Podiatry has roots in the conservative treatment of many foot disorders, the most common of which is plantar fasciitis. This condition is characterized by inflammation and degeneration of the plantar fascia at its attachment to the calcaneus and is often mechanically induced by an unstable rear foot or arch and/or tight calf musculature. The most successful management of plantar fasciitis involves a comprehensive, non-invasive treatment plan. By identifying each factor influencing this disorder, doctors can educate their patients and guide them through therapies addressing these components.
What mechanical disorder predisposes plantar fasciitis?
The most common foot type associated with plantar fasciitis is a flexible flatfoot (pes planus). These feet are not actually flat, but the midfoot and rearfoot easily collapse inward, or pronate. The arch elongates, and the plantar fascia pulls excessively at its heel attachment.
How do we control a flexible flatfoot?
Given the mechanical etiology of this problem, the most natural treatment is to stabilize the foot through taping, over-the-counter arch supports, supportive shoes, and prescriptive orthotics. The degree of the deformity generally dictates the amount of support necessary.
Can patients with other foot types get plantar fasciitis?
Yes! Although less common, a patient can have a high arch (cavus foot) and also develop plantar fasciitis. This foot type is generally more rigid and much tougher to treat, although the problem is still mechanical.
The cavus foot generally lands harder and longer on the heel and lateral side, failing to propel body weight over the medial arch. This patient may also have a history of chronic lateral ankle problems. Specially designed orthotics may be helpful in shifting the weight from the lateral heel to the medial arch.
What does a tight achilles tendon have to do with a painful plantar heel?
A tight achilles tendon or calf musculature is called equinus. In this condition, the tight tendon will limit the amount of available ankle dorsiflexion. The normal amount of dorsiflexion required for walking is considered to be 10 degrees. When this range of motion approaches zero, some other joints will be forced to make up for the lack of ankle motion. The midtarsal joint in the midfoot will flex more to compensate, creating arch collapse and excessive strain on the plantar fascia, as in the case of the flexible flatfoot.
The combination of both equinus and a flexible flatfoot leads to a vicious cycle in which a tight calf causes arch collapse, and the weak collapsing foot type demands overworking of the calf, and thus more Achilles tightening. Treatment must be aimed both at controlling the flexible flatfoot and stretching the calf musculature to restore more normal ankle motion. This may require an aggressive stretching program and special splinting.
How do we resolve the inflammation?
It is very important to treat the inflammation and thickening or degeneration of the fascia itself. Once the plantar fascia is swollen, the inflammation must be addressed, or the patient may not even tolerate the stretching exercises. There are many noninvasive techniques that help reduce inflammation:
- Low dye taping — This rests the plantar fascia by reducing its pull.
- Cold therapy — Ice is a wonderful, natural anti-inflammatory.
- Massage — Soothes swollen tissue and helps release the tight fascia. May be combined with cold therapy by using a frozen water bottle.
- Topical — Various analgesic and anti-inflammatory gels and creams may be used.
- Heel lifts — Raising the heel in the shoe decreases the Achilles tightness by effectively shortening it. This can be helpful initially, while other therapy is applied.
- Ultrasound — This modality has been utilized for over 50 years and continues to be one of the most effective means to reduce inflammation, especially when used with a topical anti-inflammatory (i.e. iontophoresis)
- Physical Therapy — Techniques such as deep tissue massage and ultrasound complement the other aspects of treatment ultrasound. Core strengthening and stabilization work above the foot and ankle to address potential gait and postural disturbances that may be contributing factors.
- Acupuncture — Acupuncture can help to deactivate trigger points that contribute to the myofascial pain and stimulate the release of endorphins.
- Offloading — Allowing tissues to rest and heal by reducing direct pressure. This can be achieved with use of the AirHeel™ device, or a walking cast boot in severe cases.
What’s the best shoe for plantar fasciitis?
The best shoe for treating plantar fasciitis is a shoe with good stability from the heel to the toe. The back of the shoe encompassing the heel (heel counter) should be firm and the heel should have slight (one inch or less) elevation. The sole of the shoe should bend at the ball of the foot, not in the middle. The shoe should not twist easily from side to side.
Quality brand names alone don’t ensure that the company has followed these principles in building their shoe. It is important to check the shoe yourself before you purchase it. Women with plantar fasciitis should avoid very high heels and completely flat dress shoes.
Patient can add stability and support with a prescriptive or over-the-counter arch support, such as Superfeet ®, Sole, or Spenco ®. Shop at stores that are accustomed to fitting clients well to maintain style and comfort. In the Seattle area, consider visiting Mirage women’s shoe store, Sole Perfection (formally Shoes and Feet), and Shoe Advantage.
Getting back on your feet!
It often takes a combination of approaches and specialties to achieve a natural restoration of normal foot function and resolution of plantar fasciitis. By properly identifying and addressing key factors affecting foot pain, patients are able to get back on their feet in a matter of weeks to months, while maintaining a natural treatment approach.