The plantar fascia is a thick band of fibrous tissue that runs from the heel to the toes. It helps to maintain the medial arch of the foot and plays an important role in shock absorption and force generation when walking and running. It undergoes repetitive stretching and shortening during these activities. This repetitive stress, if excessive, can result in microtears and degeneration at its insertion to the bottom of the heel bone, thus causing pain.
What are the symptoms of plantar fasciitis?
Plantar fasciitis is one of the commonest causes of heel pain in adults. Many patients experience chronic heel pain, which is worse during the first few steps of the morning, or after a period of rest. There may also be pain after prolonged standing or sporting activity.
Who is at risk?
This condition is more common in people who spend a lot of time on their feet, and in those with excessive bodyweight, flat feet, high arches or tight lower limb muscles.
How is the diagnosis made?
Diagnosis is made from your symptoms and a physical examination. Ultrasound examination confirms and quantifies the swelling of the plantar fascia.
An X-ray may show a heel spur, which is the result of chronic traction on the plantar fascia at its insertion. The bone spur is the result of traction and not the cause of the condition or pain.
How is the condiiton treated?
The aim of treatment is to reduce pain and promote healing and to address the underlying biomechanical causes.
1. Treating the pain To reduce the plantar fascia swelling, there are three approaches:
Rest and pain-relief medication This is effective in about 40% of patients and worth a try in the early stages, i.e. if symptoms have been present only for a few weeks.
Cortisone injection This is effective in about 60% of patients. Cortisone is an anti-inflammatory medication and, hence, effectively reduces the swelling. Unfortunately, it also increases the risk of plantar fascia tears and heel pad atrophy. The risk of tear increases with the number of previous cortisone injections and with the intensity of physical activities. Hence, it is not recommended in active individuals, unless there is great urgency in relieving the pain.
Extracorporeal shock wave therapy (ESWT) This is effective in 80% of the patients and works by stimulating the repair process at the insertion of the plantar fascia. ESWT is safe, does not increase the risk of ruptures, and can be safely repeated if symptoms recur. However, it is slow to work and you may need to lower your physical activity intensity for several weeks to allow repair of the plantar fascia. The treatment is also costly.
2. Addressing the underlying biomechanics
a) Daily plantar fascia and calf stretches These are recommended to reduce the tension in the plantar fascia. You should hold the plantar fascia stretches for 30 seconds and repeat 3 times for each side, repeat the whole process 3 times daily.
Plantar fascia stretchsee pictures 1. Stand close to a wall with your hands on it for support. 2. Slide your toes down the wall until the ball of the foot touches the floor. The toes should be slightly bent in this position to maintain tension on the plantar fascia. 3. To increase tension, bring your knee forward to touch the wall.
b) Splints Worn at night, splints may also be prescribed to stretch the plantar fascia while you sleep.
c) Customised insoles To allow one to stand without excessive load on the plantar fascia, customised orthotics can be made. These have a built-in inside arch support, longitudinal groove, and an aperture to reduce loading and traction in the plantar fascia.
Will the condition recur?
As it may be difficult to remove the underlying causes completely (i.e. prolonged standing at work), some patients experience recurrent episodes which may be interspersed with pain-free periods (lasting months or years). Attacks are often triggered by changes in activity, footwear or weight gain.
To prevent plantar fasciitis, you should:
Avoid walking barefooted. Always wear sippers when indoors.
When outdoors, always use customised insoles.
Increase your exercise gradually and pull back when you sense the symptoms recurring.
How do I get treated?
You will need to see your doctor, who will confirm the diagnosis and decide on the appropriate mode of treatment.