Plantar Fasciitis? Plantar Fasciosis? Plantar Fasciopathy? Chronic Plantar Heel Pain (CPHP)? I’m confused!

What is the Plantar Fascia?

The Plantar fascia is a dense connective tissue, it isn’t a tendon or a ligament but it is similar to both (Boabighi et al 1993). It runs along the sole of the foot and forms a strong biomechanical link between the calcaneus (heel bone) and the toes. It is made up of medial, lateral and central bands and it is the medial band that is frequently implicated with injury (Kaya 1996).  The central band is the major structural and functional component and the lateral band is actually absent in some people (Wearing 2006).

What does it do?

The Plantar fascia makes the foot become a rigid structure ideal for propulsion by using the windlass mechanism. It is very clever because if the foot was always rigid then it would not be very good at shock absorption or be able to adapt and mould to the differing surfaces of the ground. The plantar fascia contains more fibroblasts than tendon or ligament. So it does more than just transmit force it is considered that it is an active sensory structure capable of changing its composition in response to the demands placed upon it.

So what is the condition itself?

As ever the term plantar fasciitis is now up for debate. The more accurate term is Chronic Plantar Heel Pain (CPHP). The reason for this is that “itis” means inflammation and the trouble with this is that inflammation is only rarely observed in CPHP. The condition is far more likely to be related to degeneration. In fact some people have called it plantar fasciosis or plantar fasciopathy but these are a bit of a mouthful so CPHP is best. Patients with CPHP were 8 times more likely to show evidence of a heel spur than non CPHP sufferers (Cook & Purdham 2011). This highlights that the spur may be an effect of the CPHP and not a cause of it but this is impossible to say.

Incidence:

CPHP comprises 15% of all adult foot complaints and affects 10% of the population (Rome 1997). 4.5 to 10% of all running athletes will develop CPHP and this is mostly in distance runners, hence why it is sometimes called jogger’s heel (Lopes AD et al 2012), (Singh et al 2008). It is also a running pace not just distance related injury according Nielsen et al (2013).

How long does it take to resolve?

It is generally considered that the condition will go away within a year but in this study they found that it took 159 days on average to recovery in novice runners (Nielsen et al 2014). Obviously everyone is different and what they are doing to help the condition will influence the speed of recovery also.

Diagnosis:

Pain localised over the medial tubercle which is considered a key diagnostic sign for accurate diagnosis. Diagnostic ultrasound demonstrates diffuse or localised hypoechoic areas with thickening and so can be used for diagnosis.

Other variations and conditions causing similar pain are below:

Heel spur syndrome (bony spur growth)

Plantar fascial insertitis (inflammation where the plantar fascia inserts into the bone)

Calcaneal enthesopathy (Pathology of the bony attachment)

Subcalcaneal bursitis (Inflammation of the bursa)

Stone bruise: (Bruising to the fat pad from impact)

Calcaneal periostitis (Inflammation of the lining of the heel bone)

Neuritis: (Nerve inflammation)

Sever’s Disease (growth plate inflammation)

Symptoms:

Pain is in the heel and the sole of the foot, often the medial (inside) part of the arch hurts the most. 70% of all cases are on one side only (Lutter 1997) and pain is elicited when weight bearing especially walking. It is most intense when taking the first few steps after being off your feet. For example patients report intense pain on walking after getting out of bed.

Causes:

Underloading of the structure causing weakness of the tissue, which exposes the structure making it easier to overload.

Vascular and metabolic disturbances (e.g: Diabetes, Peripheral vascular disease)

Genetics: As with all things some people have a genetic predisposition to chronic connective tissue disorders.

Age: The enthesis (the part of the plantar fascia that is usually injured) is brittle and therefore susceptible to damage. CPHP is common after 50 years old and this can be in part, attributed to the degeneration of the fat pad.

Shortened calf muscles: 12% of individuals examined in a study by Kim et al (2010), revealed a continuation of the Achilles tendon and the plantar fascia. So this means that excessive tensile forces in the calf under dorsiflexion would transmit the force into the plantar fascia. In fact it has been found that the chance of developing CPHP actually triples if passive ankle joint dorsiflexion is less than 10 degrees! (Sahin et al, 2010).

Overweight:  Lutter (1997) reports that 65% of the non-sports demographic are overweight and a BMI of 25-30 doubles the chances of getting CPHP. 

Spending a lot of time on your feet especially on hard surfaces: The chance increases by 3.6 times in weight bearing occupations (Sahin et al, 2010).

Poor footwear and abnormal biomechanics: Commonly it was considered that the cause relates to your foot arch mechanics but the evidence for this is hit and miss. For example:

Abnormal shape or movement of the arch is not associated with chronic plantar fasciitis, but they found that arch mechanics may influence the severity of plantar fasciitis once the condition is present (Wearing et al 2004).

