Plantar fasciitis

What is plantar fasciitis?

Plantar fasciitis is a heel pain located on the plantar and medial part of the heel, at the level of the plantar tuberosity of the calcaneus. The diagnosis is clinical.

The term “plantar fasciitis” means inflammation of the plantar aponeurosis, but the pain is mechanical and there is only exceptionally any inflammation on histological analysis, that is to say, on analysis of the painful tissues.

The plantar fasciitis extends from the base of the heel, at the level of the plantar tuberosity of the calcaneus, to the base of the toes. It is a very strong, relatively flexible structure, made up of 3 strong fibrous bands.

During walking, the plantar aponeurosis supports the medial arch of the foot, it is put under tension and stores energy when the body’s weight passes over the foot, then this energy is returned with stiffening of the plantar aponeurosis, enabling propulsion.

The symptoms of plantar fasciitis

The main symptom of plantar fasciitis is pain, which is mechanical pain. On waking in the morning, the plantar fascia is stiff and painful during the first steps, then with tissue warm-up the pain may completely subside or persist at a lower intensity. Rest completely relieves the pain, but after each break, even a short one, resuming pressure on the foot will be painful.

80% of patients with heel pain, or talalgia, have plantar fasciitis.

If the pain starts in the morning when getting up, gradually increases throughout the day, and becomes severe enough to interfere with sleep in the evening, a nerve involvement in the pain should be considered, particularly a tarsal tunnel syndrome, or a compartment syndrome which can also cause progressive foot pain.

This pain from plantar fasciitis can disappear on its own or require medical treatment and possibly surgery if it is resistant.

What are the causes of plantar fasciitis?

Excessive tensile forces at the level of the plantar fascia may be responsible for pain.

Repeated trauma or microtrauma at the level of the plantar fascia can cause microlesions which, when healing, may stiffen the structure and be responsible for pain. Overweight and obesity are factors that increase the likelihood of pain.

In older patients, fatty atrophy of the plantar pad or the heel pad can cause pain by increasing pressure on the heel. Chronic inflammatory diseases and diabetes can be sources of enthesopathy and plantar fasciitis.

The morphology of the foot may contribute to plantar fasciitis pain. The tension is very high in high-arched feet and the plantar fascia tends to contract.

Flat feet with decompensation have muscular atrophy, the tensile forces are significant, and the fascia can be overloaded. Ligament and tendon injuries further exacerbate the overload of the plantar fascia. In elite athletes, it is possible to see partial or complete ruptures of the plantar fascia.

What treatments are available for plantar fasciitis?

Changing lifestyle habits

Pain can resolve spontaneously without treatment, however it is recommended to avoid high-impact physical activities and to wear comfortable shoes with some cushioning during the painful period.

Medical treatment

The use of painkillers and anti-inflammatories can relieve pain during the first months of progression.

Insoles and orthotics

Orthopedic insoles can help correct flat feet or relieve tension in high-arched feet.

Orthotics

Gel heel pads help relieve pain, but they worsen the shortening of the posterior muscle chains and should not be worn for too long.

Night splints are not well tolerated, but they can allow the plantar fascia to rest while stretching it.

Extracorporeal shock wave therapy

Shock waves are administered by physiotherapists or sports doctors; they are thought to create microlesions within the plantar fascia, thus causing inflammation that would stimulate repair processes.

Some patients do not tolerate shock waves well, as they can be painful.

Injections

Several products can be injected at the insertion point of the fascia under ultrasound guidance: cortisone, PRP, and botulinum toxin.

Cortisone is most often used, at the insertion of the plantar fascia or the heel spur. There is a risk of atrophy of the plantar fat pad and increased pain that will become harder to treat with the loss of heel cushioning.

Most patients with a rupture of the plantar fascia have previously received a cortisone injection.

Botulinum toxin seems to give good results, but there is still not enough evidence of its effectiveness.

PRP, “platelet rich plasma,” is collected from a blood sample from which a concentrate of platelets is obtained. Platelets are cells involved in inflammation and therefore in healing.

Stretching exercises for the posterior muscle chains

This is the most important aspect of treatment. Whether for high-arched or flat feet, there is almost always a shortening of the posterior muscle chains, of the triceps surae-Achilles-plantar system, or of the gastrocnemius or calf muscles.

The triceps surae-Achilles-plantar system is composed of:

• the calf muscles: the gastrocnemius and soleus
• the Achilles tendon
• the fibrous expansion of the Achilles tendon
• the plantar fascia

The muscles are the most flexible part of the system and their stretching will help relieve the whole system, especially the plantar fascia.

We advise patients to do stretching exercises themselves, and in some cases we recommend sessions of Mézières-type rehabilitation.

Rehabilitation: the Mézières method

This is the rehabilitation we recommend; it consists of stretching the entire posterior muscle chains. It complements self-rehabilitation.

The surgical procedure for plantar fasciitis

The surgical intervention for plantar fasciitis is rare, as 90 % of patients are cured one year after starting functional treatment and rehabilitation. There are mainly two procedures:

• Gastrocnemius lengthening
• Plantar fasciotomy

The so-called selective plantar fasciotomy is performed percutaneously, using a needle. It allows the selective release of the most painful, tightest fibers of the plantar fascia. This is equivalent to lengthening a plantar fascia that is too tight.

This is not a long-term solution if stretching exercises are not performed afterwards. Gastrocnemius lengthening is suggested by some surgeons to relax the calf-Achilles-plantar system and relieve tension on the plantar fascia.

Recovery after surgery

The percutaneous fasciotomy is performed on an outpatient basis, with discharge from the clinic on the same day. We recommend wearing a postoperative shoe for a period of 1 month. Sporting activities can be resumed from 3 months post-operation.