"Tough" Cases of Heel Pain.

Plantar fasciitis is an inflammation of the plantar fascia, the ligament that starts at the base of the heel bone and attaches near the base of the toes.  It may start as a simple "sprain" of the ligament.  Such cases are self limiting and may resolve with rest, ice massage, gentle stretching and supportive shoegear.  Anti-inflammatory medication may be helpful at this stage.

Heel pain caused by plantar fasciitis that persists often does so due to mechanical issues or biomechanics.  Chronic repetitive strain of the fascia may be caused by occupational or avocational issues combined with problematic lower extremity mechanics.

The plantar fascia has very good tensile strength, that is "pulling" strength.  Its torsional (twisting) strength is much less.  Mechanical problems of the foot/ankle/leg may be congenital or may develop over time.  Repetitive and excessive torsion/twisting of the fascia damages the ligament and often causes pain.

What are the biomechanical issues that cause plantar fasciitis to persist or worsen over time?

1) Subtalar joint overpronation:  The subtalar joint is the joint immediately below the ankle joint.  The ankle joint functions as a hinge allowing up and down motion (dorsiflexion and plantarflexion).  Subtalar joint motion is generally seen as side to side motion of the back of the foot.   Arch supports, motion control running shoes and basic foot orthotics often decrease subtalar joint overpronation.

2) Midtarsal joint oversupination:  The midtarsal joint allows the front of the foot to pivot or rotate up and down.  Motion control shoes and OTC foot orthotics have limited effect on this motion.

3) Functional equinus:  The ankle joint need dorsiflex (move upward) at least 10 degrees (15 degrees is ideal) during walking.  Lack of adequate ankle dorsiflexion range of motion is compensated for by increased subtalar joint pronation and increased midtarsal joint oversupination increasing torsional strain on the plantar fascia.

4) Poor shoe design:  Shoes are often viewed as a fashion item more than a functional platform that supports our body weight for a long work day.  Shoe design 101.... shoes should not bend at the shank!  Shoes should be flexible at the ball of the foot, the toe joints but rigid at the shank.  Steel shanks used in work shoes have been around for over 100 years.  Unfortunately, there has been significant cheapening of shoe construction in recent years.  Use of steel in the shank is an option but other materials such a plastics and carbon graphite may be used.  Walking, running and standing for long periods of time require this feature.  Lateral motion sports such as tennis, racqetball and to an extent, basketball allow shoes with more flexiblity in the shank.

The Treatment Triad

San Antonio Podiatrist, Dr. Ed Davis coined this term several years ago.  It is a term that describes the long term progress of plantar fasciitis and why different treatments are more effective for different stages of the disease.

1) Acute plantar fasciitis:

This involves a "strain" of the fascia from overuse or use of inadequate shoegear.  it is often self limiting and may be treated via rest, ice massage, anti-inflammatory medication and use of better, more supportive shoegear.

Sonographic exam may demonstrate modest swelling of the fascia.

2) Plantar fasciitis that persists/ chronic plantar fasciitis:

Plantar fasciitis that persists for more than a few weeks often does so due to chronic repetitive strain.  That may be caused by the reasons discussed on the left....subtalar joint overpronation, midtarsal joint oversupination, functional equinus or poor shoe design.   Sonographic examination often demonstrates thickening of the fascia, scar tissue, and sometimes calcification fo the fascia.  Calcification of the fascia used to be termed "heel spur" syndrome.  X-rays are two dimensional representations of the problem leading to that term.   The underlying mechanical problems need be addressed at this stage.

3) "Recalcitrant" plantar fasciitis or plantar fasciosis:

Chronic inflammation is not handled well by our bodies.  Chronic inflammation in the arteries may lead to atherosclerosclerosis.  Chronic inflammation of tendons and ligaments leads to thickening, scar tissue, decrease of tissue flexibility and a reduction in blood circulation.  Sonography demonstrates thickening of the fascia with changes in the texture of the ligament.  Scar tissue tends to crowd out good tissue.  Neovascularization (the production of new blood vessels) is difficult due to the density of the diseased tissue.   This stage had been difficult to treat with one of the main procedures involving the surgical release (cutting) of the fascia.  It is my opinion that such surgeries are obsolescent due to the availability of ESWT and the Topaz Procedure.