Plantar Fasciitis

The following information is an excerpt from The Foot Book: Advice for Athletes (Harry F. Hlavac, World Publications, Inc., Mountain View, CA 94042, ISBN 0-89037-119-9).

15. Plantar Fascia and Heel Spur

We often refer to plantar fasciitis and the heel spur syndrome synonymously. It's not complete accurate but does help in keeping the dynamic cause of both conditions in mind. Both conditions involve the long plantar ligament or plantar fascia, and both are aggravated by foot pronation.

Plantar fasciitis is most frequently an acute or semi-acut injury and appears as a strain or partial rupture of the sturdy ligament that courses from the heel to the ball of the foot. Pain is in the middle of the heel, extending forward. The plantar fascia is a firm band of connective tissue on the bottom of the foot which is often called a ligament. It functions in maintaining the inside or medial arch.

The direct cause of injury can be anything that stretches this ligament, such as a lineman in football propelling forcefully from the ball of the foot into an unyielding object. Another cause could be a gymnast jumping off apparatus onto the ball of the foot. With a more gradual onset, the cause is usually pronation, which lengthens the foot and puts a stretch on the fascia.

The plantar fascia is comprised of three slips: the center, the outside (lateral) and the inside (medial) portions. The inside and middle are most frequently involved with injury. The pain from plantar fasciitis usually is in the arch or heel area while standing and running. Direct pressure on the fascia should elicit some tenderness. If you run your fingers along the tender area, you may be able to feel a slight irregularity where the pain is occurring. If the injury is more acute, swelling can be present an spasm of the ligament often causes this structure to become bow-strung and quite prominent, especially when two toes are bent upward, pain associated with spasm is more severe.

Plantar fasciitis respons fairly well to conservative treatment. If the injury is acute ice should be used immediately to bring down swelling and reduce spasm. During the first 24-48 hours, weight bearing should be limited, after which further sports participation should be limited to pain tolerance. Felt and tape should both be used to provide additional support and compression over the involved area. A Low-Dye or rest strap (see Chapter 30) should be applied to provide support. In addition, we use a medical arch pad secured with additional tape to provide compression and support. Another treatment is to use a varus heel pad in both shoes to reduce the stretch effect on the ligament. Ice should be used continually after workouts and before bedtime until pain is diminmation (sic). A Sprots Wedge, with cupping and tilting of the heel, may be more helpful.

the more chronic plantar fasciitis we see in relation to endurance sports is handled differently. We believe this gradual presentation of pain is most commonly due to abnormal pronation of the foot, and therefore we aim our tratment at this factor. For the first six weeks after injury, the problem is handled the same as acute plantar fasciitis. Ice, again, is all-important to keep inflammation at a minimum, and the use of tape and pads provides for additional support and compression.

(Note: Many athletes will adquately cut down training to pain tolerance but continue to compete. This will greatly aggravate the problem. Competition should be prohibited until training is again full scale.)

If pain is near the heel region, x-rays may be necessary to indicate if a heel spur syndrome is taking place. Steroid injections are sometimes indicated to reduce chronic inflammation.

Prevention of plantar fasciitis is best achieved via orthotic devices. By supporting the arch, the devices reduce thestrain on the plantar fascia. Our results where orthoses are used in treating plantar fasciitis have been extremely rewarding.

Another type of fasciitis is found in downhill skiers and Nordic skiers who suffer from a fallen-arch-type pain when they firmly buckle down their ski boots. Pain is relieved by unbuckling the boots but may continue to ski through the pain. This pain is related to the stretching of the plantar fascia and is probably more frequent in skiers with varus-type foot deformities. The abnormal foot, when secured firmly in a ski boot, is functioning maximally pronated in order to maintain inside edge control which in a shot period can appear as intolerable arch pain. We suggest trying a rigid or semi-rigid orthotic device or Sports Wedge for this problem.

Heel Spur

A heel spur is a bony growth occurring on the underside of the heel bone. This growth appears in response to an abornmal pull from the plantar fascia. Initially, only the bone covering or periosteum is involved. But after years of continued stress and minor inflammation, a bony spur gradually appears. The abnormal stress that causes plantar fasciitis also causes the heel spur, but instead of involving the fascia in the arch area, its involvement is at the ligament's origin on the heel bone. In addition to bone and ligament involvement, we are seeing a large number of cases where bursitis and nerve entrapment co-exist with the heel spur. The pressure and local irritation cause the bursal sac to form, while the chronic inflammation irritates and binds down the nearby nerve.

Pain is usually greatest in the initial formative stages when only the bone covering is involved. Pain will be present on weight bearing and when pressure is firmly applied over the base of the heel.

Conservative treatment is the same as for plantar fasciitis, although the use of the medial arch pad is not as important here. A pad which has proven effective is one shaped like a horseshoe and placed in the shoe to take pressure away from the central position of the heel where the tenderness exists. If self-treatment is not progressing satisfactorily, quickly consult a podiatrist. Orthotic devices are again very helpful in cupping the heel and in reducing the pull of the plantar fascia away from the heel bone. When pain is long-standing and unremitting after using all modes of therapy, surgery occasionally is performed with fair to good results.

Looking at plantar fasciitis and the heel spur you see that treatment is directed in two stages. The initial treatment is very similar to that of many overuse injuries, and the extended treatment involves correcting the abnormal forces that initiated the entire injury process.