The clinical condition known as plantar fasciitis is
characterized by pain and inflammation secondary to strain on the
intrinsic musculature and plantar fascia at their origin from the
medial calcaneal tubercle. The classic physical examination
finding is point tenderness at the anterior edge of the fascial
attachment to the medial calcaneal tubercle. This usually
coincides with a history of pain upon rising in the morning, pain
after periods of non-weight bearing or pain after prolonged
weight bearing. Several potential etiologies of heel pain exist
which are beyond the scope of this paper. The primary etiology of
heel pain relevant to this paper are biomechanical abnormalities
of the foot which lead to increased strain on the tissues that
originate from the medial calcaneal tubercle.
The plantar fascia, or aponeurosis, is composed of central,
lateral, and medial bands that originate along the medial
tubercle of the calcaneus. The plantar fascia courses anteriorly
along the arch of the foot, where the fascia divides into slips
which eventually insert into the sides of the proximal phalanx in
each toe. At toe-off, hyperextension of the metatarsophalangeal
joints results in tightening of the plantar fascia and assists
with resupination of the foot. The plantar fascia functions
through the windlass mechanism to depress the metatarsal heads
and elevate and stabilize the longitudinal arch of the foot
during gait. Therefore, with every step from heel rise to toe-off
the plantar fascia is placed under tension.1 In some patients,
the tension within in this structure can become debilitating.
Multiple treatments have been recommended with various degrees
of success for plantar fasciitis. Conservative modalities used to
treat plantar fasciitis have included heel pads, orthotics,
padding, strapping, stretching, physical therapy, non-weight
bearing, NSAID's, corticosteroid injections, etc. The majority of
patients will improve or be fully relieved by nonsurgical
treatment. However, even with appropriate treatment, plantar
fasciitis may become chronic and recalcitrant in nature
eventually leading to surgery. There is no definitive surgical
treatment of recalcitrant plantar fasciitis that is without
complications. Therefore, a continued search for an effective
conservative modality useful in the treatment of plantar
fasciitis exists. In today's healthcare environment there is a
tendency towards active mobilization and rehabilitation. A review
of recent literature has shown an increase use of aggressive
stretching of the gastrosoleal complex for the treatment of
plantar fasciitis.
Articles documenting the outcomes of nonoperative treatment of
plantar fasciitis have for the most part shown excellent
results.2-4 However, there is no panacea in the treatment of
plantar fasciitis.
One of the easiest and cost effective conservative modalities
in the treatment of this condition is stretching. It is well
accepted that an important contributing factor of plantar
fasciitis is equinus.5, 6 Tightness within the Achilles tendon
and gastrosoleal complex results in compensatory increased
dorsiflexion of the first metatarsophalangeal joint during gait.
Dorsiflexion of the first metatarsophalangeal joint via the
windlass effect stretches the plantar fascia at its insertion. If
the foot fails to resupinate at toe-off, increased strain is
placed on the plantar fascia due to the windlass effect. Equinus
has also been linked to an increased amount of pronation of the
foot which causes prolonged eversion of the calcaneus during gait
resulting in pathologic stretching of the plantar fascia.
Therefore, it would only make sense that decreasing the tightness
within the triceps surae would eventually have a positive effect
on the plantar heel pain.
Davis et al in a review of 105 patients with 132 symptomatic
heels noted an 89.5% success rate of nonoperative treatment for
plantar fasciitis. Their treatment protocol consisted of
nonsteroidal anti-inflammatory medications, relative rest,
viscoelastic heel cushions, calf muscle stretching exercises and
occasionally, injections. The patients reviewed in this study
indicated that the stretching program was the most helpful
treatment prescribed.2
A prospective randomized trail of several nonoperative
treatments of proximal plantar fasciitis revealed a 72% success
rate in those patients who underwent stretching exercises
only(control group).3 The stretching program utilized in this
study effectively targeted both the gastrocnemius and the soleus
muscles. Although the percent improvement of some of the other
groups with additional foot support was higher, the degree of
improvement with stretching alone is impressive. Other authors
have also advocated stretching. 4,7-13
Several recent reports have shown excellent success with the use
of tension night splints in the treatment of plantar
fasciitis.8-13 Overall the success of night splints in the
treatment of plantar fasciitis has ranged from approximately 80%
to 90%.8-13 Night splints maintain a constant, consistent stretch
on the Achilles tendon and plantar fascia. When you think about
it, both night splints and stretching are attempting to
accomplish the same net result utilizing different means.
Stretching of tight soft tissues can be supported by the
physical property of creep. Creep is plastic deformation in
response to strain. Consistent stretching of the gastrosoleal
complex applies an important strain to the tight posterior
muscle/tendon group, which not only maintains functional length
but also eventually provides a net gain in length due to soft
tissue remodeling laws.14
These soft tissue adaptation laws are the reason that
stretching is beneficial. Stretching the triceps surae over a
period of time results in a decreased tightness within the
gastrosoleal complex. This avoids the many deleterious effects of
equinus during the gait cycle. In a large percentage of cases,
pronation secondary to the equinus is at the root of chronic heel
pain. With equinus, the foot attempts to compensate for the lack
of ankle joint dorsiflexion just before heel lift, by subtalar
and midtarsal joint pronation. During pronatory gait, every step
leads to a unstable forefoot because of unlocking of the
midtarsal joint.5 In an effort to compensate for this
instability, greater intrinsic muscle activity is required to
stabilize the foot, resulting in excessive stress on the
intrinsic muscular origins from the calcaneus inferiorly and
particularly the medial tubercle of the calcaneus, leading to
inflammation.15 Pronation also results in abnormal and prolonged
eversion of the calcaneus leading to flattening of the medial
longitudinal arch which increases the strain within the plantar
fascia.6 Continued strain and increased stress to the plantar
fascia and intrinsic musculature leads to the enthesopathy. This
is sometimes radiographically evidenced as an inferior calcaneal
spur of various sizes. When the local subclinical irritation
secondary to faulty biomechanics exceeds a certain point then
inflammation and pain begin.
