Guest post by:
William K. McKibbin, MD
Assistant Professor of Orthopaedics
Division of Foot & Ankle Surgery
“Plantar Fasciitis” is the diagnostic term we use for what represents the most common cause of heel pain, localized to generally the bottom, or “plantar” aspect of the heel. Quite literally, the term can be taken to mean “inflammation of the plantar fascia”. This is probably over-simplistic, but works for the discussion of this very insidious and sometimes long-lasting problem in athletes, particularly middle aged “weekend warriors”. The plantar fascia is actually a thick, long ligament that originates at the base of the heel and attaches to the bases of the toes in rather complex fashion. Among other functions, it importantly assists in the maintenance of the foot’s arch structure.
Usually, this type of heel pain occurs without any real inciting event, such as an injury. “Overuse” is most often blamed. We just happen to notice it when we try to step down on the heel, particularly in the morning getting out of bed, or after sitting for a while. This “start-up” pain often causes us to walk on our toes, or up on the ball of the foot, until it calms down enough to walk more normally. The discomfort though can become worse during the day, particularly on concrete floors. It can be quite severe, almost feeling like a “stone bruise”, or even “knife-like”.
Many different types of healthcare providers see patients who present with plantar fasciitis. There are several treatments out there as you might guess, and many of you will essentially on your own try things like stretching, icing, shoe inserts (orthotics), massage, OTC anti-inflammatory medicine, or even the “tincture of time” in order get this problem to go away. The internet is full of free advice, no question (a reasonable discussion can be found at the American Orthopaedic Foot and Ankle Society page). No one really knows what treatment(s) for any one particular individual with plantar fasciitis is(are) going to be ultimately effective in obtaining long term resolution – that is, the state of being pain free, without recurrence. That all stated, there are biases of opinion that I’ve formed over time, in the evaluation and treatment of plantar fasciitis.
The first bias that comes to mind is one of diagnostic “mistaken identity” – that is, the idea that the “heel spur” is the actual culprit. I disagree with that notion entirely, and am of the opinion that the spur that’s commonly found on x-rays is a manifestation of the ongoing inflammation, and not the cause of it. For that reason, I never recommend surgical removal of the spur. In point of fact, many patients with plantar fasciitis will not have a spur at all; and patients who come in for other reasons with no heel pain at all will have a spur show up on their x-rays! Finally, it is probably instructive to know that the spur, when present, “points” forward to the toes, and not down towards the floor into the heel pad tissue.
The most important bias that I hold with this diagnosis relates to what I really believe to be the most common cause for plantar fasciitis – that is, calf muscles that are too tight, too contracted. There is an emerging body of scientific literature in orthopaedics which supports this notion, but does not come right out and prove it. The idea is that calf muscles which are too tight, not stretched out enough, will result in “overpull” of the Achilles tendon at the back of the heel. This chronic and repetitive pull translates immediately downstream to the contiguous plantar fascia, which may set up a chronic inflammatory process. This bias has led me to essentially abandon many common “textbook” treatments (such as cortisone shots, frozen bottle massage, etc.), in favor of those which work on the attainment of a more supple set of calf muscles. Examples would include stretching, physical therapy, night splinting, and even casting. To be clear, there are no quick fixes as this can take some time. Patience usually wins out; I have come to realize that surgery is rarely necessary for the successful resolution of this very common, and sometimes stubborn foot problem.
Having trouble with resolving your plantar fasciitis? Schedule an appointment with Dr. McKibbin by calling 843-876-0111.