However there are other potential biomechanical factors other than the arch:

Irving et al (2006) found that decreased first metatarsophalangeal joint extension increased the likelihood of developing the condition.

And…

Excessive Supination causes impaired shock absorption = increased force ‘spikes’ to damage tissues directly.

Treatment:

CPHP can be a real challenge to treat.

Here is a list of common treatments:

Extracorporeal Shock wave therapy (ECSWT):

This is the conversion of a sound wave into a shockwave; actually it is very similar to lithotripsy, which is used to treat kidney stones.

ESWT was found to be more effective than placebo by a mean difference of 6% in reducing heel pain (Crawford et al 2008).

Moderate and high intensity ECSWT were effective in the treatment of chronic plantar fasciitis according to Dizon et al (2013).

But...

This evidence found manual stretching was superior to repetitive ECSWT (Rompe et al 2010) and it would appear that ECSWT is ineffective for acute CPHP.

Low dye taping:

Low-Dye taping provides improvement in 'first-step' pain compared with a sham intervention after a one week (Radford et al 2006).

Non-Steroidal anti-inflammatory drugs (NSAID’s):

Remember the condition is rarely inflamed but if you continue to overload the plantar fascia and do too much then it can inflame. In this case you could argue the use of NSAID’s, but my view is, that you shouldn’t have overloaded it in the first place to create the damage, to need the increase in inflammation, to heal the damage created. So the issue is overloading it in the first place. If you don't overload then you don't need NSAID's.

Night splints: 

Patients without previous treatments for plantar fasciitis obtain significant relief of heel pain in the short term with the use of a night splint (Bekler et al 2007). However they don’t have any long term benefit and are often poorly tolerated as they are uncomfortable.

Myofascial Trigger point therapy:

This can help to reduce the pain in the plantar fascia in the short term but has no long term effect.

Corticosteroid injections:

Same argument as above with NSAID’s. Crawford and Thomson (2008) only found a short term improvement over placebo injection.

Quality footwear:

The aim of footwear is to reduce Achilles load, support the arch and reduce effects of the 'windlass mechanism'.

How can it reduce Achilles load?

A heel raise has been shown to decrease Achilles load and therefore reduces plantar fascia load (Farris et al. 2012). So at first wear a shoe with a reasonable heel section but this should be a gradual drop to the toe. So certainly not high heels! Overtime as the pain reduces then you should ideally wean down from the heel raise with shoes that are gradually lower on the heel.

Supporting the arch:

Arch support has been shown to help to manage CPHP (Roos et al. 2006). However if you are very sensitive to touch in your arch then the arch support may not actually be tolerated especially if it is made from hard material.

The windlass mechanism:

If you can reduce the first toe extension at the MTP joint then you will minimise the strain through the plantar fascia. So a shoe with a thick rigid sole that doesn’t bend easily will help and obviously going barefoot is a bad idea!

What about barefoot minimalist trainers?

Well the above statement tells you the answer but barefoot running tends to increase load on the calf, Achilles tendon and plantar fascia as it creates more of a forefoot strike.

Overall comfort is king, so try different trainers and usually the one that feels the best are usually correct. Simple!

Orthotics (insoles): 

Custom foot orthoses can be effective in the short and long-term treatment for pain (Roos et al 2006). This too is backed up by Lee et al (2008) who also found foot orthoses (insoles) for plantar fasciitis appears to reduce pain & improve function.

Also…

Insoles and exercise were found effective in treating excessive pronation & chronic foot pain (Andreasen et al 2013). But overall clinically, comfort is the most important and relevant feature when prescribing foot orthoses (Mündermann et al 2003).

Stretching:

Stretching for plantar fasciitis is marginally beneficial over no treatment at all (Crawford & Thomson 2003). Stretching the plantar fascia has been shown to be superior to normal gastrocnemius and soleus stretching (Rompe 2010). As a stand-alone treatment, calf stretching appears not to be as effective as plantar fascia–specific stretching (Garrett & Neibert 2013).

Platelet-rich plasma injections:

The jury is still out on this at present.

In this study, pain reduced post injection, 88% of patients were completely satisfied, there was no negative changes to the plantar fascia afterwards and 1 year later there were no complications to having had the injection (Ragab & Othman 2012).

Acupuncture/Dry needling:

Dry needling provided statistically significant improvements in plantar heel pain (Cotchett et al 2014).

Ultrasound:

Ultrasound works best for: Ligament, Tendon, Fascia, Joint capsules & Scar tissue as they absorb it best (Sparrow et al 2005). Basically the denser the soft tissue the better and the plantar fascia is just that.

Surgery:

If all other methods have been unsuccessful then surgical release is an option. It generally gives relief in around 70% of cases.

So there you go, everything that you need to know about Chronic Plantar Heel Pain.

If you need any further information or would like to book an appointment then call Hawkes Physiotherapy on 01782 771861 or 07866195914

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