by Dr. Richard Beauchamp M.D., FRCSC
The “plantar” surface refers to the sole of the foot, while fascia is tough, fibrous tissue with no active muscle. The plantar fascia serves as a connecting structure from the back of the foot (at the heel bone) to the front (at the toes). It supports the arch and assists in the biomechanics of walking and running. Although the suffix “itis” suggests inflammation, the plantar fascia has a limited blood supply so inflammatory changes are minimal. A more appropriate name for this ailment would actually be plantar tendonopathy.
There are very few visible signs of plantar fasciitis (PF). The only indication for a diagnosis may be the presence of localized pain along the sole of the foot, often just beyond the heel bone and along the inside of the arch. This area may be tender to the touch. Associated symptoms seen with PF (and possible causative factors) may be tenderness and pain along the shin bones, knee malalignment or even pelvic weakness.
Symptoms of PF are worse with weight bearing, usually after an initial period of rest: the so-called “first step sign.” In cases of PF, sleeping or placing the foot in a prolonged elevated position causes the foot and ankle to rest in an equinus (toe down) position. Weight bearing then will acutely stretch the plantar fascia in anticipation of the heel strike. Continued weight bearing will result in further stretching of the contracted fascia so that the pain symptoms become less severe later in the day. Similarly, there may be PF pain at the start of a run, with gradual improvement over time.
Although PF is a common problem in running sports, there are several other causes of heel pain (i.e. pinched nerves, heel spurs, stress fractures and even tumours) that must be considered and excluded before a definitive diagnosis is made.
Non-surgical techniques for the treatment of the symptoms and discomfort associated with PF can be classified into three categories: those that reduce pain, those that reduce tissue stress and those that restore strength and flexibility of the involved tissues.
Acetaminophen should be appropriate to combat the pain associated with this condition. Although PF has a minimal inflammatory component, some advocates may prefer other non-complex anti-inflammatories such as ibuprofen.
First and foremost, the runner should begin a program of rest and rehabilitation. This involves cutting back on mileage, applying ice and performing local massage. A good technique involves rolling the sole of the foot over a frozen water bottle to stretch, ice and massage in one movement. This should be done two to three times a day for at least 15 minutes.
Local injections of cortisone have been a time-honoured method for dealing with cases of recalcitrant PF. Although frowned upon for repeated injections, the occasional use can be quite effective in relieving symptoms on a short-term basis.
Shock wave therapy is becoming a popular method in the management of PF. Sonorex® involves the administration of electrohydraulically generated shock waves to the local tissue area of injury or pain. Low-intensity infrared (IR) laser therapy has not been found to be beneficial in the treatment of plantar fasciitis.
Tissue Stress Reduction
Although we do not believe the primary cause of PF is the plantar fascia itself, we still feel that reducing the pressure on the plantar fascia will help to relieve symptoms. This can involve using foot orthotics. The use of a resting or night splint is sometimes used to relieve the symptoms of PF.
Strength and Flexibility Restoration
The cause of plantar fasciitis is probably not due to inherent pathology in the fascia itself. Rather, the development of PF is most likely due to pathology at other levels in the kinetic chain. This means the primary problems must be identified and treated in order that the PF is permanently resolved.
Surgical treatment of PF should be reserved only for extremely severe cases. This implies that the runner has first exhausted all non-operative approaches. The non-operative treatment should have been conscientiously followed for at least six months before more invasive techniques are considered.
Since I am an orthopedic surgeon, one might assume that surgery would be my preferred option if I had PF that was not responding to treatment. In fact, this could not be further from the truth. In reading the Cochrane Database of Systemic Review, their conclusions were: “although there is limited evidence for the effectiveness of local corticosteroid therapy, the effectiveness of other frequently employed treatments in altering the course of plantar heel pain has not been established in comparative studies.”
Personally, given the unpredictable results of surgery to address PF, I would not even consider it. Instead, I would seek out the advice of my experienced running peers. I would purchase a custom pair of orthotics from a professional. I would rest, stretch and ice. I would make an appointment with an experienced physiotherapist (who is also a runner) for treatment. In the case of plantar fasciitis, surgery should be a last resort.
Dr. Richard Beauchamp is an orthopedic surgeon based in Vancouver. He is the medical director of the Shriner’s Gait Lab at Sunny Hill Health Centre and a clinical professor in the Department of Orthopedics at the University of British Columbia. He is an avid runner and walker who has completed seven marathons.