Introduction to Plantar Fasciitis
Plantar fasciitis is one of the most widely prevalent causes of heel pain, and has been approximated to adversely impact on about 2 million people in the United States alone. It affects not just sportsmen and athletes – in fact, plantar fasciitis affects people who adopt sedentary lifestyles as well. It is thought to be due to a stress overload from either lifestyle, exercise or both. Risk factors for the development of plantar fasciitis include obesity, pes planus (flat foot), pes cavus (high-arched foot), poor biomechanics, prolonged weight-bearing, barefoot walking and poor footwear.
Patients typically complain of a gradual onset of pain that is localised to the medial (inward facing) side of the heel that is extremely noticeable upon taking the first few steps upon waking up from bedrest in the morning. The pain characteristically improves after a short period of walking, but returns when undertaking activities which necessitate protracted periods of weight-bearing (e.g. standing, walking or running). Patients also complain that the pain worsens when weight-bearing immediately after a period of rest (e.g. standing up after sitting down at one’s desk for several minutes).
Pathophysiology & Diagnosis
The plantar fascia is a thick layer of connective tissue which helps to support the arch of the foot. Repetitive and chronic stress overload from prolonged standing or running causes inflammatory changes in the fascia, leading to disorganized tissue and degeneration over time. Radiography with X-rays is extremely limited in the diagnosis of plantar fasciitis, but physicians may still order a weight-bearing view of the foot anyway to exclude other differential diagnoses which may present in a similar fashion (e.g. calcaneal fracture or Sever’s disease).
Ultrasound of the plantar fascia is a very useful tool as it enables the characterization of the thickness of the planta fascia (a thickness > 4.0mm is considered to be abnormal).
Management of Plantar Fasciitis
In the vast majority of patients (90-95%), the symptoms of plantar fasciitis are self-limiting and typically resolve within 12 to 18 months. In these patients, the modification of activities is strongly advised. For patients who are physically active, a transition to non-weight bearing activities such as cycling, swimming and rowing is recommended instead of running/jogging/walking. Physiotherapy is extremely useful in the management of plantar fasciitis – fascia stretch, cross-friction massage and ice-massage techniques are inexpensive and easy to learn/teach. Orthotics also have a role to play in plantar fasciitis, they relieve the load borne by the plantar fascia by holding up the medial arch.
When conservative measures don’t achieve success or if the pain is severe, a steroidal injection is recommended. These have proven to be effective in ameliorating the pain for up to 3 months. Recently, plasma-rich plasma injections have also shown promise in the treatment of plantar fasciitis.
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