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Insertional vs Proximal Plantar Fasciitis

Posted by Glen C. on 10/17/03 at 12:33 (134336)

What are the different types of Plantar Fasciitis? I've seen the adjectives 'insertional' and 'proximal' used in front of the term Plantar Fasciitis. Are these different diagnoses and, if so, what are the symptoms and treatments for each type? Are there other types in addition to these two?

Re: Insertional vs Proximal Plantar Fasciitis

Steve G on 10/17/03 at 13:37 (134349)

Glen - 'Insertional' (and proximal) just means that the pain is located at the point where the fascia inserts into the heel. 'Distal' means discomfort that occurs at other places in the fascia (arch, metatarsals). I don't this there is a different in treatments betweem distal and insertional - both emphasize stretching, icing, orthodics, etc. Only insertional is treated with ESWT, however.

Re: Insertional vs Proximal Plantar Fasciitis

Glen C on 10/17/03 at 17:21 (134422)

Thank Steve. Is it possible to have both? My pain initially was in the heel, but now (12 months later) seems to be worse in the mid-arch. I'm wondering if my first ESWT healed the proximal PF, but I'm left with the distal PF???

Re: Insertional vs Proximal Plantar Fasciitis

SteveG on 10/17/03 at 17:48 (134427)

Glen - Yes, it's possible to have both (I have both), and like you my heels were improved by ESWT; however, I still have discomfort in the rest of the fascia. Several of us have had our heel pain improved with ESWT and still have had distal problems. I was told that stretching will help take some of the strain of the rest of the fascia, so make sure you are working on your stretching. Do you wear a nightsplint?

Re: Insertional vs Proximal Plantar Fasciitis

Ed Davis, DPM on 10/17/03 at 22:01 (134481)

Glen and Steve:
Glen brings up an interesting scenario. Keep in mind that the FDA has only approved ESWT for 'insertional' PF so using the machine on other parts of the plantar fascia is off label. It is common that the insertional symptoms are the worse so that when they resolve, more distal PF becomes more noticeable. The plantar fascia thins as it goes distally so if we treat it, 'off label,' I would opt for low energy ESWT.
Ed

Re: Insertional vs Proximal Plantar Fasciitis

Dr. Z on 10/17/03 at 22:41 (134490)

Why would we even treat distal plantar fascia. I find it is very rare and usually caused by other conditions such as neuroma, plantar bursitis, equinus, plantarflexed met heads etc.
Most 'distal pf ' is from other causes and can be resolved with conservative treatment. I hope that your distal pf definition is what I am talking about

Re: Insertional vs Proximal Plantar Fasciitis

Glen C on 10/18/03 at 07:41 (134512)

I have worn a night splint, but did not for several weeks after the ESWT.

Re: Insertional vs Proximal Plantar Fasciitis

Glen C on 10/18/03 at 08:07 (134515)

Some of this is coming together for me now. Following my ESWT treatment, I was not given any guidance on follow-up conservative treatments. I didn't stretch, use the night splint, or wear orthotics. My approach was to let the injury 'heal' with relative rest.

About 10 weeks post-ESWT, I vacationed for a week at DisneyWorld. I was worried that the massive amount of walking on concrete would prompt a return of my pain. As a precaution, I bought a pair of Teva sandals with a prominent arch support. Amazingly, my PF pain was almost non-existent while walking in the parks. The only twinges I felt were at night after returning to sit in the hotel room. Later, after returning to my office job and less walking (and less stretching), my symptoms gradually returned.

Now I'm experiencing symptoms of what I consider now to be (based on this discussion) BOTH insertional AND distal PF. My orthopaedist has offered to do another Ossatron treatment at a reduced rate (no machine charge of $800, only the surgery and anesthesia charges that end up costing me ~ $200.

I'm suspecting that while distal and insertional PF are different, they're related in that the presence of one of these injuries can contribute to the other. Would going for the 2nd ESWT, to be followed soon after (1-2 days) with the use of orthotics, night splint and stretching, be reasonable?

Re: Insertional vs Proximal Plantar Fasciitis

Ed Davis, DPM on 10/18/03 at 12:01 (134557)

Glen:
There are some diagrams on this site but if you go to the library, take a look at an anatomy book and observe the shape and direction of the plantar fascia carefully. Keep in mind that it is a continuous band of tissue so if there is too much tension on the fascia, that tension exists across the entire fascia, proximal and distal (like two ends of a rope).

