross-friction massage may aid in the alleviation of symptoms.

Figure 3

Short foot exercises are performed by contracting the plantar intrinsic muscles in an effort to pull the metatarsal heads towards the calcaneus. Emphasis should be placed on minimizing extrinsic muscle activity.

Criteria for full competition

Although athletes can often continue to participate fully while suffering from plantar fasciitis, it should be understood that the longer activity is continued, the longer the symptoms will linger. For best recovery of this injury, extra activity should not be started until the athlete is able to walk a full day without any pain. Once a daily activities are tolerated, activity can slowly be increased until full participation. Throughout the rehabilitation and participation progression stretching should occur often throughout the day.

Clinical Pearls

  • While sitting, roll on a ball (tennis ball, golf ball, etc) underneath the medial longitudinal to stretch the plantar fascia
  • Fill a paper cup with water and freeze it, roll on the frozen cup to get the benefits of cold while also stretching the plantar fascia
  • Before getting out of bed in the morning, but on shoes with good arch supports to provide the plantar fascia support upon weight-bearing
  • Sleep with feet off the end of the bed to allow some dorsiflexion while sleeping
  • Wear a night splint that will keep foot in a dorsiflexed or neutral position
  • Stretching often throughout the day for a short period of time is more beneficial then stretching once a day for a long period of time
  • Do not weight high-heels or other shoes with no support (sandals) during the day

Patient education

Plantar fascia tends to be a cyclical injury. Athletes will repetitively suffer from this injury because after the initial injury, the cause of the injury is not treated, only the symptoms. Patients with plantar fasciitis need to have their gait biomechanics thoroughly evaluated and, if necessary, be fitted for custom orthotics.