Plantar Fasciitis

Plantar fasciitis (PF) is a common injury sustained by runners, with 10% lifetime prevalence for the general population. The plantar fascia is a thick aponeurotic band extending from the medial aspect of the calcaneus (plantar surface) that splits to enclose the digital tendons at the proximal phalanges and helps support the arch of the foot.

PF describes a degenerative non-inflammatory process that occurs with repetitive foot strike. Biomechanical abnormalities such as pes planus (flat foot) may predispose to PF as the lack of medial arch support leads to over-pronation, requiring the plantar facia to work harder during the gait cycle. A pes cavus (high arch) deformity may lead to PF too as the rigid foot has less ability to cushion landing forces. Tight calves and hamstrings may also predispose an individual to PF, as can increased activity, obesity and incorrect footwear.

Medial heel pain is most commonly observed on initial walking in the morning or after a period of immobility and tends to gradually improve during exercise. On examination, there is usually diffuse tenderness over the medial aspect of the plantar calcaneus, extending towards the base of the toes. X-ray may demonstrate a bony calcaneal spur. However, such abnormalities have not been causally related to PF and the diagnosis is usually made on a clinical basis.

Treatment initially consists of analgesic measures including reduction precipitating activity, ice and NSAIDs. The mainstay of management involves stretching of the calves, hamstrings and the plantar fascia itself, which can be achieved by placing the toes against a wall with the heel on the floor and pressing the arch downwards. Massage may also provide some relief from the discomfort of PF and can be achieved by rolling a golf ball underneath the arch of the foot against a firm floor. Heel and arch supports as well as cushioned footwear aim to raise the heel and reduce impact forces.

Corticosteroid injection into the plantar fascia may provide significant relief but can be painful and carries a significant risk of fascia rupture. Newer treatments such as extra-corporeal shock wave therapy have also demonstrated some promising early results. Surgery for recalcitrant cases involves resection of the middle third of the plantar fascia with evidence no longer supporting removal of any bony heel spur.

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