Joint, Ligament and Muscle Disorders

Plantar Fasciitis

Anatomy

Nearly one-fourth of all bones in the human body are in the feet. The foot is a complex, flexible structure that contains bones, joints, and more than 100 muscles, tendons and ligaments, all working together to enable movement and balance. The foot is divided into three sections, the forefoot, midfoot and hindfoot. The midfoot contains a pyramid-like group of bones, strengthened by tendons, muscles and ligaments to form three curves, or arches (medial, lateral and fundamental longitudinal), at the bottom of the foot.

Ligaments are fibrous tissues that connect bone to bone. Ligaments have an elastic structure that allows them to stretch, within their limits, and then return to their normal positions. The plantar fascia is a long, thin ligament that lies directly beneath the skin on the bottom of the foot. This ligament connects the heel to the front of the foot, and it supports the arch of the foot.

Description

Plantar fasciitis occurs when the plantar fascia ligament becomes irritated and inflamed.

Symptoms

Among the most commonly experienced symptoms of plantar fasciitis are:

• Pain on the bottom of the foot, near the heel.
• Pain with the first few steps after getting out of bed in the morning; or after an extended period of rest, such as a long car ride. Pain subsides after a few minutes of walking.
• Greater pain after (not during) exercise or activity.

Causes

Although the plantar fascia is designed to absorb the high stresses and strains placed on the feet, sometimes too much pressure can damage or tear these tissues. The body's natural response to such an injury is inflammation, which results in heel pain and stiffness of plantar fasciitis. Typically, plantar fasciitis develops without any specific, identifiable reason. However, there are many factors that can make you more prone to the condition, including: new or increased activity, or repetitive impact activity, such as running or other sports; very high arches; obesity; and tighter calf muscles that make it difficult to flex the foot and bring toes upward, toward the shin (dorsiflexion).

Diagnosis

Your physician may order X-rays to help determine that your heel pain is caused by plantar fasciitis and not another problem. Other imaging tests, such as an MRI or ultrasound are not routinely used to diagnose plantar fasciitis and are rarely ordered, however an MRI may be needed if your heel pain is not relieved by initial treatment methods.

Nonsurgical Treatment

More than 90% of patients with plantar fasciitis improve within 10 months of starting simple treatment methods. These may include:

• Rest—The first step in reducing the pain is to decrease or stop the activities that make the pain worse. You may need to completely avoid any athletic activities where the feet pound on hard surfaces (for example, running or step aerobics).
• Ice—Rolling your foot over a cold water bottle or ice for 20 minutes is effective. This can be done as often as 3 or 4 times a day.
• Nonsteroidal anti-inflammatory medication (NSAIDs)—Drugs such as ibuprofen or naproxen may help relieve pain, inflammation and swelling. Most people are familiar with nonprescription NSAIDs such as aspirin and ibuprofin, however, whether using over-the-counter or prescription strength, they must be used carefully. Using these medications for more than one month should be reviewed with your primary care physician. If you develop acid reflux or stomach pains while taking an anti-inflammatory, be sure to talk to your doctor.
• Exercise—Plantar fasciitis is aggravated by tight muscles in your feet and calves. Stretching the calves and plantar fascia is the most effective way to relieve the pain that accompanies this condition. If appropriate, a foot and ankle conditioning program may be recommended.
• Cortisone (a type of steroid) injections—To reduce inflammation and pain, cortisone can be injected into the plantar fascia. However, multiple steroid injections can cause the plantar fascia to rupture (tear), which can lead to a flat foot and chronic pain, so your physician may limit the number of these you receive.
• Supportive shoes and orthotics—Pain associated with standing and walking can be reduced by wearing shoes with thick soles and extra cushioning. As you step and your heel strikes the ground, a significant amount of tension is placed on the fascia, which causes microtrauma (tiny tears in the tissue). A cushioned shoe or insert reduces this tension and the microtrauma that occurs with every step.
• Night splints—Most people naturally sleep with their feet pointed down. Because this position relaxes the plantar fascia, it is one of the reasons for morning heel pain. Wearing a splint that keeps the plantar fascia stretched while you sleep can help avoid this.

Surgery

Surgical treatment is usually considered only after 12 months of aggressive nonsurgical treatment.

• Gastrocnemius recession—This is a surgical lengthening of the calf (gastrocnemius) muscles. Because tight calf muscles place increased stress on the plantar fascia, this procedure is useful for patients who still have difficulty flexing their feet, despite a year of calf stretches. In gastrocnemius recession, one of the two muscles that make up the calf is lengthened to increase the motion of the ankle.
• Plantar fascia release—During this procedure, the plantar fascia ligament is partially cut to relieve tension in the tissue.

With any surgery there are some risks, and these vary from person to person. Complications are typically minor, treatable and unlikely to affect your final outcome. Your orthopaedic surgeon will speak to you prior to surgery to explain any potential risks and complications that may be associated with your procedure.