Plantar Fasciitis

Synonym: Plantar fasciitis, Chronic plantar fasciitis, Heel spur syndrome, Lenoir spur syndrome

Introduction

Plantar fasciitis is a painful condition that occurs due to inflammation of the plantar fascia, a thick band of connective tissue located at the bottom of the foot. This condition can cause severe pain in the heel, affecting the quality of life and mobility of affected individuals.

Plantar fasciitis is a painful condition that occurs due to inflammation of the plantar fascia, a thick band of connective tissue located at the bottom of the foot. This condition can cause severe pain in the heel, affecting the quality of life and mobility of affected individuals.

The plantar fascia is a crucial part of the anatomy of the foot, acting as a dynamic support for the plantar arch. It extends from heel to toe, helping to maintain the structure of the foot and absorb shock during walking, running or other physical activities. However, when the plantar fascia experiences excessive stress or is subjected to repeated strain, it can become inflamed, causing plantar fasciitis.

Common symptoms of plantar fasciitis include heel pain, often felt with the first few steps in the morning or after a period of rest. The pain may also be exacerbated by prolonged walking, running, or wearing inappropriate shoes. Some individuals describe the pain as a tingling or burning sensation at the bottom of the foot.

Several factors can contribute to the development of plantar fasciitis. One of the main risk factors is excessive strain on the plantar fascia, usually caused by overuse of the foot. Activities such as running, prolonged walking or wearing inappropriate shoes can increase the risk of this condition. Additionally, factors such as obesity, excessive foot pronation, muscular imbalances or anatomical problems of the foot can also play a role in triggering plantar fasciitis.

The diagnosis of plantar fasciitis is often based on symptoms described by the patient, a thorough physical examination of the foot, and sometimes additional tests such as x-rays or ultrasound to rule out other possible conditions.

Treatment for plantar fasciitis can vary depending on the severity of the symptoms. Conservative approaches are often favored as first intention. These include rest, ice application, specific foot stretches, use of supportive shoes, and administration of nonsteroidal anti-inflammatory drugs (NSAIDs) to reduce inflammation. Custom-made foot orthotics may also be recommended to help support the arch of the foot and reduce pressure on the plantar fascia.

In cases that are more severe or resistant to conservative treatment, more advanced options may be considered, such as physical therapy, injection of corticosteroids into the affected area, or even surgery in exceptional cases.

Preventing plantar fasciitis involves adopting good foot care practices, including choosing appropriate footwear, weight management, warming up before exercise, and muscle strengthening. People experiencing persistent or recurring symptoms should consult a healthcare professional for an accurate diagnosis and appropriate treatment plan. By addressing the symptoms of plantar fasciitis early, it is often possible to avoid long-term complications and maintain a good quality of life.

Impact

It has been established that a tenth of people may suffer symptoms of plantar fasciitis during their lifetime. Bilateral PI may be present in less than a third of cases.

Anatomy of the plantar fascia

The plantar fascia, also known as the plantar fascia, is an anatomical structure located on the bottom of the foot. It is formed from a thick, fibrous band of connective tissue and plays an essential role in supporting the arch of the foot.

Here are some key points regarding the plantar fascia:

1. Location: The plantar fascia extends from the heel bone (calcaneus) to the base of the toes. It forms a sort of web that supports the arch of the foot.
2. Function: The plantar fascia has several important functions:
   • Arch support: It helps maintain the longitudinal arch of the foot, which is essential for stability and body weight distribution.
   • Shock absorption: It helps absorb shock when walking, running or other physical activities.
   • Maintaining posture: By working with other structures of the foot, it helps maintain balance and body posture.
3. Structure: The plantar fascia is made up of dense connective tissue and collagen fibers. It is thicker at the heel and becomes thinner towards the base of the toes.
4. Conditions: Problems with the plantar fascia, such as inflammation or tears, can lead to painful conditions like plantar fasciitis. Plantar fasciitis is characterized by pain in the heel, especially when taking the first steps in the morning.
5. Care and Treatment: For problems related to the plantar fascia, treatments such as stretching, rest, use of appropriate footwear, orthotics, physiotherapy and, in some cases, medical interventions may be recommended.

