Plantar Fasciitis

What is Plantar Fasciitis? 

Plantar fasciitis typically presents as a sharp heel pain that radiates along the bottom of the inside of the foot.  Pain is typically worse in the morning, immediately getting out of bed, or when starting exercises. It gradually improves after warming up or with everyday activities.  Plantar fasciitis is typically characterized by pinpoint, knife-like pain in the plantar aspect of the heel pad, at the base of the fascial insertion of the plantar fascia of the calcaneous.  Palpation will reveal localized point tenderness of the medial calcaneal tuberosity.  Both active and passive dorsiflexion (bringing toes towards shin) will elicit pain.  Curling the big toe can worsen the tenderness and pain (1,2).

What Causes Plantar Fasciitis?

Plantar fasciitis may be caused by pronation (turning sole inward) or supination (turning sole outward).  The flatfoot with associated forefoot abduction (pronation) has a stretching effect on the plantar fascia leading to repetitive tension overload.  The high arched foot is relatively rigid.  Forces usually absorbed through movement of the foot or ankle are transmitted to the plantar fascia and lower leg.  In this way plantar fasciitis can be analogous to shin splints (1,2). 

Some common predisposing factors of plantar fasciitis are tight Achilles tendon, excessive pronation or supination, training errors and poorly designed or fitted shoes, with a tight Achilles tendon being the primary contributing factor.  Because the Achilles tendon is at the back of the ankle and connects to the calf muscles, when the Achilles tendon is contracted or tight, so is the plantar fascia.  The plantar fascia is attached at the calcaneous and is the weakest attachment and the area of pain.  With each step, the tightness of the Achilles tendon causes irritation at this attachment (1,2). 

 Pain or tenderness is increased with direct pressure over the medial tubercle of the calcaneous (the fascial insertion) (1,2).

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 Evaluation

X-rays are not typically necessary.  Although x-rays might reveal a bone spur, they are not the cause, but the reaction to chronic fascial tension.  Laboratory testing is reserved for patients for no rheumatic disease or a situation where suspicion is raised by other joint complaints (2). 

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Management

Often times orthotics are prescribed for pronation or supination.  This is based on frequency or degree of pain.  Temporary solutions include taping the arch for support and gradual stretching.  Myofascial release to the plantar fascia may be helpful.  Underwater ultrasound may also be effective.  Adjustment of any foot subluxations and strengthening of foot-support musculature is typically a part of the treatment.  95% of patients respond to conservative care (2). 

References  

1.) Hammer, Warren I. Plantar Fasciitis. Functional Soft Tissue Examination and Treatment by Manual Methods: New Perspectives. 2nd Ed. 1999. p. 590-591. 

2.) Souza, Thomas A.,  Plantar Fasciitis.  Differential Diagnosis for the Chiropractor. 1997. p. 354