Plantar Fasciosis - Identification and Management

Plantar Fasciosis commonly presents in the form of pain and tenderness in the plantar medial aspect of the heel, where the Plantar Fascia attaches to the calcaneal tuberosity. Patients often report the pain is acute on standing in the morning or following a period of non weight bearing, which progresses to a dull aching pain. Although it is often called fasciitis, and thought of as an inflammatory condition, the fascial degeneration and necrosis found in plantar fascia especially in chronic cases is more similar to tendinosis than tendonitis.  

Differential Diagnosis

• Heel fat pad atrophy with age
• Calcaneal apophysitis/ enthesopathy/ periostitis/ stress fractures/ bursitis
• Pathology in other muscles/ligaments attaching to calcaneal tubercle
• Compression neuropathy/sciatica

Note a calcaneal heel spur (exostosis on the calcaneal tubercle) is not indicative of pathology or pain, and an X-ray is of little use in determining the etiology or the management plan.

Biomechanical Causes

Repetitive overuse, trauma and increased tensile stress can cause thickening and micro tears in the Plantar Fascia. An early heel lift due to tight calf muscles or excessive rearfoot pronation, puts the Plantar Fascia under load and strain for more time and sooner in the gait cycle. A poorly functioning 1^st MPJ in propulsion will also upset the windlass mechanism and causes overload of the Plantar Fascia later in the cycle.

Management

Reducing the mechanical overloading on the Plantar Fascia should be the focus. Address tight calves with stretching programs and nightsplints. Temporarily use heel raises or increase the pitch of the shoe to discourage an early heel lift. Prevent any excessive rearfoot pronation, and improve 1^st MPJ mechanics in propulsion using an orthotic device. The selection of orthotic device should depend upon the amount of excessive pronation moment which you are attempting to control, and the type of pathology in the 1^st MPJ. While a soft heel pad may feel comfortable at the inflammation stage, it will do little to reduce symptoms. Taping and avoiding walking barefoot or wearing very flat shoes for a period of time, will help to rest the area. If it is an acute inflammatory issue rather than a typical chronic degeneration, steroid Injections, hot cold therapy, NSAID’s may be useful.