The plantar fascia is a crucial structure for the biomechanics of the foot and plays an important role in locomotion and maintaining balance.

Causes of Plantar Fasciitis

Plantar fasciitis, a common ailment that often plagues individuals, arises from various factors that contribute to inflammation and irritation of the plantar fascia—the thick band of tissue connecting the heel bone to the toes. One primary cause is excessive strain on the plantar fascia, typically stemming from prolonged standing, walking, or running, especially on hard surfaces. Poor foot mechanics, such as flat feet or high arches, can also contribute to the condition. Additionally, obesity places increased stress on the plantar fascia, making individuals more susceptible to developing plantar fasciitis.

Tightness in the Achilles tendon and calf muscles is another factor, as it limits ankle flexibility and puts extra strain on the plantar fascia during movement. Moreover, wearing shoes with inadequate support or improper arch support can exacerbate the problem. While plantar fasciitis often develops gradually over time, sudden increases in activity levels, like engaging in intense sports or workouts, can also trigger the onset of symptoms. Recognizing these diverse causes is crucial for effective prevention and management, allowing individuals to adopt targeted interventions such as stretching exercises, proper footwear, and weight management to alleviate symptoms and promote foot health. As an osteopath, incorporating comprehensive assessments and tailored treatment plans for patients with plantar fasciitis can significantly contribute to mitigating the impact of this condition and enhancing overall well-being.

1. Excessive Tension on the Plantar Fascia: One of the main causes of plantar fasciitis is excessive tension on the plantar fascia. This can result from overuse, strenuous physical activity, playing high-impact sports, or long periods of walking or running.
2. Flat Feet or High Arches: People with flat feet (sagging of the arch) or particularly high arches may be more likely to develop plantar fasciitis because of the way these conditions change the distribution of pressure on the foot.
3. Obesity: Being overweight can put additional pressure on the plantar fascia, increasing the risk of developing inflammation.
4. Inappropriate Footwear: Wearing shoes that do not provide adequate arch support, are worn out, or do not fit properly can contribute to plantar fasciitis.
5. High Impact Activities: Participating in high impact activities, such as running on hard surfaces, can put excessive pressure on the plantar fascia and contribute to its inflammation.
6. Anatomical Defects: Certain anatomical defects of the foot, such as gait abnormalities, muscular imbalances, or variations in foot structure, can increase the risk of plantar fasciitis.
7. Age: Plantar fasciitis is more common in middle-aged to older people.
8. Medical Conditions: Certain medical conditions, such as rheumatoid arthritis, may increase the risk of developing plantar fasciitis.

It is important to note that plantar fasciitis can be the result of a combination of these factors. If you are experiencing persistent heel or lower foot pain, it is recommended that you consult a healthcare professional, such as a podiatrist, for an accurate diagnosis and appropriate treatment advice.

Symptoms of Plantar Fasciitis

Plantar fasciitis manifests through a spectrum of symptoms that can significantly impact an individual’s daily life and mobility. A hallmark sign is heel pain, particularly during the first steps in the morning or after prolonged periods of rest. This pain is often described as a sharp, stabbing sensation at the bottom of the heel. As the day progresses, the pain may subside, only to return after extended periods of standing or walking. The discomfort tends to intensify after activities that involve bearing weight on the feet, such as running or climbing stairs. Individuals with plantar fasciitis may also experience heightened pain after long periods of sitting, as the fascia tightens during inactivity.

A common symptom accompanying plantar fasciitis is stiffness in the affected foot, especially after waking up or following periods of rest. The stiffness may gradually improve with movement, but it remains a consistent issue for many individuals. Additionally, some people notice swelling along the bottom of the foot, primarily near the heel. This swelling contributes to the overall discomfort and may be more pronounced after prolonged periods of activity.

As the condition progresses, individuals might develop compensatory movements to alleviate pain, leading to changes in their gait or walking pattern. These alterations in biomechanics can potentially result in secondary issues, such as knee, hip, or back pain. It is essential to recognize these interconnected symptoms to provide comprehensive care for individuals dealing with plantar fasciitis.

