Plantar Fasciitis : Causes, Symptoms, Treatment

The plantar fascia is tissue found at the bottom of the foot and connects the heel bone to our toes to create what we know as the arch. When it becomes inflamed, this is known as Plantar fasciitis.


Origin of Plantar Fasciitis

Plantar FasciitisPlantar Fasciitis Inflammation is caused by overstretching or excessive use of the plantar fascia and develops a tear in the tissue. This would result in pain and will make movement difficult for patients. Those who suffer from this foot ailment experience severe pain in the arch. The most common complaint made by patients is sharp or dull pain and stiffness experienced in the arch. Some also report an ache or burning sensation at the bottom of the foot. The pain usually occurs in the morning and when a patient would take his initial steps. Patients also experience pain after long periods of standing or sitting down, when going up some stairs or after an intense physical activity.


Anatomy of the plantar fascia or superficial plantar aponeurosis

Anatomy of the plantar fascia or superficial plantar aponeurosisThe foot problem or condition known as plantar fasciitis is the most common foot condition among physically active men. The affected area is the bottom part of the foot, namely the sole of the foot, as opposed to the top of the foot. The sole of the foot includes tissue, tendons, nerves and muscles which are all integrated and superimposed to form, in conjunction with the bones, an effective structure for the movement, balance, support and absorption of body weight.

Directly under the skin, which is thicker at various points of support, lies a cushion that provides a second protection at the heel. This cushion is the plantar adipose layer. Just above this cushion of fat, over practically the entire length of the foot and below the muscle fibers, lies another layer. This layer is a relatively thick band of connective tissue (elastic) that maintains to a certain degree the tension of the arch of the foot, and ultimately maintains its curvature. This band of tissue is called the superficial plantar aponeurosis (SPA).

The SPA is attached to the heel bone and ends in the form of five strips at the metatarsal top points, where the toes begin. Firmly adhering to the plantar muscles, the SPA does not form a uniform fibrous layer; it varies in width and thickness and is divided into three sections (central, lateral, medial). The SPA is more commonly called the plantar fascia. As a ligament structure, the plantar fascia is composed of water, collagen fibers (for strength), elastin (for elasticity), proteoglycans (for flexibility) and hyaluronic acid (for cartilage viscosity).


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Symptoms of plantar fasciitis: inflammation followed by pain and swelling

Symptoms of plantar fasciitis: inflammation followed by pain and swellingFasciitis and fibrositis (plantar) are synonyms. They refer to an inflammation of this band of fibrous tissue of the sole of the foot, which is the plantar fascia. The inflammatory reaction may occur for example as a result of an infection or injury. What generally follows is pain in the foot.

Inflammation of the plantar fascia often involves micro lesions of the tissue, so ultimately a serious lesion. Symptoms of fasciitis normally include pain, sometimes burning sensations, and stiffness in the arch. If there is an injury, and the condition has become chronic, a significant reduction in inflammation could possibly occur with however a continuing condition of degeneration. This would then be called plantar fasciosis.

The pain from plantar fasciitis is usually felt the morning, from very first steps, stemming from hours of standing up, intense physical activity or even from sitting for long periods of time. Symptoms of fasciitis also include a thickening of the plantar fascia. If over 4 to 4.5 mm thick, inflammation would likely be present.

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Causes of plantar fasciitis

Plantar fasciitis is a common orthopedic problem. Both women and men can be affected, but according to statistics, male athletes aged between 40 and 70 years old are the most affected. Many other causes could also be tied to the inflammation, and many individuals may also be under certain conditions that would more likely bring about the inflammation.

The plantar fascia is an elastic band. When one is active, this elastic band works to support and absorb body weight through adequate stretching and contracting. In a standing position, while all body weight is supported, its stretching is at its maximum. Naturally, the more intense and the longer the activity, the more demands on the plantar fascia. The overuse of this “suspension system” or improper warm-up before a physical activity can lead to swelling or lesions, usually responsible for the pain. Age and overweight (obesity) conditions significantly contribute to the development of plantar fasciitis.