That being said, the two ends of the rope/fascia are not exactly being pulled on simultaneously. The back end of the rope (near the heal) is being tensioned after the heel hits the ground and the arch is flattening. As the leg moves forward over the foot and one mounts the ball of the foot, before pushing off (propulsion) the big toe joint must be pulled down, that is, stabilized against the ground. The big toe joint is most important for push off and the smaller toe joints playing a bigger role in balance and helping to shift weight (load) the big toe joint just before you push off. If the big toe joint allows you to push off without being adequately pushed against the ground, retrograde (backward) force from the ground pushes it up too much and that over-tensionss the distal portion of the fascia. Here is the big deficit with many orthotics -- well designed in the rearfoot (for the back of the fascia) but less well designed in the forefoot (midtarsal) joint-- in other words, not doing enough to bring the big toe joint down as far as possible before one pushes off.
Ed

Re: Insertional vs Proximal Plantar Fasciitis

Ed Davis, DPM on 10/18/03 at 12:10 (134561)

Dr. Z:
All the items you list are in the differential although, I have a feeling that distal PF will be less rare than in the past, especially as ESWT becomes more routine, we clear up the proximal portion, then many forget about their orthotics afterwards.
Ed

Re: Insertional vs Proximal Plantar Fasciitis

BGCPed on 10/18/03 at 12:14 (134562)

That is a good explaination Dr Ed. I usually tell patients to imagine an archery bow. The bow is the bones and the string is the fascia. If you held the bow with the string on the ground and pushed down it would reverse camber. It would flatten out and put tension on the string.

That is similar to the action that takes place when you get out of bed and have those first painful steps, the fascia is tight then all of a sudden it gets loaded.

Many orthotics fail because they dont properly address the 3 segments of the foot, hindfoot, midfoot and forefoot. There is much more to an orthotic than just making a big lump in the arch.

Re: Insertional vs Proximal Plantar Fasciitis

John H on 10/18/03 at 13:29 (134571)

BG: Just how important is the heel cup. I see some custom orthotics with much deeper heel cups than ones like i use (footmax)?

Re: Insertional vs Proximal Plantar Fasciitis

Ed Davis, DPM on 10/18/03 at 13:40 (134575)

John:
The heel cup on an orthotic has 2 functions:
1)Provide control of the rearfoot (subtalar joint)
2)Prevent the fat pad of the heel from spreading -- as such, shock absorbtion beneath the heel bone is enhanced.
When it comes to heel pain -- a deep heel cup is superior.
Ed

Re: Insertional vs Proximal Plantar Fasciitis

Ed Davis, DPM on 10/18/03 at 13:44 (134577)

PS
John, you have had your problem to long to shortcut the orthotic route. Get a good custom made orhtotic (true custom made). Richard, CPed had sent me samples of what he makes -- I am not sure how long the drive is to his office, possibly a day trip but I think that you would be very happy with his device.
Ed

Re: Insertional vs Proximal Plantar Fasciitis

Dr. Z on 10/18/03 at 13:48 (134579)

I have dispensed many of the orthosis that Richard has made and they are superior in quality and the ability to control abnormal foot function. EVA is a excellent product material

Re: Insertional vs Proximal Plantar Fasciitis

Dr. Z on 10/18/03 at 13:51 (134581)

John,
that is a very good question. If the heel is everted when the body hits the ground you need a good heel cup. Footmaxx has added deep heel cups to their product due to this biomechanical need. The footmaxx is excellent for the woman who won't change to a shoe that will allow the proper orthosis to fit into the high heel type shoe. I feel that the powerstep is just as good as the footmaxx but cost alot less

Re: Insertional vs Proximal Plantar Fasciitis

Dr. Z on 10/18/03 at 14:00 (134587)

Ed,

I am not convinced that distal pf is due to a degeneration type injury as is believed with insetional plantar fasciosis. Compensation from heel pain, extensor situation due to equinus could very well be the chief reason for this distal plantar fasciitis. Hallux limitus is a major contributing factor with plantar fasciitis, fasciosis proximal and distal.
If a person is willing to wear the proper shoe then orthosis will severely be limited in its role to prevent, control and heal pf diseases

Re: Insertional vs Proximal Plantar Fasciitis

BGCPed on 10/18/03 at 14:23 (134591)

heelcup is very important to control the heel and cup the fat pad to keep it from migrating outward. If youpuish the heel of your hand down on a hard table you will see the fat/tissue push out to the side. Footmax are premade and lack depth in the heelcup. If they made them deeper they would not fit as many patients which means more molds, cost etc.

