Here is an example of some common medical advice on plantar fasciitis. It is a well written article read by many professionals but the advice can use some fine tuning. Can you find the mistakes after reading this site? The webmasters comments in blue are here to help.

Plantar Fasciitis is a Common Cause of Heel Pain

Plantar fasciitis, which may cause the heel to hurt, feel hot or swell, is inflammation of the plantar fascia, a thin layer of tough tissue supporting the arch of the foot. Repeated microscopic tears of the plantar fascia cause pain. Sometimes plantar fasciitis is called "heel spurs", but this is not always accurate, since bony growths on the heel may or may not be a factor.

Diagnostic testing, such as X-rays, usually is not necessary to diagnose plantar fasciitis, although it may be useful to rule out other potential causes of heel pain.Comment by webmaster: since the plantar fascia is a ligament, it does not show up on x-ray. so the first step in looking at the fascia is not an x-ray but sonography (diagnostic ultrasound). Typically with plantar fasciitis, the pain is worse when first getting out of bed, or is noticeable at the beginning of an activity and gets better as the body warms up. Prolonged standing may cause pain, as well. In more severe cases, the pain may worsen toward the end of the day.

There are a number of possible causes for plantar fasciitis and they often work in combination. Tightness of the foot and calf, improper athletic training, stress on the arch or weakness of the foot are potential causes. Shoes that don’t fit, certain play or work actions or overuse (running too fast, too far, too soon) may hurt the plantar fascia. People with low arches, flat feet or high arches are at increased risk of developing plantar fasciitis. Comment by webmaster: it is not the height of the arch that matters but the integrity of the arch. a person with any arch height can have a weak or strong arch. the weaker the arch, the harder the plantar fascia has to work to support it.

Treatments
Symptoms usually resolve more quickly when the time between the onset of symptoms and the beginning of treatment is as short as possible. If treatment is delayed, the complete resolution of symptoms may take 6-18 months or more. Treatment will typically begin by correcting training errors, which usually requires some degree of rest, the use of ice after activities, and an evaluation of the patient’s shoes and activities. For pain, nonsteroidal anti-inflammatory drugs (e.g. aspirin, ibuprofen, etc.) may be recommended.

Next, risk factors related to how the patient’s foot is formed and how it moves are corrected with a stretching and strengthening program. If there is still no improvement, night splints (which immobilize the ankle during sleep) and orthotics (customized shoe inserts) are considered. Cortisone injections are usually one of the treatments of last resort, but have a success rate of 70% or better.Comment by webmaster: Cortisone does not represent a cure but rather a means of decreasing inflammation. The final option, surgery has a 70-90% success rate. Comment by webmaster; There is very little evidence to back up the statement that surgery has a 70 to 90% success rate. The authors here fail to mention the high complication rate of surgery and fail to mention the more successful alternative to surgery; extracorporeal shock wave therapy (ESWT).

In one study, 25% of plantar fasciitis patients cited rest as the treatment that worked the best. Wearing shoes with more arch support may help decrease stress on the area. Changing shoe size may also help. Athletes and active people may have to reduce the amount running or jumping they do to relieve stress on the plantar fascia.

Using an ice pack or ice bath on the area for about 15 minutes may relieve pain and inflammation after exercise and work. Massaging the foot in the area of the arch and heel before getting out of bed may help. Stretching is also important.

As reported in one study, 83% of patients in a stretching program were successfully treated for plantar fasciitis; 29% of study participants cited stretching as the most helpful treatment, compared with nonsteroidal anti-inflammatory drugs, orthotics, ice, heat, steroid injection, heel cups, walking, night splints, plantar strapping and shoe changes.

Stretching and Strengthening
To reduce pain and help prevent future episodes of discomfort, stretch the calves on a regular basis. Stand with your hands against a wall. With one foot forward and one back, press against the wall, shifting weight over the front foot, while straightening the back leg. Keep the heel of the back foot on the floor and feel the stretch in the heel, Achilles tendon and calf. Then, switch legs. Comment by webmaster: weight bearing stretches may or may not make plantar fasciitis worse. It is easy to stretch too hard during weight bearing stretches.  They can help in a minority of cases in my experience.

A similar stretch can be done by standing on a stair step with only the toes on the stairs. The back two-thirds of the feet hang off the step. By leaning forward to balance, the heel, Achilles tendon and calf will be stretched. Comment by webmaster; one generally does better to avoid weight bearing stretches.  A similar stretch can be performed when standing where the heel is on the floor and the front part of the foot is on a wood 2x4. Some patients place a 2x4 in an area where prolonged standing is done (such as in front of the sink while washing dishes). Rolling the foot over a tennis ball or 15-ounce can may also be helpful.

Almost 35% of patients in another study cited strengthening programs as the most helpful treatment. To strengthen muscles, do towel curls and marble pick ups. Place a towel on a smooth surface, place the foot on the towel, and pull the towel toward the body by curling up the toes. Or, put a few marbles on the floor near a cup. Keep the heel on the floor and use the toes to pick up the marbles and drop them in the cup.

Another exercise is toe taps. Keep the heel on the floor and lift all of the toes off the floor. Tap only the big toe to the floor while keeping the outside four toes in the air. Next, keep the big toe in the air and tap the other four toes to the floor. Comment by webmaster: not a bad exercise but  there is no evidence that such an exercise helps resolve plantar fasciitis.

Shoes and Splints

Wearing shoes that are too small may cause plantar fasciitis. Shoes with thicker, well-cushioned midsoles may help alleviate the problem. Running shoes should be frequently replaced as they lose their shock absorption capabilities. Comment by webmaster; it is the degree of support provided by the shoe that often matters the most.

Studies have shown that taping the arch, or using over-the-counter arch supports or customized orthotics also help in some cases of plantar fasciitis.Comment by webmaster: stuidies have shown that over the counter orthotics tend to be more effective in acute plantar fasciitis, that is, patients who have had plantar fasciitis for a short period of time. Orthotics are the most expensive option as a plaster cast is made of the individual’s feet to correct specific biomechanical factors. One study found that 27% of patients cited orthotics as the most helpful treatment of plantar fasciitis. Heel cups, on the other hand were ranked the least effective treatment in a survey of 411 patients. Many studies showing custom orthotics to be the most effective modality for plantar fasciitis are ignored. Like a pair of custom eyeglasses, the effective of the orthotic is directly related to the accuracy of the prescritption. The study quoted did not used well trained professionals to procure the orthotics for the 411 patients.

Night splints, which are removable braces, allow passive stretching of the calf and plantar fascia during sleep, and minimize stress on the inflamed area. According to several studies, approximately 80% of patients improved after wearing a night splint. It may be especially useful in patients who have had symptoms for more than a year. Comment by webmaster: night splints are not simply used at random. They are used when the heel pain sufferer has a tight heel cord or a lot of pain upon arising after rest (AKA, post-static dyskinesia). The information is based on an article by the following Medical College authors that appeared in the February 1, 2001, issue of American Family Physician.

Craig C. Young, MD
Associate Professor of Orthopaedic Surgery, Medical College of Wisconsin
Medical Director, Froedtert & Medical College Sports Medicine Center

Mark W. Niedfeldt, MD
Associate Professor of Family & Community Medicine, Medical College of Wisconsin
Physician, Froedtert & Medical College Sports Medicine Center

Article Created: 2001-04-12
Article Reviewed: 2001-04-12