With 26 bones, 33 joints and about a hundred muscles, tendons and ligaments, the foot is a complex structure. A congenital or acquired defect in the alignment and structuring of these elements also brings about a more or less pronounced deformation of the arch. If overly arched, this alters the normal ground support configuration: contact points are concentrated at the ends. This would be a high-arch condition. For children, the plantar fascia then functions abnormally, which can lead to imbalance and fatigue when walking, calluses and pain likely caused by plantar fasciitis.

A normal foot is a foot with a slight arch. When walking, this configuration allows the foot to partially flatten against the ground while stretching out, so acting as a shock absorber. For arches that are insufficiently curved or not curved at all, also termed flat feet, this effect is not applied. The related deficient muscle and ligament structures that are causing flat feet can be helped as the child grows up with proper orthopedic follow-up. If however the deformation is not corrected before the child reaches 16 to18 years of age, the condition will be irreversible. Apart from the discomfort and decreased propulsive capability, flat feet in adults cause significant pain due to inflammation (plantar fasciitis).

Between such extreme pathological cases, arch curvature variations exist among all individuals. Some feet are “flatter” than others. However it is wrong to think that a more pronounced curvature of the arch is preferable. Studies in biomechanics have shown that past a certain degree of curvature, the arch of the foot produces a particular effect called the “arch effect” which counters the mobility aspects that promote shock absorption (i.e.: contact with the ground while running). The load distribution upon impact against the ground is modified, where the fascia takes on an additional load. Hence the increased risk of plantar fasciitis.

The common causes of Plantar fasciitis include:

  • Flat feetor high arches
  • Running long distance especially on uneven surfaces or downhill
  • Obesity or sudden increase in weight
  • Tightness of the Achilles tendon

Examination, modeling and tests for plantar fasciitisSome types of Arthritis can also cause plantar fasciitis. They cause inflammation in the tendons that can result to plantar fasciitis. This usually occurs in elderly patients. Diabetes likewise contributes to the development of this foot ailment among the elderly.

Majority of cases of plantar fasciitis will not need surgery to relieve the pain or correct the condition. There are non-invasive treatments that can help although patients respond differently to treatments and recovery can vary from patient to patient.


Plantar fasciitis and physical activities

We have seen how structural defects can directly cause plantar fasciitis. However intense or excessive demands on the plantar fascia resulting from physical activity can also cause plantar fasciitis. Plantar fasciitis however may not affect certain runners, while others, even without excessive weight and possessing the same knowledge in training methods, are more affected. Why is that? Once again, we must resort to biomechanics to understand this more.

Anatomically perfect bodies are rare. We all have some degree of imperfection, deficiencies or imbalances linked to our musculoskeletal systems. Our feet are no exception, however the body as a whole is well made: it accommodates such faults in the medium to long term without pain warnings, under normal usage circumstances. But when overuse occurs, such as in intense physical activity, biomechanical imperfections in the foot (even minor) have more of an impact and can cause plantar fasciitis. This is the case with running.

Conditioned by stride and guided by ankle dynamics (subtalar joint), pronation is how the foot positions itself when walking or running. The heel first makes contact, with a slightly angled point of contact from the outside (laterally), because the foot is slightly inclined from the side; toes point upward and also outward. Then, in about one tenth of a second, support shifts towards the front of the foot and inward, ending with a push mainly carried out by the big toe. Total duration of the movement: ¼ second. We call this dynamic aspect the rolling of the foot, and pronation is the way in which this action unfolds! Normal pronation or universal (standard) support configuration is what we have just described.

In some case however, pronation is incomplete (underpronation). The foot moves with a normal heel impact and support shift towards the front, however remains inclined where the outer edge of the sole tends to bear the load. The shifting of support toward the inside is only partially done at the end of the cycle. This anomaly is also called supination which is the cause of some injuries. Underpronation also increases the risk of plantar fasciitis.

In contrast, overpronation is characterized by a pronounced and early weight transfer towards the lower inner edge of the foot, well before the final push. This results in excessive stretching of the plantar fascia and increased tension of musculo-aponeurotic tissue. This particular “flattening” is emphasized by an intense physical activity which is biomechanically uncorrected (such as improper shoe adjustments) and often leads to localized inflammation (more specifically plantar fasciitis).

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Pain relief and basic prevention of plantar fasciitis

A brief physical examination can confirm and identify sensitive or pain zones, swelling, misalignments (pronation), stiffness, and recommendations of foot orthotics, shoe modifications, etc. It may also be recommended that you consult a doctor of podiatric medicine for further evaluation.

