Article: Plantar Fasciitis

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Plantar Fasciitis, The Plantar Fascia & Heel Spurs:

Heal that Heel

Plantar Fasciitis, the Plantar Fascia, & The Plantar Fasciitis Test

Plantar Fasciitis, a common cause of heel pain in adults, causes repeated episodes of pain in the heel that sometimes extends to the sole of the foot. These painful bouts often occur after times of increased activity, even light activity, such as walking. Although the pain is usually "self-limiting" (it tends to go away even without medical treatment) it is commonly recurrent (meaning that the pain the pain usually returns again).


Plantar Fasciitis is due to chronic tearing or "stress failure" of the plantar fascia(Link to stress failure of soft tissue). The plantar fascia is a band of tissue that originates from the heel bone (calcneous) and extends forward along the bottom of the foot, ending at the toes. All feet have a plantar fascia and you can feel your own by pulling your toes and foot back towards your knee as in figure1. With your foot in this position, you can easily feel the cord-like fascia that runs along the bottom of your foot. If you then let your toes and foot relax you will no longer be able to feel your plantar fascia. . Plantar Fasciitis often arises in patients who have an abnormally shortened or tight plantar fascia.

Figure 1 Plantar Fascia Test

The maneuver described in the preceding paragraph is a good test to diagnose plantar fasciitis. Patients with plantar fasciitis have much more tenderness in their plantar fascia when it is stretched (fig. 1) and much less tenderness when the fascia is relaxed. The plantar fasciitis test uses this property to help diagnose patients with plantar fasciitis. To perform this test, first stretch your plantar fascia as describe above, and shown in figure 1. Then use your thumb or finger to feel the plantar fascia. If your plantar fascia is tender, then try the same maneuver with your plantar fascia relaxed (let your toes and foot assume a relaxed position). If pushing on the stretched plantar fascia causes more tenderness than pushing on the relaxed plantar fascia, then we believe that the plantar fascia is likely the source of the pain and we say you have plantar fasciitis.


Why Would my Plantar Fascia be Tight???

Origin of the Tight Plantar Fascia
The plantar fascia often tightens as we age for two main reasons. First, older adults are often less active than children or younger adults. Inactive people spend more time with there plantar fascia relaxed, while active people spend more time with their plantar fascia in a stretched position. Spending time with your plantar fascia in a stretched position causes it to lengthen and therefore loosen (have less internal tension for any given length). Conversely, inactivity leads to a shorter and thus tighter plantar fascia.

The plantar fascia is made of a protein called "collagen". The second reason that our plantar fascia becomes tighter with age is due to the difference in collagen chemistry between older and younger people. With age collagen becomes less elastic, and therefore more prone to tearing. A similar mechanism causes skin to wrinkle with age. The reduced activity of many adults and the differences in collagen chemistry between children and adults, causes a tendency of the plantar fascia to become shorter, tighter, and more prone to tearing with age.


A Tight Fascia Becomes a Torn Fascia
As mentioned, aging tends to leave our plantar fascia less elastic and inactivity causes it to tighten and shorten. Once your planter fascia is short and inelastic it tears easily. Even simple walking subjects the plantar fascia to repeated stresses. In the abnormally tight and shortened plantar fascia, the stress of walking can easily cause it to develop a small tear. Once a tear has started it will enlarge with each step you take and a painful plantar fascia develops. [see stress failure of soft tissue] The plantar fascia usually develops tears close to where it originates at the calcaneous and less often in the body of the plantar fascia.


The downward spiral of plantar fasciitis
As a small tear develops in the plantar fascia, the foot becomes painful and two things happen. First the foot pain causes patients to become less active to decrease their pain. Second, patients with a painful plantar fascia tend to hold their foot in the relaxed position. This position puts less force across the torn fascia and therefore the foot hurts less in this position. With time, even without treatment, the tear heals and the pain goes away. But keeping your foot in the relaxed position results in the plantar fascia healing slightly shorter and tighter than it was before the injury. When the fascia fully heals it is more prone to re-tear during the next excursion to the mall. Since a tight plantar fascia is more prone to tearing than a loose plantar fascia and since the plantar fascia heals in a slightly shortened position after each injury, the painful episodes become more frequent and require less activity to develop. Eventually, a patient seeks medical advice for the recurrent foot pain.

Many medical practitioners believe plantar fasciitis is due to "inflammation"((link to inflammation as a diagnosis) of the plantar fascia. These practitioners will often give the following recommendations.

a) Rest

b) Anti-inflammatory medication (NSAIDs)

c) Heel-cup

d) Cortisone injections

e) Modality oriented Physical therapy.

Since plantar fasciitis tends to improve with rest alone, the above treatment will reduce the patient?s pain leading both patient and physician to conclude that the treatment was successful. Although the treatment outlined above will allow the fascia to heal and the pain to subside, the time resting without stretching will result in a slightly tighter plantar fascia at the end of the treatment. Thus the patient has an increased risk of recurrence, especially when they increase their activity. This downward spiral of pain, rest, shortening, and recurrence continues and patients will often receive multiple treatments for painful plantar fasciitis, each apparently successful, yet each not breaking the downward spiral.

If the patient sees a clinician familiar with the "tension theory of plantar fasciitis" they typically receive the following treatment:

  1. Plantar fascia stretching

As the plantar fascia heals, it heals in a lengthier position due to the stretching and is less prone to repeated painful episodes. The downward spiral is broken.


Heel Spurs

In the past many patients with heel pain were told they had heel spurs. The diagnosis of heel spurs seemed logical. Foot x-rays of these patients would show a spur rising from the bone at the site of the pain. Surgical removal of the spur resulted in relief of the pain. Thus, heel spurs gained a reputation as a common cause of foot pain, a concept that often persists today.

Fortunately, a less invasive operation has been developed. Equally good results can also be achieved without removing any bone. Simply cutting the plantar fascia through a small incision in the foot, and leaving even large heel spurs produces equal results to operable excision of the heel spur. In fact, heel spurs do not cause pain. A tight plantar fascia is the cause of plantar fasciitis and the heel spur is inconsequential.


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