Plantar fasciitis symptoms can be chronic if left untreated, affecting the overall quality of life. The persistent pain and discomfort may impact an individual’s ability to engage in regular activities, exercise, or even stand for extended periods. As an osteopath, addressing not only the localized symptoms but also considering the broader impact on biomechanics and movement patterns is crucial. Implementing a multifaceted approach that includes targeted exercises, manual therapy, and lifestyle modifications can be instrumental in managing and alleviating the symptoms of plantar fasciitis, promoting a holistic and effective treatment plan tailored to the unique needs of each patient.

1. Heel Pain: Pain is usually felt in the heel, more specifically under the heel. The painful area may be located near the front or central part of the heel.
2. Pain upon waking up: The pain is often more intense during the first steps in the morning after waking up. It can also be felt after a period of rest or inactivity.
3. Pain after Physical Activity: Pain may worsen after periods of physical activity, especially activities that put strain on the foot, such as walking, running, or standing for long periods of time.
4. Stiffness and Pain after Rest: After a period of rest, such as sitting for a while, pain may occur when you get up and start walking.
5. Pain on the Inner Side of the Heel: Pain is often located on the inner side of the heel, where the plantar fascia attaches to the calcaneus (heel bone).
6. Burning or Stinging Sensation: Some people may feel a burning or tingling sensation in the heel area.
7. Redness and Swelling: There may be slight redness and swelling around the heel.
8. Difficulty Going Up or Down Stairs: Pain can make it difficult to go up or down stairs.

It is important to note that plantar fasciitis can be caused or exacerbated by other conditions, such as flat feet, high arches, or posture problems. If you are experiencing symptoms of plantar fasciitis, it is recommended that you consult a healthcare professional, such as a podiatrist or orthopedist, for an accurate diagnosis and treatment recommendations tailored to your specific situation. Early treatment can help prevent the condition from getting worse.

Pathophysiology of Plantar Fasciitis

Plantar fasciitis is characterized by a complex interplay of structural and inflammatory changes in the plantar fascia, a thick band of connective tissue that spans the bottom of the foot, connecting the heel bone to the toes. The pathophysiology of plantar fasciitis often begins with repetitive microtrauma to the plantar fascia, leading to microscopic tears and degeneration. This can be attributed to excessive or prolonged tension on the fascia, commonly occurring during activities that involve weight-bearing and repetitive stress on the feet.

The microtrauma triggers an inflammatory response, with the body’s immune system mobilizing to repair the damaged tissue. However, in cases of chronic stress or inadequate recovery, the inflammatory response can become persistent, contributing to the hallmark symptoms of plantar fasciitis. Inflammation in the plantar fascia is associated with the release of pro-inflammatory cytokines and the activation of inflammatory cells, exacerbating tissue damage and leading to pain and discomfort.

Tightness and reduced flexibility in the Achilles tendon and calf muscles are often implicated in the pathophysiology of plantar fasciitis. These factors can alter the biomechanics of the foot, placing increased stress on the plantar fascia during movement. Over time, this repetitive stress contributes to the degenerative changes in the fascia, perpetuating the inflammatory cycle.

Structural abnormalities in foot mechanics, such as flat feet or high arches, can also play a role in the development of plantar fasciitis. These variations in foot structure may lead to uneven weight distribution and abnormal forces on the plantar fascia, contributing to the ongoing tissue damage and inflammation.

Understanding the pathophysiology of plantar fasciitis is crucial for developing effective treatment strategies. As an osteopath, you may consider addressing not only the localized inflammation but also the contributing factors such as biomechanical imbalances and muscle tightness. Manual therapies, stretching exercises, and targeted interventions to improve foot mechanics can be incorporated into a comprehensive treatment plan. By addressing the root causes and promoting optimal healing, osteopathic interventions can play a vital role in managing the pathophysiology of plantar fasciitis and alleviating the associated symptoms for improved patient outcomes.

