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Plantar Fasciitis

Plantar fasciitis is characterized by sharp, sharp pain, stabbing pain in the posterior medial aspect of their heel. They may give the classic story of, as soon as I get up to get out of bed to go take my shower and start my day, itís like someone sticking a knife back here in my heel.

Well at night when youíre sleeping, your foot can droop down, so you sort of relax the foot, youíre not maintaining your arch, there is some relaxation of the muscle pull, so this becomes contracted, so this distance between the heel and out here to the metatarsal phalangeal joints where the plantar fascia inserts.

So that is contracted, and you go to step on that in the morning, you have to yank this thing back out to length, and this is where the least amount of compliance is, the least amount of elasticity where itís inflamed and swollen here to begin with, that is where itís yanking right on the bone and that is where they get that sharp, morning pain, or startup pain, like they have been sitting down to read the paper, or reading a book or watching a T.V. show for an hour or two, they get up and they get that sharp stabbing pain just like they got it in the morning, and this kind of converts over to an ache by the end of the day. A dull, throbbing ache that may radiate down into the toes or down along the arch.

Whatís going on here, well there is increased tension in the plantar fascia, why is there increased tension? Well perhaps they have a flat foot. You can imagine as your arch collapses, as the arch drifts down to the ground, the distance between your calcaneus and your metatarsal heads where that plantar fascia is attaching into, that distance is getting longer, so your plantar fascia is trying to stretch out as your arch is collapsing and youíre getting that increased tension and pain, and itís acting at the insertion back where the plantar fascia attaches.

Another reason for plantar heel pain is fat pad atrophy. I often see this with patientís with rheumatologic conditions, they thin out their fat pad. Itís very thin, it doesnít serve as a shock absorber and these people are complaining of direct pain with prolonged standing or weight bearing on that foot. Also, as the fat pad atrophies, the complex septae between the fat pad which helped keep it stabilized under the heel, starts to break down, so they may have a fat pad, but if were to wiggle that fat pad.

We need to reduce the inflammation. What we really need to do, what I think works most effectively, and the literature sort of brings this out, we need to sort of break that repetitive cycle of injury, and that is most manifested by that morning start up pain. Every night they go to bed, that plantar fascia is allowed to contract down, every morning, they have to sort of tear it back out, so using a night splint, which simply keeps the foot in a plantar grade position or up out of that contracted position, you donít let that plantar fascia contract down, so you donít have to stretch it out every morning.

During the day, you have them in an orthotic that has an arch support in it, so if youíre giving external support to the arch, you are effectively unloading the plantar fascia, so itís not getting that constant increase tension with every weight bearing step. 

What helps facilitate this, to make this work, is you need physical therapy to work on stretching the plantar fascia and the Achilles tendon. That is sort of a very recurring theme with me, I think there are a lot of problem with Achilles tendon contractures, that if you have a very tight Achilles tendon, itís going to throw the weight to the front of the foot, more weight on the front of the foot stresses the arch, stresses the structures that support the arch, the plantar fascia. That is why they need to do heel stretching exercises and also exercises to help stabilize their arch, the posterior tibial tendon and the peroneus longus.

When I look at someone who presents to me with a foot complaint, I try to break it up into what the primary pathology is, and what are the secondary manifestations that they are coming to me to complain about? The foot is a complex weight bearing surface. There re 28 bones and nearly 60 articulating surfaces, so there are a lot of inter-relationships going on between the different segments of the foot, the hind foot, mid foot and forefoot, and problems in one region can have manifestations elsewhere. So it is very important to recognize what the root cause of the problem is, as well as identifying all the secondary manifestations.

There are the seven tarsal bones in the hindfoot region, we have that defined as the calcaneus, and the talus, that separates the hindfoot from the midfoot through the transverse tarsal joint. The remaining five tarsal bones are the middle, medial and lateral cuneiform, the cuboid bone, and the navicular. Then you enter into the forefoot which has the five metatarsal bones and the 14 phalanges. As you know, in the hallux, there are only two phalanges, whereas in the lesser toes.

Another concept that I use frequently when I am looking at foot problems, is that the foot should have an axis of balance. That axis of balance runs along the sagittal plane. It goes from the center of the calcaneus, to the center of the midfoot, and runs between the second and third metatarsals in the forefoot. Weight bearing forces are balanced across that access medially and laterally, in fact, minimal muscle activity is required for quiet standing. The muscle forces, or the dynamic forces during the phases of gait are also balanced across this access for dorsiflexion, plantar flexion, but mostly for inversion and eversion of the foot .

It needs to be rigid when youíre standing on it, and it needs to be flexible as it strikes to the ground, so it can absorb the shock forces and the weight bearing forces as it strikes the ground. These static restraints such as the ligaments, as they start to weaken and the foot starts to collapse, you start to overwork or atrophy some of the dynamic restraints.