Plantar Fasciitis

By David J. Pochatko, M.D.

Plantar fasciitis is one of the most common foot ailments that patients come to see us for at Northtowns Orthopedics. The plantar fascia is one of the mechanisms that support the arch. It originates at the bottom of the heel and inserts into multiple areas from the ball of the foot out to the toes. This can become inflamed and partially tear.

The causes for these microscopic tears can be many. Usually it is caused by overacting or suddenly increasing your activity on your feet. Some believe it is due to heel spurs; however, they are only present in about 50% of cases. Others attribute it to inflammation caused by a systemic disease like rheumatoid arthritis. Whatever the cause, proper evaluation and treatment are necessary.

Evaluation of plantar fasciitis includes taking an accurate history of the symptoms, physical examination, as well as x-rays. Plantar fasciitis pain is pain on the bottom of the heel usually worse with the first step of the morning or after sitting for an extended period of time, proceeds to get better with walking, and then is aggravated again with prolonged activity. The pain is not present at rest, and there is no swelling or bruising associated. The physical exam will reveal pain at the origin of the plantar fascia on the bottom of the heel. X-rays are obtained to look at the overall alignment of the foot and its mechanics, and to rule out a fracture or other causes for the heel pain.

When we evaluate someone for plantar fasciitis we take into consideration other causes of plantar heel pain. Other causes include atrophy of the fat pad on the bottom of the heel. This causes pain secondary to lack of cushion on the bottom of the heel. More possible causes include a systemic arthritic condition, nerve impingement/entrapment, stress fracture or low back disc herniation.

Conservative treatment of plantar fasciitis is 95% successful within 6-12 months of commencing treatment. The protocol for treatment includes such things as good shock absorptive shoe wear (sneakers), heel cushions, orthotics (inserts with arch support and heel cushion), night splints, stretching of the Achilles tendon and an anti-inflammatory to decrease the pain. Avoidance of impact loading exercises is also advised.

The heel cushions or orthotics allow for shock absorption to the heel when you are active on your feet. Less stress on the heel helps.

The night splint is used to promote healing of the plantar fascia at the proper length. As we sleep, our feet naturally point down and in. This position increases the arch and shortens the plantar fascia. Then when we stand up in the morning our arch flattens and the plantar fascia is stretched, ruining any healing that occurred over night and causing pain. The night splint is a device that is made to hold your foot at a right angle to your leg, or the position your foot is in for standing. It can be made in the office by casting your leg. We then cut the cast off and you use this as the splint at night. While the splint is on, the plantar fascia is healing at the correct length. When you stand up in the morning there is no stretching or tearing of the plantar fascia.

Stretching of the Achilles tendon also stretches the plantar fascia since they are connected. Doing stretches twice a day for a few minutes on each side stretches the plantar fascia, preventing it from becoming too tight and then tearing with activity.

Anti-inflammatory medication, such as Motrin/Ibuprofen, can help decrease your symptoms. It appears to significantly help the healing of plantar fasciitis in the earlier period of the disease, less than six months.

Injections of steroid are rarely used because they rarely cure the disease. They may decrease the symptoms for a while, but the symptoms usually recur as before. Injections have risks, including possible nerve damage, atrophy of the fat pad (the cushion on your heel), infection and possible rupture (complete tear) of the plantar fascia.

We follow our patients every four-six weeks to see how their symptoms are progressing and adjust the conservative treatment protocol accordingly.

If the pain persists beyond six months, with consistent and good conservative care, and your symptoms are not continuing to improve, then other treatment options can be entertained. Surgery is one of these. It consists of releasing enough plantar fascia to relieve your symptoms, but not too much. An incision is made on the inside of the heel, where the plantar fascia is located and cut.

After the surgery you are casted for four weeks to allow the plantar fascia to heal back together and then you are put back into the plantar fasciitis conservative protocol until you are pain free. The more common risks of surgery include continued heel pain, heel fat pad atrophy, nerve damage, infection, and arch pain due to loss of arch support. The arch pain is most common after releasing too much plantar fascia.

Another option is extracorporeal shockwave therapy (ESWT) applied to the heel. This is a relatively new technique in treating plantar fasciitis, similar to lithotripsy, which is used to break up kidney stones. The FDA approved use of high-energy shockwaves for the treatment of plantar fasciitis in 2000. Repetitive high-energy shock waves are transmitted transcutaneously though the skin into the plantar fascia after the foot is anesthetized (numbed up). Pain relief can come quickly or it can take months because the actual repair of the tissue takes weeks to months to occur. After the treatment we ask that you continue your normal conservative treatment protocol – stretching, night splints and heel cushions/orthotics.

Dr. David Pochatko is a fellowship trained foot and ankle orthopedic surgeon, specializing in the surgical and non-surgical treatment of foot and ankle problems, injuries and deformities.

Northtowns Orthopedics – where your first surgery is your best chance to get better.

This information is intended for education of the reader about medical conditions and current treatments. It is not a substitute for examination, diagnosis and care provided by your physician or a licensed healthcare provider. If you believe that you, your child, or someone you know has the condition described above, please see your healthcare provider. Do not attempt to treat yourself or anyone else without proper medical attention.