Re: Insertional vs Proximal Plantar Fasciitis

John H on 10/18/03 at 15:53 (134603)

BG you just ruined my day by informing me my $400 footmax was premaid! Yuck. I have always wondered why there was virtually no heelcup. Dr. Adamoski in St Louis, where I went for a ESWT treatment, told me I could use an orthotic with a heelcup as my footmax was flat and did not control motion. Oh well what is another $400 after 8 years and thousands of dollars. If you were as close as St Louis I would give you some business. This sucks.

Re: Insertional vs Proximal Plantar Fasciitis

John H on 10/18/03 at 15:59 (134604)

I would add with little heel cup and a shoe that is probably already a little wide in the heel area your foot is all over the place. I have read time and time again that a proper fit in an orthotic is a must if they are to help you but I just glazed over it. Would you say that to get a proper fit on an orthotic you need to go the Doctor's office and not just fit one off of the typical mold that could be mailed???????? Do you and BG agree that one type of orthotic to be better than another (rigid,semi regid)????? Seems to me BG wrote one time he preferred the hard orthotic but that could be my memory going south.

Re: Insertional vs Proximal Plantar Fasciitis

John H on 10/18/03 at 16:01 (134605)

If BG was as close as ST Louis I would be on the next plane. He is probably in some place like DeLuth or Bangor. I think he is in South Carolina come to think about it.

Re: Insertional vs Proximal Plantar Fasciitis

BGCPed on 10/18/03 at 16:23 (134608)

I am near deroit john and i would make you a pair for free if you made the trip. I think you are a stand up guy

Re: Insertional vs Proximal Plantar Fasciitis

BGCPed on 10/18/03 at 16:25 (134609)

I only use hard (graphite) in dress shoes and hockey/figure skates. I use firm eva 99% time with soft topcover and it works well

Re: Insertional vs Proximal Plantar Fasciitis

BGCPed on 10/18/03 at 16:28 (134611)

Sorry but they are custom matched to the scan meaning they are not vacum formed or milled. There are many shell sizes that are matched up to the closest based on the scan

Re: Insertional vs Proximal Plantar Fasciitis

John H on 10/18/03 at 18:40 (134628)

BG I used to make the Detroit run from Little Rock on a regular basis when I was with AVis. We were always attending the car shows. Got to tour Willow Run before it closed down and drive on the GM test tracks and spin out. Always stayed near Ford Headquarters. I think we may have a direct flight from Little Rock on Southwest. I may check that out. Always nice to meet someone from the board in person. Are you in the burbs or where? Do you mold the orthotics yourself?

Re: Insertional vs Proximal Plantar Fasciitis

AngelaC on 10/19/03 at 16:13 (134678)

Another reason why I have pf in my left foot!!!! Little toes are important. . . I'm not sure I completely understand your post, but maybe you can answer this. I'm a 50 year old female, and at age 2 had one (two?) tendons removed from my foot. Both small toes curl under, and for the most part, I adapted somehow or other to these. Orthotics never seemed to have considered the unusualness of my small toes. Now, as I do all the good stuff I can think of for pf, shoes seem to be correcting my pronating outward. But I've noticed the oddest thing; in my Boston Birks, (and other shoes) the big toe rubs against the top of the shoe, and has become quite painful. Even bruised looking. Could this be related to not pronating outward as much now?????? Any thoughts on this would be appreciated.
I don't know if it's ok to ask a question in the middle of a link. Sorry if it's not the way to do it. I'm new at this. Thanks!

Re: Insertional vs Proximal Plantar Fasciitis

Rachael T. on 10/20/03 at 21:35 (134781)

Hi John! I also have Footmanagement Orthotics....& I sent mine back & they made the heel cup deeper for me upon my request & my Phys. Therapist's advisement. They did this even after I wore them for a while. In fact, I returned them 3 times to get what I wanted & they cooperated......so, maybe you should talk w/ your prescribing dr. who deals w/ the orthosis company. Good luck & I hope you get some relief.