Plantar Heel Pain: How To Get Treatment Results

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A Guide To Key Anatomical Considerations

The plantar aponeurosis (plantar fascia) serves to elevate and stabilize the medial longitudinal arch during stance. It also augments the transformation of the foot from a mobile adaptor at heel contact to a more rigid lever at heel-off and during the propulsive phase of gait.2-4

Hicks provided experimental evidence of the biodynamic role of the plantar fascia during gait.5 He referred to the tensioning of the plantar fascia as a “windlass mechanism.” This mechanism results in elevation (supination) of the foot as a coupling influence of digital dorsiflexion (especially hallux) acting upon the subtalar joint axis, leading to supinatory force being directed across the subtalar and oblique axis of the midtarsal joints.

Other structures, including the adipose heel cup and ligament and Achilles tendon, contribute to the function of the plantar fascia. The adipose heel cup serves to dissipate the initial impact and shear load of heel contact. However, due to the arrangement of septal fibers and the blending of the heel cup ligament with the plantar fascia, the adipose heel cup may also serve to dampen occasional peaks to the linear load, which would otherwise be dissipated by the less elastic plantar fascia. The fibers of the Achilles tendon insertion serve to increase tension in the proximal fibers of the plantar fascia via its periosteal attachment during stance and gait.

Today, we recognize the importance of the plantar fascia not only as it serves to tension the longitudinal arch but also as it acts to elevate and stabilize the medial longitudinal arch in static stance. When functioning appropriately, the plantar fascia effectively augments the structural integrity of the longitudinal arch.5 When the plantar fascia and windlass mechanism malfunction, the foot fails to adequately transform to a more stable appendage. This exposes the plantar fascia and associated structures to greater eccentric loads, which may increase the potential for overuse injuries.

One can easily account for heel expansion by measuring the unloaded heel widthand applying the appropriate conversion formula.
You can also account for heel expansion by measuring loaded heel width directly with the patient in stance.
Stretching exercises should be performed two to three times a day, targeting specific anatomical structures. A minimum of three sets of five repetitions with a sustained hold of at least 15 seconds is recommended for each stretch.
Night splinting has proven to be an effective tool in managing persistent plantar fasciitis, according to the author.
Extracorporeal shock wave therapy (ESWT) may help patients suffering from chronic and recalcitrant plantar fasciitis restore normal tensegrity to the injured tissues and return to pain-free activity.
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.

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