Plantar Fasciitis - Fast Facts
By Chris Doyle, Exercise Physiologist of TSIC.

Plantar Fasciitis

Plantar fasciitis is a very common cause of heel pain. Plantar fasciitis primarily afflicts the middle-aged and elderly populations and athletes. Pain is often localised to the area of the medial calcaneal tuberosity, with discomfort increasing over time. Pain is typically reported to be worse on initial weight bearing and also after walking or standing on rigid surfaces. If left untreated the condition typically becomes chronic lasting 12-24 month.

Mechanism of Injury

The plantar fascia is found as the superficial layer on the sole of the foot. The plantar fascia is dense regular connective tissue which functions to maintain the medial longitudinal arch [1]. At the mid stance phase of gait, the tibia rotates internally, resulting in eversion of the heel, pronation of the subtalar join, and unlocking of the midtarsal joint. Pronation (foot in dorsiflexion, eversion, and abduction) allows flattening of the foot, which stretches the plantar fascia. The flattening of the arch allows the foot to accommodate to changes in surface and to absorb shock. The repetitive traction places on the plantar fascia during walking may lead to micro tears, which lead to a chronic inflammatory response of the plantar fascia [3]. Leading Orthopaedic surgeons Mr William Edwards and Mr Andrew Beischer explain to patients that fatigue failure of the fascia causes fasciitis - "wear gets ahead of repair".

Evaluation of patients with inferior heel pain

• Subjective assessment (appropriate medical history)
• Observational assessment (appropriate examination and biomechanical assessment of the lower extremity and foot)

Note: Anatomic features that can make plantar fasciitis more likely: pes planus foot (pronated), cavus-type foot (high arch), fat pad atrophy, overweight, pregnancy, and the presence of tight Achilles tendon etc. Ultrasound allows confirmation of the clinical diagnosis in plantar fasciitis.

Conserve Management - An exercise Physiologists Perspective

• Reducing pain (i.e. icing and /or inflammatory cream)
• Ensure natural length is maintained through stretching the plantar fascia (see exercise 1 below)
• Achilles tendon are functionally linked to the plantar fascia and for this reason attention should be given to maintaining their natural length also.

Plantar Fascia Stretching - Exercise 1

Body position: patient sitting on flow with knees bent and heels flat on the floor (or sitting with one ankle resting the opposite knee).

Stretching: Holding onto the phalanges, passively and gently hyperextend the metatarsophalangeal joins and dorsiflex the foot with the hand.

Sensation: Stretching discomfort in the sole of the foot in the area of plantar fascia (do not stretch to the point of pain) - may experience a concurrent stretch within the gastrocsoleus complex.

Additional treatment options:

1. Modification of activity: Reduce time spent standing on rigid floors, particularly in the one sport for long periods of time. Switch to low-impact exercise.
2. Weight Loss: for BMI > 30, less body mass to reduce pressure on the plantar fascia.
3. Strengthen the foot intrinsic musculature (which the fascia covers): With bare feet, the goal is to pick up small objects like marbles with your toes.
4. Refer on to other relevant Allied Health Professionals (e.g. Podiatrists): This should include reporting back to patient’s Medical Practitioner.
5. Orthotics: Encourage assessment and sitting by a podiatrist.
6. Taping
7. Appropriate footwear
8. Deep friction massage: Encourage assessment and treatment by a physiotherapist.
9. Night Splints
10. Acupuncture through abductor hallucious tendon

References

1. Brotzman, S.B., Wilk, K.E. (2003). Clinical Orthopaedic Rehabilitation Philadelphia: Mosby, Inc.
2. Guten, G.N. (1997). Running Injuries. Philadelphia: W.B. Saunders Company.
3. Singh, D., Angel, J. Bentley, G., Trevino, S.G. (1997). Plantar Fasciitis. British Medical.

This article was written by Chris Doyle, Exercise Physiologist of the Sports Injury Clinic..

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