Clinical Considerations: Plantar Fasciitis

Heel pain is a common presenting complaint in chiropractic, podiatric, orthopedic and family-practice offices. Heel pain can be helped most of the time with quality conservative management. A common cause of heel pain is plantar fasciitis. This can occur in the athlete or nonathlete. This short article will not cover biomechanics of the foot and ankle complex. I would recommend Dr. Michaud's Foot Orthosis as an excellent text on foot biomechanics.

Plantar fasciitis patients commonly complain of pain, particularly upon rising in the morning, after sitting for an extended time, or with the onset of exercise. The patient will have pinpoint tenderness to deep palpation of the calcaneus, particularly at the medial tuberosity. Dorsiflexion (active or passive) of the foot and toes often causes pain with plantar fasciitis, but not always.

Common causes of plantar fasciitis include abnormal gait biomechanics, excessive supination or pronation, leg-length inequality, bad shoes, or what is probably the most common cause, shortened gastrocnemius, soleus and Achilles tendon.

A concern with heel pain is a calcaneal stress fracture. Cupping your hand on the medial and lateral sides of the calcaneus, not the plantar side, and squeezing firmly causing an acute increase in pain raises your suspicion of a stress fracture. I spoke with Bryan Hosler,DC,DACBR, about this. He suggested a CT scan to rule out a fracture, as the plain films will usually not reveal a calcaneal stress fracture. The x-rays will reveal a heel spur if present. The spur is the "result" of the problem, it is not the "cause." The spur develops subsequent to the tractioning on the periostal attachment of the fascia to the calcaneus.

Surgery for heel spurs is rare these days because the results are poor, due to the underlying problem not being addressed. Cortisone injections are still commonly used and when they are helpful, it is typically temporary. Dr. Hosler also said if you are looking for nonspecific bone pathology in the area, a bone scan is very sensitive and usually tells you if there is a problem, but it does not identify the problem.

If there is a stress facture, the foot must be put in physiologic rest. This can mean a cast, an air cast, or strong, supportive strapping and taping of the involved foot with no running or extra walking.

If a stress fracture is not a concern, and the diagnosis of plantar fasciitis has been established, then you are ready to help these people. My office protocol varies, and in this age of managed care and cash practices, cost must be considered. I may use any combination of the following:

• adjustments and mobilization for the foot and ankle as indicated by palpation findings with particular emphasis on the subtalar joint;

• orthotics if indicated, including addressing any leg-length inequality;

• stretching of the hamstrings and gastrocnemius via a contract and relax stretch on the hamstrings. I add passive dorsiflexion of the ankle simultaneously while stretching the hamstring to stretch the gastrocnemius.

• soft-tissue work to the plantar fascia. There are lots of ways to address this component, including cross friction, stripping of the fascia, deep massage, etc.

• modalities, including ultrasound or electrical muscle stimulation.

Remember, if there is a stress fracture, the ultrasound will make it worse.

Home protocol is also very important and may include the following:

• Stretch the gastrocnemius and soleus on a step, initially 3-4 times per day for one minute each time. If the step is not available, then a slant board is fine. A modified stretch against the wall with the foot flat on the ground and the leg behind you, while leaning into the wall, also is adequate. These stretches can be increased in quantity, or the time can be increased. For example: 1H to 2 minutes per session after a week and then increased again in H or 1-minute increments after another week. This stretching at home is very important, so emphasize it to your patients.

• Ice should be used in 15-minute increments, anywhere from two times a day up to 6-8 times per day.

• Toe curls, especially using a towel on the floor and grabbing it with the toes, help to strengthen the plantar fascia.

• You can do much with nutrition, though this is too large a topic for this article. I keep it simple: supplements directed toward decreasing inflammation and strengthening tendons and ligaments.

You can expand your practice and give yourself some new challenges by addressing extremity problems.

One final recommendation for those of you interested in treating sports injuries: Functional Soft Tissue Examination and Treatment by Manual Methods by Warren Hammer,DC. It is a tremendous resource and reference book that has helped me many times with difficult cases. Good luck with your practice and your patients' health.