Plantar Fasciitis / Heel Pain

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Common cause and symptoms of chronic Plantar Fasciitis heel pain.

Symptoms:

Many who suffer from Plantar Fasciitis feel a stabbing pain in the boot of the heel of the foot. The pain will worsen as you take your first steps after awakening.

Causes:

Your plantar fascia ligament performs like a shock-absorbing bowstring that supports your foot arch. Tension and stress on this can cause minor tears causing inflammation and irritation.

Solutions:

1. Dorsal night splints are worn on the front part of the foot. Straps are used to pull the toes upward. This pulling effect provides dorsal flexion which helps to stretch the plantar fascia ligament. The dorsal night splint is most often preferred due to comfort.

2. The Boot night splint is commonly used by most sufferers of plantar fasciitis because it has a more rigid, plastic outer layer with a soft inner layer. It also has a more adjustable angle of flexion. This type of foot splint is generally worn on the back of the leg and effectively stretches the plantar fascia ligament reducing heel pain.

Plantar Fasciitis – How to Manage the Orthopedic/Podiatric Condition?

What is Plantar Fascia?

Plantar fascia or aponeurosis is a band of thick fibrous tissue present on the underside of the sole. It extends forward from the calcaneus bone (or heel) to get inserted onto the heads of metatarsal bones. It may be anatomically divided into three components i.e. central (maximum thickness), medial and lateral parts. Plantar aponeurosis strengthens the sole musculature by wrapping around the long tendons of abductor hallucis & flexor digitorum brevis. (1) It helps maintain the foot curvature and assists in foot mobility during normal gait & during running as well.

What is Plantar Fasciitis?

Plantar fasciitis is an inflammatory condition of the plantar fascia, triggered by excessive straining or by small tears of this aponeurotic band. It is undoubtedly the most commonly observed cause of heel pain in orthopedic & podiatric clinics worldwide.

Epidemiology of Plantar Fasciitis: (2, 3)

The overall incidence of plantar fasciitis in the U.S.A has been estimated to be around 10.5 per 1,000 person-years (Scher, C. D. L et al). A number of risk factors have been identified for plantar fasciitis, as stated below:

(1) Females - Gender

(2) African American individuals - Race

(3) Old individuals (>65 years) - Age

(4) Athletes, army soldiers, heavy weight lifters - Profession

Presenting complaint:

Patients usually experience sharp pain in the sole of their affected foot. Certain factors may aggravate the pain symptom, such as taking the first few steps after getting up in the morning, running or doing strenuous weight-lifting. Moreover, pain is also stimulated upon clinical palpation by a physician.

Any major diagnostic modality is not recommended in this condition since diagnosis can be effectively established through careful history and clinical examination. However, a few clinicians might suggest an X-ray or MRI scan so as to rule out other less common possibilities i.e. heel fractures or even tarsal tunnel syndrome.

Course of Clinical Management: (4)

Clinically, treatment of plantar fasciitis can be managed on conservative or surgical grounds.

1. Conservative treatment plan:

Podiatrists usually advise a complete bed rest to comfort the aching feet. All sporting activities and weight-lifting must be avoided for the time being. Meanwhile, following measures can be taken to provide symptomatic relief to the affected patients:

- Intake of aspirin / NSAIDs or painkillers. But it should be kept in mind to prescribe an adjuvant therapy of PPIs (Proton-pump Inhibitors) so that there is no accompanying incidence of gastric acidity.

- Oral corticosteroids are used for managing mild to moderate pain symptoms. For severe refractory pain, localized Ultrasound-guided administration of injectable corticosteroids is efficacious.

- Recently, non-invasive extracorporeal shock-wave therapy (ESWT) has also been used for an efficient healing of fasciitis, similar to treatment of carpal / tarsal tunnel syndrome.

Some newly established techniques include PRP (platelet-rich plasma) therapy, Botulinum Toxin A injection etc.

