Mark D. Dollard, DPM Podiatrist, Foot and Ankle Specialist 46440 Benedict Dr., Suite 111

Sterling, VA 20164 (703) 444-9555

Plantar Fasciitis

Persistent pain located on the plantar, or bot· tom, aspect of the heel and closest to the in· side, or medial, aspect of the foot can be a challenging problem to both the athlete and the medical practitioner. This plantar fasclitis is most noticeable in the morning upon wak­ing up and taking those first few steps, It sub· sides as walking becomes more prolonged. However. after the sufferer sits for long periods of time, especially at work, those first few steps can once again produce discomfort and irrita­tion. During athletic actiVity. discomfort may come early and then subside. There are few in­juries to the athlete that can be more persis· tent and aggravating than plantar fasclitis,

A careful look at the anatomy and bio­mechanics of the area can go a long way to­ward understanding, and therefore alleViating, the symptoms of plantar fasciitis. Anatomi·· cally, the plantar fascia is a fibrous. tendon­llke structure that runs the entire length of the bottom of the foot. It originates on the cal· caneus, or heel bone, and extends to the base of the toes (Figures 4.14 and 4.15), The plan-

Figure 4.14 The plantar fascia forms a wide band extending from the heel into the toes, viewed from the bottom of the foot.

Figure 4.15 The plantar fascia inserts into the heel, as Viewed from the side of the foot.

tar fascia helps support the plantar aspect of the foot. During the excessive stress of activity, the plantar fascia can become irritated, in­flamed, or even tom if enough repetitive stress occurs at the area.

The main difference between running and walking. other than in speed, is that both feet can be off the ground at the same time tn run­ning, whereas this does not happen in normal walking. The heel serves as a shock absorber for the body. During the gait cycle, heel con· tact occurs first in the supinated, or "up and in," position of the foot, just before full heel contact. As full heel contact occurs, the foot begins to roll the opposite way, or pronates, and goes "down and out. II

This repetitive stress usually occurs at a specific area on the bottom of the heel. Known in medical terms as the medial-plantar aspect of the heel. it is at the junction where the plan· tar fascia is attached to the heel bone. In the athlete, the continued stress can produce scar­ring, fibrosis, degeneration, and quite often a heel spur or calcium deposit located on the bottom of the heel bone. X-rays are needed to confirm· the diagnosis of heel spur. In the ab­sence of undue stress on the plantar fascia the heel spur can be asymptomatic. However, in athletes who do have plantar fasciitis and damage to thl~ plantar fascia. a heel spur may be present. The area can become so. inflamed that swelling is present and the area is qUite painful to the touch. In this instance, an acute

condition is present and treatment should be instituted immediately,

Causes of Plantar Fasciitis Biomechanically, the athlete who has the high·arch, rigid type of foot, or the flat, pro· nated type of foot. Is more susceptible to plan· tar fasciltis than others. Because the high·arch foot has a tight bandlike plantar fascia, it is un­able to move during the gait cycle. Repetitive stress and pulling occurs, then inflammation and pain. In the flat or pronated type of foot, excessive motion Is the culprit, Here the plan­tar fascia is working overtime. As the foot pronates past neutral or normal position at the midstance of the gait cycle, the excessive pull­ing causes undue stress and strainat the'ori· gin of the plantar fascia at the heel bone,

Improper shoe wear is also implicated as a causative factor in plantar fasc11tis. A person who has a flattehed longitudinal arch or a pro­nated foot and wears a light, flexible shoe only accentuates the stress and strain of the plantar fascia, Shoes that have been worn excessively also allow the foot to roll or pronate beyond normal, thereby causing stress on the plantar fascia.

Improper: training methods are often found to be the most common cause of plantar fascl1tis, The athlete who suddenly increases activity either on a daily or weekly basis is put· ting undue strain on the plantar fascia. This does not mean that the athlete should nqt in­crease activity but, rather, that it shOUld be done at a gradual rate,

Treatment Often, if plantar fascl1t1s is not cilught early, its treatment can be slow anq lengthy. Hot or co1d packs, strapping, massage, functional or biomechanical orthoses, cortisone injections, stretching, and oral anti·inflammatory medi­cations are some of the modalities used.

In deciding the best form of treatment, It is imperative that the athlete and medical prac· titloner first elimin,ate all causative factors. A complete history and pedal examination, including gait analysis. is warranted. X·rays are recommended not only to check for a heel spur 'but also to check for stnictural or posi· tional osseous changes.

Once the causative factors, such as improper traihing method~~?!~~iminate_~and gait

'Sugiiested Reading for "Plantar Fasciitis", Baxter & Thigpen (1984) Goulet (l984) Herrick & Herrick (1983) Snider et al. (1983)

analysis performed, relief Of discomfort can be instituted, Ice application and strappih& are two of the most common forms ofearly treat­ment. Rest. either through reduced actiVity or compl~te rest, is usually necessary. Physical therapy involVing Whirlpool and ultrasound application has,been found to be very success· ful. Anti-inflammatory medication is also qUite successful in alleviating severe discomfort in acute cases.

The importance of correcting biomechanical problems and alleviating stress and strain on the plantar fascia cannot be ignored. For long· term therapy and control, functional orthotic devices are the most Widely accepted form of treatment in cases that are persistent. It is im­perative that pronatory forces exerted on the plantar fascia be halted. A neutral position cast of the foot should be obtained to allow the foot to function in Its proper fashion. A full weight-beaiing cast is not recommended, for this does not prevent the foot from pronating past neutral. Materials for orthoses range from sponge to plastic. In general, the more rigid, high-arch foot should have an orthosis made from softer materials for shock absorption. The hypennobile, flexible, flattened-arch foot, though, should make use of a more rigid orthosis to control pronation and excessive stress and strain on the plantar fascia. Such material~ for rigid orthoses include a fleXible plastic or semirigid leather material.

Cortisone injections are often used. The painful area is injected duIing the acute phase and as a temporary measure to alleviate pain. More often than not, the pain USually returns unless the causative factors are found and cor­rected, Plantar fascia and calf muscle stretch­ing exercises help prevent recurrence once the acute pain has subSided '(s~e chapter 12, Stretch Exercises 1. 2, and 3).

Most patients respond to these forms of treatment. In asmall percentage of patients, -though, surgery isindicate'd. However, this should be discussed in futI detail with the doctor, and it is recommen&d that all conser· vative forms of treatment lJ'e instituted first.

Summary Most athletes with plantar fasciitis respond to conservative forms of treatment. Once the causative factors are found, treatment can be instituted, Improper shoes, training methods, and biomechanical reasons are all implicated

- in causing plantar fascl1tis. Too much stress­and straln. causing wear and tear with inflam· mation and fibrosis, leads to pain and dis­comfort. With appropriate initial treatment and a functional biomechanical orthotic de­Vice, the athlete can resume normal routines without difficulty.