1. Repetitive Tension on the Plantar Fascia:
   • Plantar fasciitis is often associated with repeated strain on the plantar fascia, which can result from a variety of factors such as strenuous physical activities, overuse of the foot, abrupt changes in physical activity, or even poor foot biomechanics.
2. Microtraumas and Tears:
   • Repetitive strain can lead to microtrauma and tears to the plantar fascia, particularly at the attachment point at the heel. These microtraumas may be the result of excessive stress placed on the fascia during walking, running, or other activities.
3. Inflammatory reaction:
   • In response to microtrauma, the body triggers an inflammatory response to heal damaged tissues. This results in increased blood flow to the affected area and the release of inflammatory substances.
4. Formation of Scars and Limescale Deposits:
   • Healing tears can lead to scarring of the plantar fascia. In some cases, lime deposits may also form at the site of tears, contributing to stiffness and discomfort.
5. Heel Traction:
   • When walking or standing, tension on the plantar fascia can put excessive traction on the attachment point at the heel (the plantar aponeurosis). This can cause sharp pain, especially when taking the first steps after a period of rest, such as in the morning.
6. Calcaneal Spurs Training (Optional):
   • In some cases of prolonged plantar fasciitis, bony growths called heel spurs may form in the heel. However, these spurs are not always present and are not the main cause of the pain.
7. Pain and Symptoms:
   • The pain associated with plantar fasciitis is usually felt in the heel, near the arch of the foot. It is often more intense in the morning after rest, but can also be present when walking and putting weight on the foot.
8. Risk factors:
   • Certain risk factors such as obesity, inappropriate shoes, flat or hollow feet, and sudden changes in physical activity can increase the likelihood of developing plantar fasciitis.

Mechanism of plantar fasciitis

The mechanism of plantar fasciitis involves a series of intricate processes that ultimately lead to inflammation and pain in the plantar fascia. The condition typically arises from repetitive stress and strain on the plantar fascia, a thick band of tissue that supports the arch of the foot. One of the primary mechanisms is the overloading of the fascia, commonly occurring during activities that involve prolonged standing, walking, or running on hard surfaces. This repetitive stress leads to microtrauma and strain, setting the stage for the development of plantar fasciitis.

The plantar fascia acts as a shock absorber, supporting the arch of the foot and facilitating normal foot mechanics during movement. When subjected to excessive tension or repetitive stress, the fascia undergoes structural changes, including microscopic tears and degeneration. This process initiates an inflammatory response as the body attempts to repair the damaged tissue.

The inflammation in the plantar fascia is a key component of the mechanism of plantar fasciitis. In response to the tissue damage, the body releases pro-inflammatory cytokines and attracts inflammatory cells to the affected area. While inflammation is a natural part of the healing process, chronic or unresolved inflammation can contribute to persistent pain and discomfort associated with plantar fasciitis.

Tightness in the Achilles tendon and calf muscles also plays a significant role in the mechanism of plantar fasciitis. Reduced flexibility in these areas can alter the biomechanics of the foot, placing additional stress on the plantar fascia during movement. The increased tension in the Achilles tendon and calf muscles can contribute to the development and perpetuation of plantar fasciitis by creating an environment conducive to ongoing microtrauma and inflammation.

Biomechanical factors, such as flat feet or high arches, can further complicate the mechanism of plantar fasciitis. These structural variations in foot mechanics may result in uneven weight distribution and abnormal forces on the plantar fascia, contributing to its overuse and susceptibility to injury.

Understanding the intricate mechanism of plantar fasciitis is crucial for developing targeted treatment approaches. As an osteopath, addressing not only the inflammation but also the contributing factors such as biomechanical imbalances and muscle tightness can be integral to effective management. Manual therapies, stretching exercises, and patient education on proper foot mechanics may form part of a comprehensive treatment plan aimed at alleviating symptoms and promoting the optimal healing of the plantar fascia.

