Plantar Fasciitis

Plantar fasciitis is among the most prevalent musculoskeletal conditions. The condition involves chronic inflammation of a plantar fascia, a thick band of soft tissue that starts by attaching to the heel bone, runs across the bottom of the foot, and ends by joining to the base of the toes, where they provide arch support and shock absorption during walking. It is more frequent among obese persons, runners, and middle-aged individuals.

Symptoms

Typically, plantar fasciitis creates pain, a tight or stabbing sensation at the sole, often close to the heel area but sometimes to the balls of the feet. Mostly, pain can happen in one foot, but sometimes it can happen to both feet. The pain is intense following the first few steps in the morning and relieves after walking for a while. Moreover, it may reappear after prolonged standing or upon rising from a long-seated position.

Causes

The exact etiology of plantar fasciitis is unclear. One possible explanation is it may arise from continuous or excessive sudden stretch or tension on the plantar fascia. Repetitive mechanical force on the fascia can result in injury, minor breaches, and chronic inflammation.

Risk factors

Several factors may enhance the chances of having plantar fasciitis:

• Age: Plantar fasciitis is more prevalent in those aged 40 to 60.
• Certain forms of exercise: Running, dancing, and high-impact aerobic exercise impose heavy stress on your heel and plantar fascia.
• Flat feet: Prolonged standing or walking in persons with flat feet can alter the weight distribution of the foot and consequently increase the tension on the plantar fascia.
• Overweight: The added weight places additional stress on your plantar fascia

Complications

Untreated plantar fasciitis can result in persistent heel or foot pain that interferes with daily activities or your work.

Diagnosis

Plantar fasciitis is diagnosed based on the patient's medical history and physical exam. Your doctor will ask you about the location of pain, pain characteristics, and activities that aggravate or relieve the pain. Then, the doctor will examine your foot, move the ankle and foot, and palpate the tenderness spot.

Imaging Test

Typically, no tests are required. Your doctor may recommend an X-ray or MRI to ensure that other conditions, such as a fractured bone, are not causing your symptom.

Treatment

Most patients with plantar fasciitis heal with conservative therapy, including behavioral modification, medication, stretching exercise, supporting devices, physical therapy, extracorporeal shock wave therapy, and steroid injection. Surgery is rarely necessary.

•  Medications
  Oral medication, for example, paracetamol or NSAIDs (non-steroidal anti-inflammatory drugs) (ibuprofen, naproxen, meloxicam [Mobic], celecoxib [Celebrex], etoricoxib [Arcoxia]) for a short period are effective pain relievers for plantar fasciitis. Topical medication (cream or gel), for example, diclofenac gel (Difelene gel), is safer and can alleviate your foot pain.
  All oral medications may have side effects on your kidney, liver, stomach, or heart. Moreover, you may be allergic to some of the drugs. Topical medication may also irritate or cause skin allergies in some patients. Therefore, please consult with the doctor before starting the medication.
• Exercises
  The main exercise to relieve foot pain is stretching exercises at the plantar fascia, Achilles tendon, and calf muscle.

Stretching exercise of the plantar fascia

• Instruction

1. 1. Sit with a leg crossed. 
   2. Use your hand to stretch your toes backward. 
   3. You should feel a slight stretching in the sole but without pain.
   4. Hold this position for 20 seconds (count 1 - 20).

Stretching exercise of Achilles tendon and calf muscles

• Instruction

1. 1. Sit on your bed or chair with one leg straight out in front of you.
   2. Wrap a towel around the ball of your foot just below your toes.
   3. Gently pull on the towel toward your body, allowing your foot to slowly bend up while keeping your knee straight.
   4. You should feel a slight stretching at the back of your lower leg but without pain. 
   5. Hold in this position for 20 seconds (count 1 - 20).

Caution during stretching

• Gentle and slow stretching. Please do not stretch fast or hard.
• You should not do too much stretching. Just a slight stretching sensation without pain.

Behavioral modification

The following self-care methods to alleviate pain from plantar fasciitis:

• Select proper footwear. Avoid wearing worn-out footwear and shoes that are thin or have rigid soles. Wearing shoes proper in size and width, composed of the material that comforts your feet and provides arch support and absorption of the sole during walking and exercising.
• Do not walk barefoot. In case of chronic pain, you should avoid walking barefoot inside and outside the house.
• Maintain healthy body weight. Extra weight place extra strain on the plantar fascia. You can maintain your body weight through diet control and low-impact aerobic exercises, for example, walking, elliptical training, swimming, and bicycling.
• Modify your exercise and sports. Avoid high-impact exercise, for example, running, high-impact dancing, tennis, badminton, basketball, and football.

Supporting devices

You may consider supporting devices under the doctor’s prescription to relieve pain. These include

• Heel pads: The purposes are shock absorption and cushion at the heel during standing and walking. You may consider a heel pad for a short time to relieve foot pain.
• Medial arch support: The objective is to relax the plantar fascia. Having good elasticity of the plantar fascia will allow it to maintain the property of good shock absorption and be ready for standing and walking without pain.  
• Insole: Your doctor may advise you to wear a proper insole to relieve the pain. You can buy an insole that comforts your foot over the counter. Sometimes, a customized insole under the doctor’s prescription to ensure complete contact and fits with your foot shape can result in proper weight distribution during standing and walking.
• Night splints: During sleep, the whole body is relaxed, resulting in foot drops at night and causing tightness of the plantar fascia. When you wake up and walk in the morning, the plantar fascia will immediately stretch out, resulting in foot pain. A night splint can prevent foot pain by preventing foot drop and facilitating stretching of the plantar fascia in an optimally lengthened posture overnight. The doctor may consider patients who have refractory pain wearing a night splint.

Physical therapy

Physical therapists can help relieve your foot pain with physical means, for example, hydrocollator pack and ultrasound therapy. Moreover, they can demonstrate gentle stretching of the plantar fascia, Achilles tendon, and calf muscles. In addition, when you are relieved from foot pain, the physical therapist can show you how to do proper strengthening exercises for the lower leg muscles to prevent recurrent plantar fasciitis.

Extracorporeal shock wave therapy

Shock wave therapy is not radiation or electrical therapy but uses high-energy sound waves to target the deep plantar fascia layer. The mechanism is to cause the plantar fascia to repair and build the new tissue, resulting in less plantar fascia tightness from chronic inflammation; the patient will have less pain from plantar fasciitis. Shock wave therapy demonstrates its efficacy and safety in treating plantar fasciitis, especially in chronic or refractory cases.

Injection

Injecting steroids at the heel may alleviate the pain because it can decrease inflammation. However, performing steroid injection with the wrong technique or imprecision can cause serious side effects because steroids may weaken the plantar fascia and cause it to be at risk of rupture. Moreover, the steroid can increase the risk of atrophy of the fat pad under the heel and infection of the heel bone. Therefore, steroid injection should be the last conservative treatment option, especially in those who have severe symptoms and are refractory to other treatments. The doctor who does the injection should be a specialist with experience in this procedure. Ultrasound can help to perform this procedure more precisely.

Surgery

Nowadays, surgical detachment of the plantar fascia from the heel bone is rarely necessary. Generally, only when other therapies have failed; and the pain is severe despite conservative treatments would surgery be performed.