The Science

Plantar fasciitis, frequently referred to as heel spurs, is a common musculoskeletal disorder affecting two-million Americans each year and 10-16% of the populations over the course of a lifetime (Riddle et al., 2003).  This disorder affects 25% of athletes (Clement et al., 1981) and is responsible for up to 15% of all foot complaints requiring medical attention (League, 2003) and 1% of all visits to orthopedists.

Plantar fasciitis is inflammation of the plantar fascia, the band of tissue that runs from the anteromedial calcaneus to the proximal phalanges of the toes. It is thought to result from repetitive microtrauma and excessive strain. The hallmark symptoms are pain along the medial aspect of the calcaneus, pain that is worse with the first few steps in the morning, pain that lessens with activity, but worsens toward the end of the day. Risk factors include running, occupations that involve standing on hard surfaces, pes planus, obesity, and the most important-limited ankle dorsiflexion or an equinus contracture (Riddle et al).

Patel and DiGiovanni (2011) performed a prospective evaluation of 254 patients with both chronic and acute plantar fasciitis and found that 83% had limited ankle dorsiflexion.  Of the 99 patients with chronic plantar fasciitis, 82% had equinus contracture and 52% had isolated gastrocnemius contracture.  The link between equinus contracture and the development of plantar fasciitis may not be as simple as a cause-and-effect relationship, but the pathomechanics and etiology of its development seem to stem, at least in part, from this tightness in these posterior compartment muscles.

Ninety percent of patients can be managed with non-operative treatment. One of the cornerstones of treatment is stretching the posterior lower leg compartment which includes the gastrocnemius, soleus and Achilles tendon to improve ankle dorsiflexion.  Other common treatments include Nonsteroidal Anti-inflammatory Drugs (NSAIDs), manual massage techniques, orthoses or inserts to off-load the plantar fascia, and corticosteroid injections.

Self or formal physical therapy centers around a stretching program for the gastrocnemius, Achilles, and plantar fascia-the muscles that control ankle dorsiflexion and plantarflexion. The goal of these stretches is to maximize the length of both the gastrocnemius and soleus muscle groups in a controlled manner.  Stretches are ideally done immediately after getting out of bed in the morning, in the afternoon, and before bedtime, or after a period of prolonged sitting or standing.

Nonsurgical treatment of plantar fasciitis has a success rate of 85-90%. Patients need to understand that it may take up to 12 months for pain to improve. This often causes frustration for patients and physicians alike.

A simplified approach needs to be developed to treat and control plantar fasciitis especially prior to embarking on surgery.