Plantar fasciitis is one of the most common causes of heel pain. The plantar fascia, or plantar aponeurosis, is located on the sole and runs from the tuber calcanei on the heel bone to the ends of the metatarsal bones. It is a robust connective tissue plate directly under the skin, which is fundamentally involved in building and maintaining the longitudinal arch of the foot. It prevents the bony arch of the foot from touching the ground evenly under the weight of the body and load and is therefore exposed to the most influential forces.
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Symptoms of the plantar fasciitis
Various factors lead to irritation of the plantar fascia and eventually to inflammation of the same. Especially the attachment point on the tuber calcanei is affected by the load and the inflammation. As a result, the sole, especially the heel, is painful, which is why the inflammation is perceived by those affected.
Causes of the plantar fasciitis
The plantar fasciitis usually has a simple explanation, namely chronic overloading. This overstraining of the tendon can, in turn, be caused in various ways.
Especially sports where there is much pressure on the plantar fascia or the foot is bent or stretched to a high degree are affected. Cycling, running, or ballet plays a significant role here.
However, occupational stress due to prolonged standing or a similar stress pattern also exerts a high pull on the plantar fascia. The resulting forces, which are both very high and repetitive, are distributed over the relatively small plantar tendon and the particular points of attachment to the bone. It is important to remember that the heel, and precisely the point where the plantar fascia is attached, must bear most of the weight of the body.
With regular overloading, the tissue of the plantar fascia cannot regenerate sufficiently and to allow injuries, such as small tears that can occur during loading, to heal. This irritates the tendon and leads to the development of inflammation.
Irritation can also be caused by incorrect footwear, which does not sufficiently support the longitudinal arch of the foot or causes pressure points on the sole and thus puts additional strain on the plantar fascia. Sometimes the heel spur, a bony projection on the heel bone, is erroneously counted among the causes of the plantar fasciitis. However, this is caused by an inflammation and can aggravate the symptoms or bring them to light, but it does not trigger the inflammation.
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Diagnostics of the plantar fasciitis
The plantar fasciitis can be identified diagnostically by a detailed anamnesis and clinical examination alone. Affected persons usually report pain that has developed gradually and is located below the heel. This also means that the heel is no longer able to bear weight as it was initially, as it can cause very severe pain with each step. As a result, the affected persons cannot do sports and, depending on their profession, are no longer able to do them and report this.
During the clinical examination with suspicion of an plantar fasciitis, no changes can be seen on the sole and the heel, purely externally. However, when the tendon at the heel is palpated, especially at the central point of the front edge of the tuber calcanei, an increased sensitivity to pressure pain can be detected. In some cases, a very slight thickening of the plantar fascia can also be felt, which can be caused by an oedematous swelling in the context of the inflammation.
Besides, inflammation can be verified by a simple test. Here, the big toe should be actively pulled upwards. This puts tension on the plantar tendon and the point where the tendon attaches to the heel under increased tension, which either triggers the pain in the heel or makes it easier to provoke the pain of pressure.
In most cases, an X-ray of the foot is taken to clarify an plantar fasciitis. Although relatively little can be said about the nature of the soft tissue, one can look at the heel and especially the tuber calcanei to see indications of a pathological change at the transition to the plantar tendon. Sometimes a heel spur is found that has developed in the course of the inflammation and is seen more as an accompanying reaction than as the cause of overloading and inflammation. The presence of a heel spur does not cause discomfort for some, but for others, it intensifies the symptoms of plantar fasciitis.
Alternatively, a bone scintigraphy can also be performed, but this is not part of routine diagnostics. An accumulation in the area of the suspected inflammation supports the suspicion.
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Therapy of the plantar fasciitis
In most cases of plantar fasciitis, conservative therapy is the primary goal. On the one hand, this includes insoles for shoes, which have a recess at the site of the heel spur or the area of origin of the plantar tendon, so that when the foot is loaded, the load that arises at this point is no longer as pronounced as before and this area can recover better.
On the other hand, ointments are often applied locally, which have an anti-inflammatory and pain-relieving effect. This can be applied to the inflamed area as required. Besides, depending on the intensity of the pain and the inflammation, an appropriate medication can be given together with a stomach protection prophylaxis to avoid pain peaks in the daily routine and a relieving posture.
In addition to this, physical therapy in the form of ultrasound treatment is also possible. The aim is to promote the healing of the inflammation through specific metabolic processes using the heat and vibrations in specific frequencies that are generated in the tissue. This treatment can take place in a physiotherapeutic practice.
Also, targeted stretching exercises of the plantar tendon and a night splint are intended to increase the durability, strengthen the tissue and counteract inflammation caused by excessive strain.
If conservative therapy does not work, a surgical intervention can be considered. However, this is used extremely rarely, as it is not always sensible, and there is sometimes no real improvement.
If surgery is nevertheless indicated, e.g., if the therapy is not successful for more than six months, the following can be done: The connection between the plantar fascia and the tuber calcanei can be dissolved, but a loss of stability must be expected.
Furthermore, the heel spur can be reduced. However, it usually is not removed, as it would not bring any improvement, and it could possibly damage the plantar tendon unnecessarily.
The operation can be performed either open or endoscopically and requires follow-up treatment.
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Various measures can be taken to prevent plantar fasciitis. First of all, it is beneficial to avoid activities that put a lot of stress and tension on the plantar fascia or at least not to do them too often. If this were the case, then “warm-up” the plantar fascia and stretch it. There is nothing to be said against sports activities in general, which are carried out regularly and correctly, as it improves the general well-being. Only the overloading, in particular, should be reduced.
An orthopedic surgeon or physiotherapist can explain and give you tips on how to do this best, or you can simply try what is right for you and what is not. Furthermore, insoles can help to minimize the load on the plantar tendon and prevent inflammation.
Even if an plantar fasciitis may seem harmless at first glance, it can still cause a high level of suffering in those affected. The reason for this is that the pain in the heel often lasts for a very long time, and improvement usually comes very late or, in rare cases, does not even occur. Therefore, every step and every strain on the foot is felt as unpleasant. The treatment of the inflammation and the pain is, therefore, complicated and not yet wholly satisfactory. Nevertheless, there is hope that the therapy mentioned above options will help to get the pain and inflammation under control.
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