Plantar fasciitis is an epidemic amongst our society and has resulted in numerous treatment plans that vary from one health care provider to another. Guidelines for treatment protocols exist and even those differ from one specialty to another. Plantar fasciitis is searched monthly on google over 550,000 times with web pages revealing information ranging from explaining the cause to sites marketing gimmick treatment devices to take advantage of those suffering in pain.
The purpose of this post is to give hope to those suffering and hopefully point runners in the right direction who are trying to overcome this chronic condition.
To begin, plantar fasciitis has been described as an inflammation of the plantar fascia – a band of tissue that originates on the heel bone and fans out to the toes of the feet providing structure and protection to the underlying vessels, nerves, and muscles of the foot. Surprisingly, studies have demonstrated inflammatory cells are not present within the plantar fascia in those suffering from the condition suggesting it may not be “inflammation” within the plantar fascia. There are 3 muscles that attach to the heel bone in conjunction with the plantar fascia – the abductor hallucis, abductor digiti minimi, and flexor hallucis brevis. These muscles develop tendonitis when overused or weak from being in shoegear all day. This leads to pain upon arising in the morning, and again throughout the day after increased activity.
The muscular tissues that are inflamed are attempting to heal themselves and need to be stretched or warmed up to reduce the pain. Then, after periods of activity, the muscles again become sore leading to pain later in the day. The result – chronic pain to the heel and or arch area.
When runners develop plantar fasciitis, what should they do?
In my practice, if they are able to complete a run without pain, I encourage the patient to continue running. I then advise:
1. anti-inflammatories if they are able to take them
2. Stretching exercise to be performed 4 times a day
3. Ice 30 minutes as many times a day to the area
4. Barefoot activities 20-30 minutes per day to encourage foot strengthening gradually increasing weekly
5. Flat shoes without a heel to promote anatomic positioning of the foot and rest of body
6. Splinting may be done but only temporarily
If the condition persists, cortisone injections are utilized to aid in decreasing the inflammation. They are safer in theory then NSAIDS as they are local and not systemically absorbed.
If the above treatment fails, then the condition is most likely secondary to the runner’s form which will need to be analyzed and changed. I simply tell patients who have tried all of this and failed, then something they are doing at home, work, or while running is precipitating the condition.
Orthotics are not the answer for my patients who are runners as they simply promote weakening of foot musculature.
What about a plantar fasciotmy? (Surgical release of the plantar fascia)
To reiterate, studies show that after performing a plantar fasciectomy (surgical release of the plantar fascia) the tissue sent to the pathologist revealed no inflammatory changes. This leads many practitioners to believe the condition is more muscular which explains the pain upon rising in the morning or after periods of rest. Why then would cutting the plantar fascia be indicated to help overcome this condition? As a surgeon, I stopped doing this procedure several years ago as the studies do not advocate it’s relevance.
Consider this, why would we cut an anatomic structure that process structural integrity to the foot, protects the underlying vessels, and is not even scientifically proven to be inflamed in clinical studies?
Therefore, treat this like a tendonitis.