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Magazine Article

Time wounds all heels

April 3rd, 2012

Understand your options for treating plantar fasciitis

By Dr. Eric J. Heit

WAC Mag Cover April 2012Many of us have experienced heel pain. Sometimes it goes away. Sometimes it gets worse. Often, the cause is plantar fasciitis. But what is plantar fasciitis and how can it be treated?

The plantar fascia is a long ligament that originates at the heel and attaches to the ball of the foot. Its fibers at the heel become contiguous with the insertional fibers of the Achilles tendon. Plantar fasciitis remains the most common problem we see at the Virginia Mason Sports Medicine clinic, and it accounts for the vast majority of bottom-heel pain.

Although it has become more well-known of late, plantar fasciitis was described in medical literature as early as 1812, when it was thought to be a complication of tuberculosis. The modern form of this condition was not mentioned again until the early 20th century, when it is believed Dr. William Scholl—yes, that Dr. Scholl—described a condition called “policeman’s heel.”

The cause of plantar fasciitis remains unknown. Complicating matters is that it occurs in adults of all kinds, regardless of age, gender, physical activity, body type and foot type.

A dynamic problem

The plantar fascia serves as an arch support or truss for the foot. What we don’t know, however, is the role it plays in the dynamic function of the foot. The one consistent finding with plantar fasciitis is that it tends to occur in people who spend most of their day walking, standing or running on hard flat surfaces.

With 23 joints to absorb shock, the foot is a structure that can adapt very well to uneven terrain. On hard flat surfaces, however, the joints don’t move as much or absorb as much shock.

In turn, tissues such as the plantar fascia end up absorbing more shock than they were built for. The bottom line is that plantar fasciitis occurs because too much of a dynamic load is placed on a part of the foot not designed to handle it, which results in inflammation, tearing, and scarification of the ligament where it attaches to the heel.

When a person with plantar fasciitis sits down, the ligament attempts to cure itself, resulting in scar tissue. The problem is, that scar tissue inevitably stretches when they stand up again, causing the pain to recur, sometimes worse than before.

The best treatment is one that decreases dynamic load on the fascia, reduces inflammation and encourages the body to break down scar tissue.

Treatment choices

Plantar fasciitis tends to limit the activity of most patients. Therefore, almost all patients are given an initial treatment plan of over-the-counter or custom orthotics, night splinting to stretch the ligament while they sleep, stretching regimens, icing, massage, and anti-inflammatory medication when appropriate. We usually consider more-aggressive treatment options only after these have failed.

Corticosteroids, for example, reduce inflammation and decrease scar tissue. When plantar fasciitis becomes chronic and doesn’t respond to the treatments above, cortisone injection therapy is often a good option.

Recent studies suggest proper targeting of cortisone injections into the plantar fascia can effectively treat plantar fasciitis and minimize recurrence rates. Additionally, cortisone injections are more efficacious and cost-effective than other invasive treatments.

Anecdotally, we have found cortisone injection to be the most effective treatment to permanently relieve symptoms of chronic plantar fasciitis. These injections, however, are painful and come with risks, including local steroid flare and plantar fascial rupture, both of which are exceedingly rare and treatable.

Other options

Another option for treatment is ASTYM, a form of augmented deep tissue massage that uses contoured plastic instruments. The theory behind ASTYM, which stands for “a stimulation,” is that it triggers the body’s natural healing response to send new collagen to the injured tissue, replacing it with healthy tissue.

The exact mechanism of action, however, is unknown. ASTYM was developed in the late 1990s, and quite a bit of research has proven it effective in treating chronic conditions. To date, however, it has not been well-studied specifically for plantar fasciitis. Then again, there’s no evidence showing it ineffective either.

Treatments such as high-energy ultrasound, platelet-rich plasma injections, and acupuncture also can be used, particularly for those with persistent plantar fasciitis that’s proven challenging to treat. All represent reasonable treatments, but a lack of consistent long-term results keeps us from recommending them as a first-line approach.

Surgery is another option, but it’s rarely necessary. Also, because surgery patients can take up to a year to heal, we try to avoid surgery whenever possible. Moreover, surgery patients develop mild arch collapse, which can lead to symptomatic arthritis.

The worst thing a person with plantar fasciitis can do is to ignore the symptoms. It rarely goes away on its own, and the pain almost always gets worse.

—Dr. Eric J. Heit is a podiatrist at Virginia Mason Sports Medicine. He works diligently to offer noninvasive solutions to foot problems before recommending other options.