Update on Plantar Fasciitis
If you've ever had trouble with heel pain when first getting out of bed, you may know how disabling plantar fasciitis (PF) can be. PF is the cause of heel pain in 80 per cent of patients who report this symptom.

In this article, two foot and ankle surgeons review and update information on PF. This is a brief summary of their findings. Two hundred years ago, doctors thought PF was caused by tuberculosis. Later, it was blamed on bone spurs, impingement of the fat pad, and inflammation of the fascia. Today, we recognize it as a chronic, degenerative (not inflammatory) condition.

As we age, the protective fat pad in the heel starts to thin out. It loses its thickness and height. The fat pad offers less shock absorption. Microtears in the fascia and death of collagen tissue occur as a result of repetitive microtrauma. The damage occurs at the insertion point. This is where the plantar fascia attaches to the calcaneus (heel bone).

Treatment can be helpful but a correct diagnosis must be made first. Heel pain can be caused by many other things besides PF. Nerve entrapment, tendinitis, fractures, and tumors can be confused with PF. First, the orthopedic surgeon or podiatrist takes a history and performs a physical exam.

X-rays aren't very helpful. But an MRI, ultrasound, or bone scan can be helpful. Ultrasound may be the preferred choice. It is fast, easy, painless, and doesn't expose the patient to any radiation. A blood test may be ordered if there is any suspicion of rheumatoid arthritis.

Treatment always begins with conservative care. Heel pads, shoe inserts, night splints, and antiinflammatory drugs have been used with varying degrees of success. The physical therapist may be able to help with local modalities (to heat) and manual therapy techniques (to stretch the soft tissues). Specific stretching exercises are also prescribed.

More recently, success has been reported with extracorporeal shock wave therapy (ESWT). Shock waves aimed at the PF may disrupt the tissue enough to start a local healing response. Increased blood to the area and the release of growth factors cause new cells to form. Radiofrequency waves is another way to stimulate healing through angiogenesis (formation of new blood vessels).

If nonoperative care doesn't help, then surgery may be needed. The surgeon makes an incision into the fascia to release part or all of the tissue. There are always risks with surgery. In this case, slow healing and changes in the biomechanics of the foot may cause even more problems.

There aren't enough studies to compare conservative care to operative care to say which choice is better. Likewise, there are no studies that compare different methods of surgery to correct the problem. When surgery is needed, an open incision is advised if there's any nerve involvement. This approach will help reduce the risk of further damage to the nerve.

Given the lack of firm evidence on how to treat PF, doctors rely on expert opinion. Six months (even up to 12 months) of nonsurgical treatment is tried first. It may take that long (or longer) to find the best choice of treatment. Often, it takes a combination of many treatment approaches to find one that works for each patient. The success rate is reported as 90 per cent, so patience in finding the right treatment pays off.
Steven K. Neufeld, MD, and Rebecca Cerrato, MD. Plantar Fasciitis: Evaluation and Treatment. In Journal of the American Academy of Orthopaedic Surgeons. June 2008. Vol. 16. No. 6. Pp. 338-346.