1. Repetition of walking or running can cause microtrauma and inflammation causing the plantar fascia on the calcaneus – During the heel lift phase of the gait cycle, tension increases on the plantar fascia (stores the potential energy) ; during toe strike, the plantar fascia contracts passively, converting potential energy into kinetic energy, resulting in greater acceleration of the foot.
2. Windlass Effect: Toe extension stretches the plantar fascia over the metatarsal heads (like a pulley) to tighten the fascia and shorten the longitudinal arches (loading the “spring” for toe lift).
3. Irritation of the Sharpey fiber insertion on the calcaneus leads to remodeling of the bone along the fascia line, resulting in a bone spur (the bone spur is secondary to inflammation, not the cause – note: many people have asymptomatic bone spurs)

Risk factors for having Plantar Fasciitis

The main risk factors for plantar fasciitis include:

1. Age: Plantar fasciitis is more common in middle-aged and older people, although it can affect people of any age.
2. High-Impact Activities: Regularly participating in high-impact activities, such as running, jumping, or other sports that put excessive strain on the feet, can increase risk.
3. Obesity or Overweight: Excessive body weight can increase pressure on the plantar fascia, contributing to the development of plantar fasciitis.
4. Gait Abnormalities: Gait abnormalities, such as excessive pronation (inward rolling of the foot) or supination (outward rolling of the foot), can influence the stress placed on the plantar fascia.
5. Arches of the Foot:
   • Flat Feet (Excessive Pronation): People with flat feet are more likely to develop plantar fasciitis.
   • High Arches (Supination): Excessive supination can also contribute to stress on the plantar fascia.
6. Inappropriate Footwear: Wearing shoes that do not provide adequate arch support, are worn, or do not fit properly can be a risk factor.
7. Standing Work: Occupations that involve long periods of standing on hard surfaces may increase the risk of plantar fasciitis.
8. New or Intense Activities: Sudden increases in the intensity or duration of physical activities, especially those involving the feet, can increase the risk.
9. Anatomical Defects: Certain anatomical defects, such as posture problems or muscular imbalances, can contribute to the development of plantar fasciitis.
10. Medical Conditions:
    • Arthritis: Certain forms of arthritis can increase the risk of developing plantar fasciitis.
    • Diabetes: People with diabetes may be more likely to develop foot problems, including plantar fasciitis.

The combination of these factors can increase the likelihood of developing plantar fasciitis. If you are experiencing symptoms or have risk factors, consult a healthcare professional, such as a podiatrist or orthopedist, for an accurate diagnosis and treatment recommendations tailored to your specific situation.

Clinical test

Windlass test

Calcaneus Compression Test

Heel spur

The heel spur is a bony growth located at the level of the calcaneus (the heel bone). It is often associated with plantar fasciitis, an inflammation of the plantar fascia (the connective tissue under the foot).

Common symptoms of heel spur include heel pain, especially with the first few steps in the morning. Diagnosis is usually based on the patient’s medical history, a physical examination, and sometimes x-rays to confirm the presence of the thorn.

Differential diagnoses of Plantar Fasciitis

1. Calcaneal spur (heel spur):
   • The presence of a heel spur can be associated with plantar fasciitis, but it can also be present without causing symptoms.
2. Tarsal tunnel syndrome:
   • This condition involves compression of the posterior tibial nerve inside the tarsal tunnel, causing pain similar to plantar fasciitis.
3. Posterior compartment syndrome:
   • Characterized by increased pressure in the muscle compartments of the foot, this syndrome can cause pain similar to that of plantar fasciitis.
4. Inflammatory arthritis:
   • Forms of arthritis like rheumatoid arthritis can cause inflammation and pain in the feet.
5. Morton’s neuroma:
   • A thickening of the nerve tissue between the heads of the metatarsal bones, causing pain and numbness in the front of the foot.
6. Retrocalcaneal bursitis:
   • Inflammation of the bursa located between the Achilles tendon and the calcaneus can cause heel pain.
7. Foot fractures:
   • Fractures of certain bones in the foot may present with symptoms similar to plantar fasciitis.
8. Achilles tendonitis:
   • Inflammation of the Achilles tendon can cause pain in the heel and lower part of the foot.
9. Muscle overuse syndrome:
   • Excessive activity or sudden changes in exercise intensity can lead to heel pain similar to plantar fasciitis.

