Fairfax Journal
April 13, 1997

What a pain in the foot!
By Dr. Robert P. Nirschl

If you've got pain at the bottom of your heel, it could be caused by plantar fasciitis, a painful degenerative condition.

The plantar fascia is a flat tendon which attaches to the heel on the bottom of the foot. The constant stretching common to running sports causes a degeneration and ultimate loss of blood supply to the tendon attachment (also known as a "heart attack of the tendon") and on occasion, a bone spur may form. It is a common characteristic to experience pain and stiffness when taking the first steps after long periods of inactivity. Symptoms include pain at the bottom of the heel with standing, walking, and running. High demand running athletes and overweight folks are at a higher risk as well as people with abnormal foot postures (high arched or flat footed). Interestingly, our research demonstrates no inflammatory cells in the injured tissue; therefore, the name fasciitis in my opinion should be changed to plantar tendinosis or fasciosis due to the nature of the condition. This point is quite important since this malady is still commonly treated by rest and anti-inflammatory medication (including cortisone injections), which have no known curative potential. It should also be noted that cortisone use should have proper indication as this drug can have a tissue-weakening effect. These cautions should also be noted with other tendon injuries such as the rotator cuff, tennis elbow, and the Achilles tendon.

Plantar tendinosis is commonly accompanied by weakness and loss of flexibility in the leg and hip muscles. Quality rehabilitation to restore strength, endurance, and flexibility must, therefore, include all areas of the leg. The biological goals of treatment include restoration of blood vessel supply (new nutrition) and the tissue production of the protein collagen ("healing glue"). The key elements of rehabilitation are strength training and stretching of all the deficient areas of the lower leg, foot, thigh, hip, and back. A night stretching splint or foot box may help the restoration of flexibility. Protective aides of the foot during the rehabilitative phase include taping, soft orthotics, or in many instances a more effective and in-expensive counter-force foot brace. Proper shoes with reasonable mid-foot flexibility are always in order. Since the cause of this specific heel pain problem is not by impact but by a repetitive stretching with overuse, heel cups are usually less effective.

For a minority of cases, rehabilitation fails and surgery may be indicated. Again, it should be noted that the abnormal tissue is not inflammatory, although many surgeons may not be aware of this recent research. This point is extremely important, however, as standard surgical techniques of total tissue release, including the new technology of endoscopic microsurgery, are based on the erroneous previous premise of presumed inflammation. Older surgical concepts which may include the endoscopic technology release the entire plantar fascia (tendon) and, on occasion, the heel spur, if present. Full surgical release increases post-operative pain and, more importantly, may unnecessarily weaken the foot support mechanism. If foot weakening occurs, the risks of injury to other areas of the foot and leg tend to increase. To avoid these potential problems, the advanced surgical concept is not plantar fascia release but very select removal of the painful tendinosis tissue which is usually located in the inside (medial) third of the plantar fascia near its attachment to the heel.

Finally, with or without surgery, the decision to return to sport is best accomplished with objective criteria. The goal is restoration of sufficient, if not normal, strength, endurance, and flexibility. This requires appropriate and adequate rehabilitation and accurate strength and flexibility measurements. Time, per se, is not relevant, but I have not observed anyone who has achieved these rehabilitation goals in less than four months.

In summation, the current research conducted in conjunction with our fellowship programs reveals that plantar fasciitis is not an inflammatory problem, but a painful degenerative plantar tendinosis. As such, anti-inflammatory medications and cortisone injections may have a temporary comforting effect but no true curative potential. Active participation in a meaningful rehabilitation program is the most effective approach although surgery may be indicated in the occasional recalcitrant situation.

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Nirschl Orthopaedic Center for Sports Medicine & Joint Reconstruction
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