Brief overview
- Symptoms: Heel pain (worsening in the course), morning start-up pain, gait disturbances.
- Treatment: Conservative treatment with relief, cooling, painkillers, for a short time also cortisone, stretching exercises, shoe inserts, splints, tape bandages, physiotherapy with massage, extracorporeal shock wave therapy (ESWT), x-ray inflammation irradiation, surgical treatment with open incision.
- Prognosis: After conservative treatment or surgery, the prognosis is usually good. Recovery is possible within six months, sometimes takes one to two years.
- Diagnosis: Physical examination with medical history, X-ray and ultrasound examination, magnetic resonance imaging (MRI).
- Causes: Overuse and irritation of the plantar tendon (common during sports or with a shortened Achilles tendon), injury.
- Prevention: Appropriate and stabilizing footwear, orthopedic insoles, warm-up and stretching exercises before sports, stretching exercises after sports
What is plantar fasciitis?
The plantar fascia originates at the lower and front edge of the calcaneus, the so-called calcaneal tuberosity (tuber calcanei). It connects the tarsus to the metatarsals and metatarsophalangeal joints. All together, it forms the longitudinal arch of the foot.
When the foot rolls, the plantar fascia is put under tension by the so-called windlass effect, which ensures the transmission of force from the forefoot to the hindfoot. The purpose of the fascia is to tension the longitudinal arch, align the hindfoot and forefoot, absorb shock, and passively elevate the arch of the foot.
The term plantar fasciitis borrows from the Anglo-American term “plantar fasciitis”. In terms of the disease (pathology) and anatomy, however, the symptoms correspond to “heel pain syndrome”, whereas “plantar fasciitis” refers to a clinical picture that occurs over the second cuneiform bone and metatarsal.
What are the symptoms of plantar fasciitis?
The onset of plantar fasciitis is gradual. Over time, the symptoms gradually worsen, usually over weeks or months. The symptoms, which mainly include heel pain (calcaneodynia), initially occur only with exertion, later also in the morning when getting up and at rest. Affected persons usually report burning or pulling pain under the foot or in the heel area. They sometimes lead to an inability to walk.
One sign of plantar fasciitis is heel pain immediately after standing up (start-up pain), which disappears after a short period of walking. During sports, sufferers also initially experience painful episodes at the beginning of exertion, which diminish as they warm up. Towards the end of exercise, the symptoms return. Sprinting and jumping in particular intensify the pain.
How is plantar fasciitis treated?
Conservative treatment
In order to reduce the inflammation and pain of plantar fasciitis, the treatment consists first of all of relieving or adjusting the sporting movements. In this process, the doctor analyzes the training methods and circumstances, for example, mountain runs, running surfaces of sand or scree, sudden increase in training, and suggests a change if necessary.
Stretching exercises: For the calf and plantar muscles, stretching exercises are an essential part of conservative treatment for plantar fasciitis. In one study, 72 percent of patients improved symptoms with stretching exercises alone.
For example, one stretching exercise involves rolling the foot over a bottle filled with ice. Passively flexing the foot with a towel wrapped around the forefoot and pulled toward the head is also a good stretching exercise. Doctors and therapists recommend repeating the stretching exercises about three times a day for at least ten minutes.
Tape bandages: Tapes and bandages can be used to stabilize the foot and arch. Both dampen the pressure on the tendon when walking, thus reducing stress and heel pain.
Physical therapy: special massages such as transverse friction massages at the base of the tendon are uncomfortable at first, but help relieve pain. Also part of the therapy is targeted foot muscle training.
Weight reduction: Overweight people are more prone to plantar fasciitis, as they put more strain on the plantar tendon. If there is inflammation and also greater overweight, weight reduction is often part of the therapy.
Medications: Medications that are suitable are non-steroidal anti-inflammatory drugs(NSAIDs). Injection therapy with cortisone is another option, with up to 70 percent of the pain disappearing. However, repeated injections may reduce the metabolism of the tendon tissue to such an extent that the risk of rupture increases.
X-ray inflammatory irradiation: Doctors also use X-ray inflammatory irradiation for plantar fasciitis that has been treated conservatively without success. About two-thirds of patients treated with this method become pain-free. The disadvantage, however, is the radiation exposure.
Surgical treatment by incision
In rare cases where there has been no improvement after six months despite conservative measures, doctors consider surgery. This is usually reserved for cases that do not respond to conservative treatment attempts – about five percent of all sufferers with plantar fasciitis undergo surgery.
Open notching is the standard procedure for surgical treatment of plantar fasciitis. In this procedure, a short, oblique incision is made in the skin over the point on the sole of the foot where the pressure pain is most severe to notch the plantar fascia at its origin. This immediately reduces the tension in the tendon. It also helps to avoid painful scarring. If a heel spur is present, it can also be ablated at its base.
