Plantar fasciitis

What does the plantar fascia consist of?

The plantar fascia is a fibrous soft-tissue band extending along the foot from the heel to the metatarsal region. Plantar fasciitis is the inflammation of this thick tissue band, known as fascia or aponeurosis, located on the plantar aspect of the foot.

Excessive stress on this part of the foot produces inflammation and pain around the plantar-medial aspect of the heel. The inflammation doesn’t present acutely; instead, it has a gradual onset. It can often be painful walking on the initial steps in the morning after waking up, and is also exacerbated following a period of physical activity, as opposed to during the activity.

The plantar fascia, or aponeurosis, has an important biomechanical function when walking. Along with other foot structures, it takes the bearing of maintaining the plantar arch, taking/absorbing the impact loads of the foot on the ground when walking, as well as protecting the metatarsal region.

Is plantar fasciitis a common problem?

Plantar fasciitis is often noted in adults but especially in women between 40-60 years old. Recent studies show that up to 1 in 10 people will suffer from this condition at some point in their life.

This condition should be treated promptly; otherwise, it may become chronic, greatly affecting daily activities and promoting the development of other problems in the knees, hips and back.  

It is a very frequent condition, mainly in young inactive people that suddenly take up an activity or in those that are already active and simply increase their usual activity levels. 

What symptoms can make us suspect of plantar fasciitis?

Overstressing this part of the foot produces inflammation and pain around the anteromedial aspect of the heel (insertion point of plantar fascia). The pain is more severe first thing in the morning or upon standing up after a period of prolonged rest. The reason for this phenomenon is that when we rest the fascia is also at ease and when we start to walk again it produces a strong traction on the fascia which after a while stretches and becomes more bearable. Nonetheless, the pain can worsen throughout the day.

In the initial stages of plantar fasciitis among sport people, the onset of pain occurs in the morning or after exercise. If not managed correctly, the condition may deteriorate and become chronic to the point that it limits the person’s daily life.

What’s the difference between plantar fasciitis and a heel spur?

The prime difference is the presence of a heel spur. A spur is a calcification that occurs at the level of the heel bone (calcaneus) and requires specific treatments. Such calcification is caused by repetitive and excessive strain on the plantar fascia insertion that causes micro trauma. Whenever a plain film X-ray demonstrates a calcification we are talking of a spur, and when it doesn’t show calcification we are talking of plantar fasciitis. Both share the same treatment aim: to reduce tension within the plantar fascia, thus relieving the inflammation and pain in the area. 

Consequently it is imperative to recognise the condition early to decrease the strain and tension within the plantar fascia as soon as possible and prevent it from becoming chronic.

In what gender is plantar fasciitis more common?

Women that don’t regularly exercise and patients with spondyloarthropathies have a greater incidence of plantar fasciitis. However, in those that regularly exercise there’s an equal prevalence between genders.  

When talking about plantar fasciitis in women there is a direct link between posterior leg muscle shortening (contracture) and plantar fasciitis. The long-term use of heeled footwear causes a progressive shortening of the posterior leg muscles that increases the probability of developing plantar fasciitis.

Women that suffer recurring episodes of plantar fasciitis and habitually wear high heels must remember the importance of reducing heel height progressively; otherwise, a sudden change in heel height can lead to Achilles tendonitis and even back pain. 

How to resolve plantar fasciitis?

The greatest difficulty when trying to resolve plantar fasciitis once and for all is focusing on assessing the source (aetiology) of the problem.

Inflammation of the fascia causes pain but such inflammation is caused by the increase in stress at the plantar fascia due to, for instance, foot type, type of gait, musculoskeletal abnormalities, etc.

When considering plantar fasciitis in its acute phase only, the inflammation is reduced and the pain ceases but the patient only improves temporarily until symptoms recur because there hasn’t been a reduction in the increased strain over the plantar fascia.

Why does plantar fasciitis recur?

If one only treats the inflammation of the fascia without correcting or reducing the excess strain, the problem recurs and becomes chronic. Not only that but plantar fasciitis in its chronic stage becomes much more difficult to resolve.

What’s the usual treatment for plantar fasciitis?

When a patient presents with the initial symptoms of plantar fasciitis the first things one should do is rest and take anti-inflammatory medication as prescribed by your doctor to reduce the inflammation. In addition to these, one can start with physical therapy exercises.