Many patients will try almost any conservative regimen in an
effort to avoid surgery. The authors utilize an aggressive
stretching program in the treatment of plantar fasciitis. A few
positional modifications during stretching have added to our
patients success. It is very important to avoid pronation during
calf stretching because of the resultant compensatory mechanism
of an unlocked midtarsal joint that destabilizes the foot
decreasing the effectiveness of the stretch and possibly
increasing the strain on the plantar fascia. Therefore, the
authors have instructed their patients to stretch their calf
muscles with a traditional wall stretch holding the foot in a
slightly supinated position. Recently, a patented prefabricated
device available on the market helps accomplish this position
during stretching by utilizing the windlass mechanism (FootFlex
Performance Stretching Device). This device dorsiflexes the
hallux which places the plantar fascia under tension elevating
the arch of the foot into a more supinated position. Stretching
with foot in proper biomechanical alignment allows a more
effective stretch of the gastrosoleal complex and at the same
time also is gradually stretching the plantar fascia. This
effectively stretches both the triceps surae and the plantar
fascia at the same time. There is no study, to our knowledge,
documenting the effectiveness of this modification of traditional
stretching exercises. Success noted at this time is purely
anecdotal. However, stretching has been shown to be helpful in
reducing the symptomatology of plantar fasciitis, and, the
authors believe an even higher percentage of success could be
achieved with proper foot positioning during stretching. A
prospective outcome study comparing the two different stretching
modalities would help determine the efficacy of this type of
stretching in the treatment of plantar fasciitis.
Recent literature has shown stretching to be an effective
adjunctive therapy in the treatment of plantar fasciitis. A
review of the literature and theories behind stretching are
presented. A stretching program of the gastrocnemius and soleus
should be considered a cornerstone of any effective treatment
plan.
1. Hicks JH. The mechanics of the foot: the plantar
aponeurosis and the arch. J Anat 88:
25-31, 1954.
2. Davis PF, Severud E, Baxter DE. Painful heel syndrome: results
of non-operative treatment. Foot Ankle 15: 531-535, 1994.
3. Pfeffer G, Bacchetti P, Deland J, Lewis A, Anderson R, Davios
W, Alvarez R, Brodsky J, Cooper P, Frey C, Herrick R, Myerson M,
Sammarco J, Janecki C, Ross S, Bowman M, Smith R. Comparison of
custom and prefabricated orthoses in the initial treatment of
proximal plantar fasciitis. Foot Ankle 20: 214-221, 1999.
4. Wolgin M, Cook C, Graham C, Mauldin D. Conservative treatment
of plantar heel pain: long-term follow-up. Foot Ankle 15: 97-102,
1994.
5. Root ML, Orien WP, Weed JH. Normal and Abnormal Function of
the Foot: Clinical Biomechanics, Vol. #2, Los Angeles, Clinical
Biomechanics Corp, 1977, p 174.
6. Valmassay RL. Clinical Biomechanics of the Lower Extremities,
St. Louis, Mosby Year-Book Inc., 1996, p 23,76.
7. Schepsis AA, Leach RE, Gorzyca J. Plantar fasciitis: etiology,
treatment, surgical, and review of the literature. Clin Orthop
266: 185, 1991.
8. Wapner KL, Sharkey PF. The use of night splints for treatment
of recalcitrant plantar fasciitis. Foot Ankle 12: 135-137, 1991.
9. Pezzullo DJ. Using night splints in the treatment of plantar
fasciitis in the athlete. J Sports Rehab 2: 287-297, 1993.
10. Ryan J. Use of posterior night splints in the treatment of
plantar fasciitis. Am Fam Phys Vol.52, #3: 891-898, 1995.
11. Batt BE, Tanji JL, Skattum N. Plantar Fasciitis: A
prospective randomized clinical trail of the tension night
splint. Clin J Sports Med 6: 158-162, 1996.
12. Powell M, Post WR, Kenner J, Wearden S. Effective treatment
of chronic plantar
fasciitis with dorsiflexion night splints: a crossover
prospective randomized
outcome study. Foot Ankle 19(1): 10-18, 1998.
13. Jimenez AL, Goecker RM. Night splints: Conservative
management of plantar
fasciitis. Biomechanics 4(9), 29 - 33, 1997.
14. Frank C, Ameil D, Woo SL-Y, Akeson W. Normal ligament
properties and ligament healing. Clin Orthop 196: 15-25, 1985.
15. Forman WM, Green MA. The role of intrinsic musculature in the
formation of inferior calcaneal exostosis. Clinics in Podiatric
Medicine and Surgery Vol. 7, #2: 217-223, 1990.