After the sixth postoperative week, it is possible to slowly increase the running load, although initially only light endurance training is recommended. Before the tenth to twelfth week after surgery, jumping loads are still strongly discouraged. The entire healing process takes at least twelve weeks, in individual cases even up to one year.
Endoscopic treatment is also possible. The healing period is then usually shorter.
Complications of the operation
As a complication, for example, pain remains after surgery or migrates to the midfoot. This happens when the entire plantar fascia has been cut because the tension of the longitudinal arch has changed. As with any surgery, general surgical risks such as superficial or deep infections, painful scars or deep vein thrombosis cannot be ruled out.
Other treatment options
The same applies to alternative medicines with castor oil or capsaicin. Castor oil stimulates the formation of collagen in particular and is thus said to strengthen the structure of tendons, among other things. It also has an anti-inflammatory effect. Capsaicin is widely used as a painkiller in the form of plasters and ointments, especially in sports.
Cold also acts to a certain extent against pain and reduces the burning sensation in the sole of the foot. Doctors therefore advise cooling the foot in the event of acute heel pain. Cooling pads (cool packs) or quark compresses are suitable for this purpose.
Heat is an equally helpful remedy for heel pain. Like cold, it stimulates blood circulation and thus the body’s self-healing powers. But it also provides relaxation and loosens hardened tissue. Massages with heated, skin-friendly oils are therefore well suited as a supportive measure in the therapy of plantar fasciitis and can be performed at home.
Home remedies and homeopathy have their limits. If the symptoms persist for a long time, do not get better or even get worse, you should always consult a doctor.
What are the chances of healing plantar fasciitis?
For the majority of patients with plantar fasciitis, conservative treatment methods are successful and a cure is possible in 80 to 90 percent of cases. However, the course of the disease or healing process is often protracted and takes one to two years. Doctors advise athletes to severely limit their exertion during this time. After surgical treatment, about nine out of ten patients, including athletes, report an 80 percent improvement in their symptoms.
How is plantar fasciitis diagnosed?
If plantar fasciitis is suspected, family doctors or orthopedic specialists are the first people to contact. Plantar fasciitis has a characteristic medical history (anamnesis), which means that the diagnosis can be made quickly. Typical questions the physician may ask during the history interview are:
- Have you had an acute injury to your foot?
- Does it hurt under the heel with weight bearing?
- When does the pain occur? With which movements?
- Where does the pain radiate to?
On examination, the affected individual usually reports localized tenderness under the heel at the base of the fascia. In the case of a rupture, there would be a bruise on the sole of the foot with pressure pain.
If the discomfort occurs acutely, it is probably a strain or, in rare cases, a (an)rupture of the plantar tendon. The affected person states that further strain and running were no longer possible due to the pain. On the other hand, the complaints worsened. Sometimes a swelling or hematoma indicates other injuries such as fractures, muscle injuries or a tear.
Imaging diagnostics
For a more detailed diagnosis of plantar fasciitis, doctors consult ultrasound and magnetic resonance imaging (MRI) in addition to X-rays.
X-ray
Lateral x-rays show a heel spur in about 50 percent of those with plantar fasciitis. However, this is not diagnostic and occurs in about 25 percent of the population. To rule out hindfoot malalignment, doctors take x-rays of the foot in three planes.
Ultrasound
Magnetic resonance imaging
With the help of magnetic resonance imaging (MRI), the doctor makes precise cross-sectional images of the foot. For a better assessment, the doctor usually uses a contrast medium, which he injects into the blood via the vein. With the MRI, the exact location and extent of the inflammation can be determined. The use of MRI is particularly useful before surgery, also to avoid overlooking possible fractures, partial fractures, tendon abnormalities and bone contusions.
What causes plantar fasciitis?
Plantar fasciitis is essentially caused by overuse of the plantar fascia. This often occurs in connection with sports, especially running or jumping. Plantar fasciitis is particularly common in the fourth and fifth decades of life, which is probably related to age-related wear and tear. About ten percent of all athletes in running disciplines are affected by plantar fasciitis. Other high-risk sports include basketball, tennis, soccer and dancing. There is no correlation between training duration and the frequency of complaints.
Furthermore, injuries are sometimes the cause of plantar fasciitis. Even the smallest changes sometimes cause injuries to the collagen fibers and thus lead to chronic inflammation. Patients report, for example, that they have caught their heel on the edge of the road while crossing it.
Can plantar fasciitis be prevented?
Since plantar fasciitis is usually caused by overloading of rather untrained muscles and the corresponding tendon, doctors advise athletes in particular to always warm up the muscles well before doing sports. Stretched muscles and tendons are less prone to inflammation or tearing. Preventive stretching exercises help both before and after sports. This also applies to activities in which people do a lot of running or jumping – whether for work or leisure.
The right shoes are also important. Wearing shoes with good support and cushioning can prevent inflammation of the plantar tendon.
