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Plantar Fasciitis

Definition:
The plantar fascia is a wide, thick, flat band of fibrous connective tissue that runs from the heel to the ball of the foot and serves to support the longitudinal arch and transmit weight across the foot when walking or running. It is subjected to enormous stress at every step and although it is tough and elastic, it is vulnerable to damage. When injured it can become inflamed and painful, the condition known as plantar fasciitis.

Occasionally the terms plantar fasciitis and heel spurs are used interchangeably. Although they are often associated (about 70% of people suffering from plantar fasciitis have heel spurs, visible on an X-ray), they are not necessarily connected.

Causes:
Plantar fasciitis is a common condition, often caused by overuse. Athletes are prone to developing it because of the repetitive stress placed on the ligament. A sudden increase in the intensity of training, or switching to a harder surface, can cause tears and inflammation.

Other causes include:
  • A rapid increase in weight, which places extra stress on the plantar fascia.
  • Wearing poorly fitting shoes that do not support the foot properly.
  • Arthritis
  • Diabetes
  • Structural abnormalities of the foot such as flat feet, over-pronation, or high arches
  • Tight calf muscles or tight Achilles tendons
  • Biomechanical factors such as an unusual way the foot strikes the ground
  • Pregnancy: during pregnancy hormonal changes cause ligaments to soften. There is also additional body weight adding to stress on the plantar fascia
  • Occupational factors such as a job that requires standing for long periods
Symptoms:
Pain from plantar fasciitis is usually felt near the point where the ligament attaches to the calcaneus (the heel bone) and is often described as an aching, shooting or burning sensation. Overnight the discomfort tends to lessen but, on first stepping onto the foot in the morning, the tight plantar fascia is again stretched and the pain can be quite severe. With gentle use the tissues of the ligament warm up and symptoms diminish, although the pain is likely to return with standing, walking, running, climbing stairs, or other physical activity, or after a period of resting.

Diagnosis:
Your doctor will ask you questions about your symptoms, what activity or time of day makes the pain better or worse, and any injuries to the foot you may have suffered. Your general health, lifestyle, and level of physical activity will also be discussed.

You will probably be asked to stand and walk around so that the doctor can evaluate how weight is distributed across the foot and whether any biomechanical factors might be contributing to your symptoms. Your foot will be physically examined.

If considered necessary, for instance if the doctor suspects that there might be a bone fracture, X-rays will be taken of your foot.

Treatment:
Initial treatment of plantar fasciitis is conservative (non-surgical). It will probably take several months to fully recover. Typical measures include:
  • Rest: Avoiding activity that triggers pain will allow the ligament to rest and the tissues to begin healing.
  • Ice: Placing your heel on a bag of crushed ice (wrapped in a towel), or rolling the sole of the foot over a frozen bottle of water, will help to reduce swelling and pain.
  • Medication: Over-the-counter pain medicine such as ibuprofen (Advil), naproxen (Aleve) or aspirin will reduce inflammation and pain.
  • Footwear: Change your shoes to ones with good supportive arches. Another method is to insert heel cups in both shoes to relieve pressure on the plantar fascia. Avoid walking barefoot, especially on hard surfaces.
  • Night splint: Wearing a splint during the night keeps the ligament stretched so that it does not tighten up and cause pain when first stepping on the foot in the morning.
  • Exercise: Although prolonged physical activity will exacerbate your symptoms, it is extremely helpful to perform stretching exercises for the tissues around the heel bone, especially first thing in the morning.
  • Maintain a healthy weight to avoid adding stress to the ligament.
If the above measures do not provide relief, your doctor can administer a cortisone injection. This carries the risks of rupturing the plantar fascia, or causing the pad of fat under the heel to atrophy, both of which would worsen, rather than lessen, your symptoms. Although these problems only affect a few sufferers, doctors are often reluctant to use cortisone injections as a treatment.

An experimental treatment is showing signs of being a successful option for plantar fasciitis. ESWT (extracorporeal shock wave therapy) inflicts tiny traumas to the ligament, which is believed to trigger tissue repair.

If all else fails, surgery to loosen the plantar fascia may be considered, but conservative treatments should be attempted first, for at least one year, before surgery is discussed. The success of surgical treatment is unpredictable.

Exercises:
Ideally, these should be done twice a day, but primarily first thing in the morning. Be sure to exercise both legs to avoid developing an imbalance.
Calf stretch:
Stand facing a wall and place hands on it for support. Lean forwards until a stretch is felt in the calves. Hold for 30 seconds. Bend at the knees and hold for a further 30 seconds. Repeat 5 times.
Toe dips:
Stand with your toes on the edge of a stair step or something similar, with your heels hanging over the edge. Place one hand against a wall for support. Slowly lower one heel until you feel a stretch in the back of the heel. Hold the stretch for 10 seconds then raise the heel up again. Repeat 10 times.
Plantar fascia stretch:
Sitting on the floor, bend one leg over the other and rest the ankle on the straight thigh. Hold the heel of the bent leg with one hand and the toes with the other. Pull the toes towards the shin until a stretch is felt on the bottom of the foot. Hold the stretch for 10 seconds. Repeat 3 times.
Toe pull:
Sitting on the floor, loop a towel or exercise band around the top half of your foot. Keep your knee straight and toes pointed at the ceiling. Pull on the ends of the towel so that your toes are drawn towards you. Hold for 10 seconds. Repeat 3 times.

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