Plantar Heel Pain: How To Get Treatment Results

By Kirk M. Herring, DPM, MS

Heel pain, especially pain associated with the plantar aponeurosis, is one of the most common overuse injuries affecting adults. Approximately 10 percent of runners as well as many other athletes are affected by plantar fasciitis.1 Conservative estimates have suggested more than 2 million Americans annually receive treatment for this condition.1 As common as this injury may be, there is no universally accepted etiology or treatment for this complaint. In addition to having a strong anatomical grasp of the heel (see “A Guide To Key Anatomical Considerations” below), it’s essential to understand the etiology of the heel pain. While there is no precise etiology as of yet, many consider plantar fasciitis to be an overuse injury caused by frequent overloads of the plantar fascia that lead to failure of the “windlass” mechanism. Most frequently, the proximal and central fibers are involved in this overuse injury. Repetitive and excessive tension leads to a syndrome of overuse and the development of micro-tears to the plantar fascia. These forces are best described and understood as a repetitive series of eccentrically generated forces that exceed the resiliency of the plantar fascia. Many other circumstances have been associated with the development of this injury. These include abnormal foot function (excessively flat or high arched feet), limited ankle joint dorsiflexion range of motion, tight or short tendo Achilles and/or triceps surae, weak triceps surae, limb length discrepancies, fat pad atrophy, poor and inappropriate footwear, athletic training errors, prolonged standing on concrete and obesity. What Are The Clinical Findings? Athletes and individuals complaining of plantar fasciitis experience foot pain that is aggravated by walking, standing and other weightbearing activities. Any portion of the plantar fascia may be affected although most patients describe heel and/or plantar arch pain. Typically, they will experience pain with the first steps of the morning and this pain gradually dissipates or “warms up” with activity. This pain cycle may be repeated following any period of inactivity such as sitting. Patients characterize plantar fasciitis as a deep aching or bruising pain, which may present occasional burning, stabbing and throbbing tendencies. A frequently described cyclical pain profile starts with pain being more severe in the morning, becoming gradually subdued by mid-day only to worsen gradually again by afternoon or evening. Pain typically is localized to the anterior inferior and medial aspect of the calcaneus where the plantar fascia originates at the medial calcaneal tubercle. Pain frequently extends distally several centimeters along the more medial fibers of the central portion of the plantar fascia. A zone of fibrous degeneration may develop and results in thickening of the proximal and medial aspect of the plantar fascia. You can often delineate this zone from adjacent normal tissue and it is painful to palpation. One can also detect differences in heel temperature. You may note a greater warmth to the injured limb. Medial to lateral compression of the affected heel is infrequently painful. Gait patterns are frequently antalgic and the patient will often exhibit a limp especially after brief episodes of sitting. What The Diagnostic Images Will Tell You Radiographic images of the affected foot may exhibit a calcaneal spur or enthesophyte. Generally believed to be the result of longstanding tension at the origin of the plantar aponeurosis, the resulting traction spur is slightly deeper. It resides within the fibers of the abductor hallucis origin or even the most medial fibers of the flexor digitorum brevis, which both share their origins to the calcaneus with the plantar fascia. However, this finding is inconsistent. Only 50 percent of those with plantar fasciitis exhibit this finding.6 In addition, 10 to 16 percent of heel spurs are asymptomatic, which precludes an adequate finding and confirmation of plantar fasciitis.

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