The next stage is to schedule a visit to the foot specialist to carry out a detailed gait analysis to examine plantar pressures distribution and thus evaluate its relation with the symptoms you present. The results of the study will aid in the prescription of a custom-made orthotic taken from a plaster of paris mould. Such insole will be made to measure to reduce the stresses over the plantar fascia, thus resolving the inflammation and pain. Once the plantar fascia stops hurting it’s important to remember to increase activity levels gradually, wearing the right footwear for the activity.

It’s worth remembering that there are currently multitude places offering ‘gait analysis’ but not all offer the same. Gait analysis carried out in sports shops are exclusively designed to guide customers choose the right type shoe and, as such, they are not meant for treating plantar fasciitis or other problems.

Similarly, some places carry out gait analysis and issue off the shelf insoles from a lab technician who’s not qualified to diagnose and prescribe orthotics. Their task is to exclusively manufacture orthoses as per the prescription and instructions of the podiatrist specialist, orthopaedic or rehabilitation specialist.

Last but not least, one must remember that a correct and indicated prescription of a bespoke orthotic device can significantly improve the patient’s quality of life; however, off the shelf insoles or an incorrect use of orthotics can cause new problems and aggravate existing ones. If wearing certain insoles are causing pain one should take them out and go back to see the professional that issued them. Most centres often don’t have an in-house manufacturing lab to carry out modifications and have to send the insoles back to the factory so they can amend them.

Medical treatment with anti-inflammatory medication

Nonsteroidal anti-inflammatory drugs (NSAIDs) have an analgesic and anti-inflammatory effect that help reduce the inflammation and pain in the sole of the foot. Such medication may include Ibuprofen or Diclofenac, among others. One should always consult their doctor and read the instructions before taking any medication. If there are no contraindications, you can take the medication daily for two weeks following the prescription indicated by your doctor. If symptoms persist, you should review this with the doctor again.

The medication must be taken with food.

Bespoke orthotics

Notwithstanding the extensive variety of prefabricated insoles on the market offering limited support and comfort, insoles must be adapted to the particular needs of each foot. For this, it is necessary to obtain a detailed biomechanical examination and gait analysis by a qualified health professional to examine plantar pressures and assess the way the patient walks.

Plantar fascia stretches

It consists of leaning the body forward, placing the affected leg behind in such a way that the leg and toes are completely straight-out and in extension. Bending the forward knee while keeping the back leg straight with the heel firmly on the ground creates a stretch within the plantar fascia and at the back of the leg. Do 10 repetitions holding this position for 10 seconds. The best time to perform the exercise is usually either first thing in the morning or at the end of the day.

At the medical-podiatric Clínica San Román we recommend doing the plantar fascia stretches before and after exercise. In cases where stretching exercises prove insufficient in relieving symptoms, at Clínica San Román we perform a computerised gait analysis examination that follows with a prescription of bespoke (i.e. custom-made) orthotics using plaster of paris moulds.

Request an appointment now using our contact form or by calling us on the phone, we will deal with any queries you might have.

Does the way I walk influence the incidence of developing plantar fasciitis?

The foot type and the way one walks are the main causes for the development of plantar fasciitis. The foot types that we’ll encounter include both pes cavus and pes valgus. In both cases, there’s a reduction in contact area on the lateral-plantar aspect of the heel, leaving the plantar fascia in a compromised position of increased strain that, with time and continued exercise, gets inflamed and causes pain.

Are there any novel treatments for plantar fasciitis?

The least invasive treatment that yields the best results are bespoke orthotics made-to-measure that relief the strain on the plantar fascia.

Besides, your doctor may prescribe you medication to reduce the pain and inflammation. Such medication may include nonsteroidal anti-inflammatory drugs (NSAIDs) that help to improve pain and reduce inflammation on the foot.

In cases of acute plantar fasciitis pain that fails to improve with NSAIDs, your foot specialist or doctor can administer a local steroid injection on the heel.

If medication, rest, and local cold application fail to improve the symptoms, it may be necessary to prescribe a set of strengthening and stretching exercises for the plantar fascia, Achilles tendon and posterior leg musculature. Contrast bath therapy (hot/cold), massaging, and therapeutic ultrasound therapy can aid in the improvement long-term.

Only when plantar fasciitis has become chronic and has not improved with any of the aforementioned treatments, surgery may be required.

It’s worth noting that treatments based on extracorporeal shockwave therapy (ECSWT) have shown to be painful and with mixed results.