Fasciitis Plantaris

Cause of fasciitis plantaris

Plantar fasciitis or heelspur is a multifactorial overburdening of the tendon insertion with the heel. When the foot is loaded, the plantar fascia (tendon bone) must bear the full weight of the body. This will stretch the tendon blade and may cause small inflammations, from which the body can recover. When the load is too much, the body cannot repair the inflammations and the tendon blade becomes painful. There are several risk factors for developing plantar fasciitis. These risk factors are obesity, limited mobility of the ankle, excessive foot pronation (foot tilting outwards), prolonged walking, hollow foot and prolonged standing (Goff and Crawford, 2011).

Evolution of the clinical picture

The symptoms are reasonably tolerable and people usually continue their activities until the pain becomes unbearable. There is a sharp pain after inactivity and an increasing pain during long periods of strain. When the rehabilitation process is started, the sensitivity and inflammation of the tendon blade will decrease as the load is reduced and better distributed to other structures of the body.

Symptoms

Most patients experience pain in the morning when they get out of bed or after sitting still for a long time (Goff and Crawford, 2011; Cutts et al., 2012). While sleeping, the foot will be in a resting position with the tendon blade contracting and shortening slightly. Getting out of bed will put strain on the contracted tendon blade and lead to the pain (Cutts et al., 2012). The pain will improve after a short period of walking, but the pain will worsen again with a longer period of weight bearing activities such as standing, walking or running (Lim et al., 2016, Thompson et al., 2014). Walking barefoot, in flip-flops, on toes or on stairs will worsen the pain (Cole et al., 2005).

Articular

The origin and the attachment of the tendon blade can be irritated. It is also possible that the mobility of the bones of the foot is limited, which causes the tendon blade to be overloaded.

Neurologic

There are no neurological symptoms.

Muscular

The muscles in the vicinity of the tendon blade can be overstrained or shortened and/or hypersensitive. We are thinking mainly of the foot and calf muscles.

Other symptoms

Not applicable

Role of physical therapy and your physiotherapist

Physiotherapy plays an important role in relieving the foot arch by acting on the function and tension of the surrounding muscles, the movement pattern and the mobility of the joints in the foot and ankle.

Physiotherapeutic examination

The physiotherapist will first conduct an interview with the patient in order to outline his/her complaints. On the basis of this information, the physiotherapist will carry out a clinical examination. This will include an inspection of the feet and the lower limbs during stance and movement. Possible anatomical abnormalities are also examined, as this is also a risk factor for heel spur. In addition, the physiotherapist will also examine the foot and sole and ankle in detail. A neurological examination is carried out to exclude other disorders (e.g. tarsal tunnel syndrome, also known as entrapment of a foot nerve). Medical imaging is not helpful for the diagnosis of plantar fasciitis, but can be used when another condition is suspected (Cole et al., 2005).

Physiotherapeutic treatment

Treatment is conservative (without surgery) with 90-95% of patients being symptom-free within 12 to 18 months (Lim et al., 2016).

Manual therapy

Deep tissue massage of the tendon blade can be performed by the physiotherapist. The physiotherapist can also stretch the plantar fascia.

Pain control

An important part of treatment is activity modification. Activities with repetitive impact such as prolonged walking and running should be avoided (Cutts et al., 2012; Lim et al., 2016). Activities that do not require weight bearing such as cycling or swimming may be maintained. A gradual build-up of walking is possible when the patient is asymptomatic for 4 to 6 weeks and no longer experiences sensitivity (Lim et al., 2016). An (ice) massage in which the arch of the foot is slightly mobilised may help to reduce pain (Goff and Crawford, 2011; Lim et al., 2016). The patient can do this by rolling his/her foot over a cold bottle of water or a tennis ball. For persistent pain, night splints can help to maintain the length of the foot arch during the night (movement of the foot upwards), which can reduce the pain (Cole et al., 2005; Lim et al., 2016).

Exercise therapy

Stretching of the tendon blade, intrinsic foot muscles (local muscles in the foot that are important for stability) and calf muscles will improve the symptoms in most cases. The patient can roll a tennis ball over the painful areas of the sole of the foot to stretch the tendon. Functional strengthening of the intrinsic foot muscles and calf muscles is important for the stability of the foot and to relieve the tendon blade.

Rehabilitation pathway

Within each rehabilitation, we always distinguish between short-term and long-term goals. Depending on the type of pathology, this will differ.

Short term

In the first phase, the main objective is to reduce the irritability of the tendon blade, which will reduce the sharp pain after long periods of inactivity. Irritation under load will also be less intense. In addition, the tendon blade will be relieved by ensuring that it stretches less when loaded. Adjustment of the walking pattern plays a crucial role here.

Long term

By adjusting the pattern of movement, the mobility of the joints, any excess weight and the functioning of the muscles, the aim is to reduce the strain on the tendon. This prevents relapse and allows the patient to independently avoid the symptoms.

Multidisciplinary approach

If necessary, a podiatrist can help determine whether orthotics are needed. Orthoses can reduce the pressure on the plantar fascia during weight-bearing activities (e.g. walking or running) (Lim et al., 2016). It is important that a multifactorial approach is also taken for this multifactorial condition. Single bets on soles are therefore not recommended.