Plantar Fasciitis

Plantar Fascia Described

The plantar fascia consists of two bands of thick ligamentous tissue located deep in the plantar (bottom) side of the human foot. These bands of tissue lie generally in a direction from heel to toe, and start at the bottom leading edge of the calcaneus (heel bone). The smaller of the two bands runs along the lateral side of the bottom of the foot. The larger spreads out laterally like a fan and inserts across the balls of the foot into the toe bones called metatarsals. The plantar fascia supports the foot as a spring system, maintaining the springiness of the arch in standing and in gait. It is the arch of the bottom of the foot against gravity that retains the tension of the fascia, similar to a bowstring that keeps a bow bent, except the bowstring would have some give to it.

Plantar Fasciitis

The term plantar fasciitis (pronounced “fashee-EYE-tis”) indicates a condition whereby the plantar fascia is inflamed from whatever cause. In fact, inflammation plays only a minor role in the condition, and some corners of the medical profession appear to favor “fasciosis” as a more accurate name for the condition (more on that on this page below). There are several possible causes of the condition, some of which will be described in this discussion. Generally speaking, the plantar fascia becomes irritated and neurologically hyperactive.

Symptoms of the condition are intense pain in the heel and/or along the bottom of the foot, especially upon standing first thing in the morning, or when standing for long periods of time, jogging, running, or other springing activities, or when dorsiflexing the ankle joint. There may be the sensation of tension running up the back of the lower leg in the muscles that terminate with the Achilles tendon.

Plantar fasciitis is a very common condition, occurring in about 10% of the population at one time or another. When it first begins, pain is felt when first putting feet on the floor when rising first thing in the morning. The pain dissipates quickly in beginning stages, usually with walking around the home for a few minutes. It may disappear for the rest of the day and not return until a person gets out of bed the next time.

If untreated, plantar fasciitis tends to return during the day after sitting for long periods. Later, a person may feel pain or aching in the heel or arch of the foot with walking or athletic activity, and particularly while barefoot. Advanced plantar fasciitis may present with spurring on the medial anterior edge of the heel, known as the calcaneal tuberosity. However, bone spurring occurring at that location is rarely a cause of pain. Rather, pain often is caused by microtearing of the ligamentous tissue at the periostial junction.

Diagnosis

As with any medical condition, a physician should be sought for diagnosis of plantar foot pain so more complicated issues can be ruled out. There are various tests a doctor can perform to eliminate other possibilities, such as Achilles tendonitis, bursitis, tumor, infection, Tarsal Tunnel Syndrome and other vascular, radicular, and neurological symptomology.

Outlook for Plantar Fasciitis

Common plantar fasciitis tends to self-resolve without treatment, but may take a year or more to do so. The greatest dangers of not treating the condition is continual microtearing of the plantar fascia at the periostial junction, buildup of scar tissue at the site of microtearing, and spurring of the calcaneus. Occasionally, the thin spur may fracture off and the loose bone matter may create further complications, tearing nearby tissue or lodging in surrounding structures in the area before eventually dissolving.

However, what is becoming more of a concern and slowly becoming recognized lies in the new name for the condition: “fasciosis”. In medical terminology, the suffix “-osis” infers death or dying, and this may literally the case in some plantar fasciitis patients — the tissue is dying. Particularly in patients with bunions.

While this train of thought has not been entirely proved out yet, indications are that the fault lies with the modern shoe. The toe box area of shoes force the hallux (commonly known as the “big toe”) laterally from the ball of the foot to the end of the toe. Attached between the calcaneus and first phalange of the big toe along the inside edge of the foot is a muscle called the abductor hallucis, and its job, as you can gather from the name, is to abduct the big toe (pull it towards the other foot). Between the big toe and the second toe lies abductor hallucis’ counterpart, the adductor hallucis, which pulls the toe laterally.

In our first developmental years as infants and small children, the abductor and adductor hallucis work to keep the big toe and first metatarsal  straight. But modern shoes tend to squeeze the toes together into a more pointed shape.

Enter the vascular and neural systems transiting the medial side of the foot near the heel. The posterior tibial artery and vein and tibial nerve all pass through the tarsal tunnel and beneath the extensor retinaculum, then curve under the medial strip of plantar fascia and abductor hallucis. When the arch of the foot drops under the weight of the body first thing in the morning, the plantar fascia is stretched, and the abductor hallucis is pulled tight, venous supply and return is temporarily cut off. Without a blood supply there, the local tissue begins to necrose and die off.

More than three-quarters of the population diagnosed with plantar fasciitis will resolve untreated. Approximately 15% may have complicating factors develop. Around 5% will likely require an operation to surgically release the plantar fascia.

However, plantar fasciitis may be treated conservatively with very good success. What is pivotal in recovering from the condition is how it developed to begin with. Oftentimes, plantar fasciitis is itself only a symptom of problems elsewhere. If the original problem is not resolved, PF will likely return no matter what corrective action is taken to resolve it.

The Manchester-Bedford Myoskeletal Response to PF

We look at plantar fasciitis from a two-pronged viewpoint. First, an assessment must be made to locate problematic areas which created the condition to begin with. Typically, stress from structures in the posterior calf and neurologic inhibition and facilitation up and down the entire kinetic chain are at fault. Both of these will be assessed and treated. Homework is also given, and the patient can usually look forward to changing some lifestyle habits to avoid PF from returning later in life.