2. Surgical Intervention:

For those cases that show poor pain control following long-term conservative therapy, surgical intervention is carried out as a last resort. It involves surgical resection (partial or complete) of the plantar fascia, termed as a plantar fasciotomy. It can be carried out via open or endoscopic procedures.

Role of Orthoses in Conservative Management of Plantar Fasciitis:

An indispensable role is played by orthoses in the non-invasive treatment of plantar fasciitis. Orthoses include all those externally applied medical prostheses which are used for relieving neuromuscular pain at various body sites. In the case of plantar fasciitis, some examples of orthotic equipment are night splints and leg casts.

What are they made of?

Night splints/casts are usually manufactured from plaster or fiberglass materials.

Figure 1: Orthoses; Foot Splint & Leg cast.

How do they work? (5)

Orthoses are useful since they allow minimal passive dorsiflexion of the foot (i.e. upward bending of the foot). While sleeping at night, feet are involuntarily in a partial plantarflexed state (or bent downwards). This causes a little shortening of the plantar aponeurosis. However, orthoses (e.g. night splints) help avoid this shortening by keeping a patient’s foot slightly dorsiflexed. In this way, the plantar fascia is mildly stretched. Hence, this helps the fibrous band to undergo adequate healing while maintaining its original length (~12cm).

Evidence from clinical studies:

Barry, L. D et al (2002) (6) carried out a prospective study in which two patient groups of plantar fasciitis were established. One group (89 patients) received conservative therapy through night splints whereas the second group (71 subjects) was treated with a series of stretching exercises. It was subsequently noticed that the night splint group not only experienced a much faster recovery but also underwent a fewer number of secondary therapeutic measures, comparatively.

In an earlier prospective study published in 1998, Lynch, D. M et al (7) carried out a comparative analysis regarding the relative efficacy of analgesic therapy, accommodative treatment, and mechanical management by orthoses, in a total of 103 cases of plantar fasciitis. The study concluded that the use of orthoses was a far superior model of treatment as compared to the other two measures.

Concluding remarks:

In the light of clinical research, it is highly recommended that plantar fasciitis must first be managed conservatively, through the use of orthoses. In case of non-compliance, secondary treatment modalities (pharmacological treatment/surgery) can be offered to the patients.

References:

1. Stecco, C., Corradin, M., Macchi, V., Morra, A., Porzionato, A., Biz, C., & De Caro, R. (2013). Plantar fascia anatomy and its relationship with A chilles tendon and paratenon. Journal of anatomy, 223(6), 665-676.

2. Scher, C. D. L., Belmont Jr, L. C. P. J., Bear, M. R., Mountcastle, S. B., Orr, J. D., & Owens, M. B. D. (2009). The incidence of plantar fasciitis in the United States military. JBJS, 91(12), 2867-2872.

3. Scher, D. L., Belmont, P. J., & Owens, B. D. (2010). The epidemiology of plantar fasciitis. Lower Extremity Review.

4. Thompson, J. V., Saini, S. S., Reb, C. W., & Daniel, J. N. (2014). Diagnosis and management of plantar fasciitis. The Journal of the American Osteopathic Association, 114(12), 900-901.

5. Martin, J. E., Hosch, J. C., Goforth, W. P., Murff, R. T., Lynch, D. M., & Odom, R. D. (2001). Mechanical treatment of plantar fasciitis: a prospective study. Journal of the American Podiatric Medical Association, 91(2), 55-62.

6. Barry, L. D., Barry, A. N., & Chen, Y. (2002). A retrospective study of standing gastrocnemius-soleus stretching versus night splinting in the treatment of plantar fasciitis. The Journal of foot and ankle surgery, 41(4), 221-227.

7. Lynch, D. M., Goforth, W. P., Martin, J. E., Odom, R. D., Preece, C. K., & Kotter, M. W. (1998). Conservative treatment of plantar fasciitis. A prospective study. Journal of the American Podiatric Medical Association, 88(8), 375-380.

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