Recommendations for those with plantar fasciitis

1. Ice massage or an ice pack can help reduce inflammation.

Rub ice on the sore heel in a circular motion using medium pressure for 5 to 10 minutes.

2. A night splint

A splint worn at night to keep the foot and ankle in a neutral position after stretching.

Exercise and stretching

1. Heel Rope Stretch:

• Stand facing a wall, the knee of the unaffected limb bent, the affected limb straight. unaffected limb bent, affected limb straight, and toes pointed slightly inward.
• Keeping the heels of both feet flat on the floor, lower your hips toward the wall.
• Hold the stretch for 30 seconds, then relax for 30 seconds.
• Repeat the exercise 4 times.
• Perform this exercise daily, 2 or 3 times a day, for 3 to 4 weeks.

2. Plantar Fascia Massage:

• Sit in a chair with your feet touching the floor.
• Place a tennis ball under the affected foot.
• Roll the foot back and forth and side to side. on the tennis ball, applying pressure on the ball to obtain a greater massage, for 60 to 90 seconds. (This exercise may cause slight discomfort, but should not be painful. If you feel pain, reduce pressure on the tennis ball).
• Perform this exercise 2 to 3 times a day, for 3 to 4 weeks

3. Plantar fascia stretching

• Sit with your ankle resting on your opposite knee.
• Grasp your toes and gently pull them back until you feel a stretch in the arch of your foot.
• Hold this position for 30 seconds and repeat six times.

4. Toe flexion using a napkin

• Sit with your foot flat on the end of a towel placed on a smooth surface.
• Keeping your heel on the floor, pull the towel toward your body, curling it with your toes.

5. Collecting marbles

• Place a few marbles on the floor near a cup.
• Keeping your heel on the ground, pick up the marbles with your toes and drop them into the cup.

Osteopathy for the treatment of plantar fasciitis

Osteopathy can be used as a complementary approach in the treatment of plantar fasciitis, but it is important to note that this condition may require a multidisciplinary approach. Osteopathy focuses on the manipulation of soft tissues, joints and muscles to improve mobility and overall function of the body. Here is how osteopathy could be involved in the treatment of plantar fasciitis:

1. Overall Assessment: The osteopath will begin with a complete assessment of your posture, the mobility of your feet, ankles, knees and hips. A comprehensive understanding of biomechanics can help identify imbalances that contribute to plantar fasciitis.
2. Joint Manipulations: Gentle joint manipulations can be used to improve mobility in the joints of the foot, ankle, knee and hips. This can help reduce pressure on the plantar fascia.
3. Soft Tissue Release: Soft tissue release techniques can be applied to relax the muscles of the leg, foot and ankle, as well as to release tension in the plantar fascia.
4. Stretches and Exercises: The osteopath may recommend specific stretches and exercises to strengthen the muscles of the foot, ankle and calves, helping to stabilize the foot.
5. Posture Correction: Posture advice and postural adjustments can be provided to reduce the load on the plantar fascia and promote more balanced walking.
6. Patient Education: The osteopath can provide educational advice on lifestyle modifications, advice on choosing appropriate footwear, and strategies for avoiding aggravating factors.

It is important to emphasize that osteopathy should generally be integrated with other treatment approaches for plantar fasciitis, such as specific exercises, stretching, orthotics and physical activity modifications. It is recommended to consult a healthcare professional, such as a podiatrist, for an accurate diagnosis and treatment recommendations tailored to your specific situation. The osteopath should work in collaboration with other health professionals to ensure complete and coordinated care.

1. Strain Counterstrain

Flexion of the calcaneus (FCA), also called quadratus plantae, is a tender point located on the plantar surface of the foot, at the anterior end of the calcaneus, near the origin of the plantar fascia. This point can become sensitive after the appearance of a dysfunction and can be treated with counterstrain. FCA tender point is likely related to quadratus plantae dysfunction.

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10. Credit in part: Benjamin K. Buchanan; Donald Kushner.