Offloading The Plantar Fascia: What You Should Know
Heel pain is the most common musculoskeletal complaint of patients presenting to the podiatric physician. While heel pain is estimated to comprise 10 percent of athletic injuries, the incidence of heel pain in the active and sedentary population appears to be significantly underreported in the medical literature. Most experienced practitioners report that heel pain complaints have risen to epidemic proportion over the past 20 years for reasons we still do not fully understand.
Certainly, changing demographics figures into the equation. The average patient with heel pain is between the ages of 40 and 60 and this segment of the population has grown more than any other over the past two decades.
Many theories have emerged explaining the possible etiologies and anatomic structures involved with plantar heel pain syndrome.1 Today, most authorities agree that plantar fasciitis is the most common cause of heel pain in both active and sedentary patients.2-4
Lemont, et. al., have questioned the term “plantar fasciitis.”5 They examined histologic findings from specimens taken during heel spur or plantar fasciotomy surgeries, and found no evidence of inflammation. The findings of myxoid degeneration with fragmentation of the plantar fascia led Lemont to propose that the true pathology of the plantar fascia is a “fasciosis” rather than fasciitis. Other research has validated that the histologic changes in the plantar fascia associated with heel pain are consistent with structural failure and not with inflammation.6 Researchers have hypothesized that the structural failure is due to microtears in the plantar fascia in the area of its insertion on the medial tubercle of the calcaneus.7
Podiatric physicians have long believed the most appropriate treatment for the painful heel involves some method to decrease strain or offload the plantar fascia. Many of these interventions are based upon biomechanical principles. The most common principles include the use of custom functional foot orthoses, arch taping and stretching of the heel cord and calf musculature. Yet if one were to survey any group of podiatric physicians around the country, there would be a lack of agreement about how and why these interventions work. Clearly, there is little understanding of how the plantar fascia may become overloaded in stance and gait and, more importantly, how one can use certain interventions to offload the plantar fascia.
Defusing The Standard Assumptions About Custom Foot Orthoses
It is well recognized that the plantar aponeurosis or plantar fascia is the most important static stabilizer of the arch of the human foot. In dynamic gait, the plantar fascia, through the windlass mechanism, has a threefold greater arch supporting power than the posterior tibial tendon.8