Plantar fasciitis

Findings

Type 1 – The inferior surface of the calcaneum is painful, and worse on palpation, but squeezing the rim of the calcaneal fat pad relieves this palpatory pain. It is probably not a true fasciitis.

Type 2 – As for type 1, but the pain can also be produced by forced dorsiflexion of the foot and toes, and by rocking up over the balls of the feet and toes at 45 degrees, such as in a sprint start position. There is tenderness to palpation over the calcaneal enthesis of the spring ligament.

Type 3 – There is a history of acute or semi-acute pain, often under the arch of the foot, and the tenderness is not under the calcaneum but over the spring ligament, which may be thickened and tender.

Cause

Possibly plantar fasciitis is a “catch-all” phrase that may include flexor hallucis and medial calcaneal nerve problems as well. Type 1 is not a fasciitis, but trauma of the fat pad. However, this lesion is often talked of as a fasciitis, so has been included under this heading.

Type 1 – Damage to the fat pad of the heel, which presents more often in the elderly. The fibrous stroma separates the fat into compartments so that, during compression, the loculated fat is prevented from spreading and therefore acts as a good shock absorber. When the stroma weakens, the fat pad is less tightly contained and becomes functionally thinner, thus allowing impact to reach the calcaneal periosteum.

Type 2 – An enthesitis of the plantar spring ligament.

Type 3 – A degenerative lesion within the spring ligament, which may lead to partial rupture.

Treatment

Type 1:

a)      An orthosis to squeeze the fat pad, diminish impact and correct calcaneovalgus.

b)      Low Dye strapping to squeeze the fat pad(1), possibly with iontophoresis of acetic acid(2).

c)      “Air-soled” shoes, which use the same principle as the stroma of the fat pad, will reduce impact.

d)     Non- impact cross-training, such as biking, rowing or swimming.

e)      Electrotherapeutic modalities to settle inflammation in the fat and around the periosteum.

Type 2:

a)      Treat as for type 1.

b)      Use a heel raise, especially a shock- absorbent raise, in the early phase to reduce the tension in the spring ligament.

c)      Cortisone injection to the enthesis.

d)     Stretch and load the enthesis and spring ligament by rocking over the toes, as in a sprint start, or use a foot rocker. This stretch may be maintained at night by a cast that holds the foot dorsiflexed.

e)      Stand on the edge of the stairs, rise onto tiptoe and then drop the heels as low as possible over the edge of the stairs to stretch the spring ligament, and then load it by standing on tiptoe.

f)       Return to running, etc., via the Achilles ladder.

Type 3:

a)      Electrotherapeutic modalities, such as ultrasound, to settle the inflammation.

b)      Rest, and shorten the spring ligament with a heel raise, and then gradually reduce the height of the heel raise as the injury heals.

c)      Gradually introduce strech and load exercises, as for type 2.

This is a troublesome condition that takes several months to settle. No contact and change of direction sports are protected from this type of lesion. Defining the lesion will make rehabilitation and treatment easier. A heel raise, in types 2 and 3, may be made of sheets of paper, reduced by one a day, to gradually stretch out the plantar fascia. Types 1 and 2 should respond to cortisone, and type 3 should pass if there is an inflammatory element.

"Concise guide to sports injuries, 2^nd edition",Churchill Livingstone, Malcolm T.F. Read,  foreword by Bryan English