Benign fasciitis can be controlled by ceasing the activities that tax the plantar fascia. Since we’re dealing with inflammation, the pain and swelling can be controlled by taking traditional pain medecine such as acetaminophen and ibuprofen. Applying ice and using foot orthotics are also potentially effective measures to counter the pain. Where complications from the condition would arise, only a podiatrist would have the qualifications to administer injections or perform surgery.

While it is important to quickly undergo examination when pain appears to avoid worsening the condition, many foot problems could still be avoided with proper shoes. Shoes without adequate support (for the arch of the foot), that don’t fit well, or lacking shock absorption features are responsible in most cases for the development of plantar fasciitis. So it is important to choose the right shoes and running shoes, with respect to features, comfort and fit to avoid problems.

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Examination, modeling and tests for plantar fasciitis

We use the Footmaxx™ technology at the CDP Foot Clinic for the biomechanical analysis of your feet. This technology detects problems which cannot be seen by simple visual inspection.


Treatment of plantar fasciitis

The goal is to prevent the reoccurrence of plantar fasciitis by focusing on the causes rather than the symptoms. Biomechanical forces act on the plantar fascia taking into consideration the specific musculo-skeletal and ligament structures. By thoroughly understanding how abnormalities affect elastic features of the plantar fascia, it then becomes possible to better assess the patient’s problem and effectively treat plantar fasciitis.

At one end of the foot we have the calcaneus, one of the heel bones, and at the other end we have the metatarsals (the longest toe bones). Attached between them is an elastic band under tension (the plantar fascia) which prevents the foot from collapsing (which would be the equivalent of the deformation of the arch and an increase in distance between the metatarsals and the calcaneus). Under load and during movement, there is elastic deformation of the arch of the foot, but there is also an increase in plantar tension also produced by the momentary shortening of the fascia which marginally wraps around the metatarsophalangeal joints during dorsiflexion of the big toe. To picture this, imagine a winch located at the end of an arch which is convexly positioned against the floor, with the winch wrapping the rope.

Depending on imperfections and morphological elements of the foot (overpronation and underpronation among others), excessive tension could occur during dorsiflexion of the toes, and consequently irritation or inflammation of the plantar fascia and medial calcaneal tuberosity. Through modeling, it has been possible to quantify the potential forces involved and to develop the windlass mechanism test. With this test, which involves moving the big toe at various positions while the subject is standing, clinicians can assign values, validate new biomechanical relationships, more precisely diagnose plantar fasciitis and consequently optimize the effectiveness of suggested orthotics.


Stretching exercises for plantar fasciitis

Stretching exercises for plantar fasciitisSome wait many months before consulting a foot specialist, others cannot cease their activities (those who work standing up for example). Many are consequently susceptible to chronic plantar fasciitis. Fortunately, since 2001, different hands-on techniques now help in managing the pain associated with this inflammation.

The manual stretching of the sole of the foot is among these techniques. More specifically, the stretching of the plantar fascia. It’s a simple procedure: while sitting, the subject raises aching foot, the right foot for example, on left knee with the outer part of the ankle well supported. The subject then grabs toes with hand, index finger pressed along the metatarsal joints (the other fingers also pressing under toes with thumb on top). Then apply pressure bringing the toes back, and maintaining this forced dorsiflexion for 10 seconds, and then releasing the pressure to have toes come forward to their initial position.

Repeat this action ten times, three times a day (total of 30 flexions per day), ideally after getting up in the morning, and after being idle or sitting down for a few hours. The idea here is to stretch the sole of the foot and to extend, in a controlled way, the plantar fascia. Pressing with the thumb (of the other hand), one can check if the fascia is well stretched out while toes of aching foot are flexed back. The pain will decrease within a relatively short time. For long-term relief, these daily stretching exercises must be maintained for several months without interruption.


Advice and orthotics for your feet

At the CDP Foot Clinic, we offer orthopedic solutions with the aim of providing you with the proper means to better manage plantar fasciitis: biometric evaluation, orthotics, insoles, stretching techniques, etc. Contact us now to deal with your plantar fasciitis condition effectively.

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