Plantar fasciitis • What helps?

Plantar fasciitis is a painful inflammation of the tendon plate that runs from the heel to the front ball of the foot (plantar fascia). What are the symptoms and causes of plantar tendinitis? Is there always a heel spur behind it? And which therapy is the most effective at relieving pain?

Regular stretching exercises prevent plantar fasciitis.
© iStock.com/Yuri_Arcurs

Plantar fasciitis (also called plantar tendinitis, plantar fasciosis, plantar fasciopathy or fasciitis plantaris) is a painful, usually one-sided and chronic inflammation of the plantar fascia: a tendon plate made of firm fascia tissue (connective tissue) in the sole of the foot that connects the toes, metatarsal bones and supports the longitudinal arch of the foot. In addition, the plantar fascia ensures stability when walking, because it provides numerous orientation nerves. It is estimated that around 80 percent of all heel pain is due to plantar fasciitis.

The disease is considered widespread, but there are no reliable figures on its occurrence. Some experts estimate that about one in ten people will experience inflammation-related pain in the heel at least once in their lifetime. People between the ages of 45 and 65 are particularly affected. Basically, plantar fasciitis can occur at any age. Women are more vulnerable than men.

Heel spur: How to get rid of it

Heel spur: How to get rid of it

How does plantar fasciitis develop?

A combination of different factors often leads to inflammation of the plantar fascia, which is why experts speak of multifactorial development. The trigger is usually an overload or irritation of the plantar tendon.

The main risk factors for this are:

  • Obesity / obesity (body mass index / BMI> 27)
  • a shortened calf muscles (Achilles tendon), which is anatomically related to an increased tension of the plantar tendon
  • various misaligned feet (e.g. hollow, flat or flat feet)
  • different leg lengths (pelvic obliquity)
  • muscular imbalances (e.g. in the hip, lumbar, knee or trunk muscles)
  • minor accidents (e.g. bruises in the heel area)
  • Bursitis in the area of ​​the plantar fascia approach
  • a standing professional activity
  • a strong run
  • too tight shoes or frequent wearing of high heels
  • insufficiently developed foot muscles or too uniform
  • (Asphalt) floors that offer the foot too little variety and training

A heel spur (calcaneus spur) can also be considered as the cause of plantar fasciitis. It is a thorn-like outgrowth (limescale) in the area of ​​the sole of the foot (plantar) or at the base of the Achilles tendon (dorsal / cranial), which is usually caused by years of overloading the respective area and can cause tears and inflammation in the surrounding tissue . However, recent studies conclude that heel spurs are more often the result of plantar tendinitis than their cause.

Plantar fasciitis is often caused by heavy exercise. Risk sports include:

  • all running disciplines (sprint, medium and long distance running)
  • basketball
  • Soccer
  • To dance
  • tennis

What are the symptoms of plantar fasciitis?

An inflammation of the plantar fascia is characterized by severe (often described as stinging) heel pain in the foot, which primarily occurs when the first steps are taken immediately after getting up or generally when the tendon is first stressed after prolonged inactivity (start-up pain). In the advanced stage of inflammation, the pain often radiates into the entire sole of the foot and towards the Achilles tendon or can also be clearly felt when lying down (i.e. without stress on the foot). Many sufferers can hardly bend the inflamed foot.

Athletes traditionally register the heel pain primarily when warming up. In the course of further training, the complaints then become weaker or disappear completely. Intensive sprints and jumps or a consistently heavy load on the foot (e.g. due to jumps or sprints) can reactivate the symptoms. If the heel continues to be heavily loaded, the pain usually increases.

The main differential diagnoses (other diseases with similar symptoms) to plantar fasciitis are:

  • Arthrosis in the ankle: non-inflammatory, wear-related changes in the ankle
  • Reiter's disease (Reiter's syndrome): Autoimmune disease, which can spread to the entire body of inflammation through infections of the urinary tract or gastrointestinal tract
  • Bechterew's disease (ankylosing spondylitis): chronic inflammatory rheumatic disease that is accompanied by painful and stiff joints
  • rheumatoid arthritis (chronic polyarthritis): most common chronic inflammatory disease of the joints
  • Broken bones in the foot area
  • Soft tissue abscesses (especially with a pre-existing condition such as diabetes mellitus)
  • Tumors in the foot area

How is plantar fasciitis diagnosed?

In the case of unclear pain in the heel area or if there is a specific suspicion of plantar tendinitis, the specialist for orthopedics is the right contact. Based on a thorough medical history and a clinical examination, he can usually diagnose plantar fasciitis quickly and often even without the help of imaging techniques.

In the case of the medical history, the doctor asks, for example, about the type, occurrence and location of the pain as well as the course of the disease, previous illnesses and regular exercise / occupational stress on the heel.

The clinical examination for heel pain initially includes a palpation test: if the complaints are increased by palpating or pressing the plantar fascia approach to the heel, this indicates plantar fasciitis.

The so-called Silfverskjöld test, named after its first descriptor, the Swedish orthopedic surgeon and surgeon Nils Silfversköld, is suitable for detecting certain foot deformities or shortened calf muscles: The active and passive freedom of movement of the foot in the ankle towards the back of the foot with the foot stretched and bent at a right angle Knee checked (dorsiflexion).

An X-ray of the foot is usually only taken if the heel pain continues to appear despite long-term conservative therapy. For example, heel spurs or connective tissue calcifications and thickening are clearly visible on it. The use of other imaging methods such as ultrasound (sonography), magnetic resonance imaging (MRI) or skeletal scintigraphy is also possible within the framework of the diagnosis of planta fasciitis, but their necessity is controversial among specialists.

What helps against plantar fasciitis?

Many medical publications report that heel pain subsides or disappears within a year regardless of therapy. So far, however, this thesis has not been supported by scientific studies. What is certain is that more than 90 percent of all those affected use conservative treatment approaches well within six months. These include:

Medicinal therapies:

In the case of acute, painful plantar fasciitis, the (oral) administration of non-steroidal anti-inflammatory drugs (NSAIDs) is usually carried out: pain relievers with drugs such as acetylsalicylic acid, arylpropionic acid derivatives (e.g. ibuprofen) or arylacetic acid derivatives (e.g. diclofenac), which have an anti-inflammatory effect. Locally applied ointments or gels with ibuprofen or diclofenac can also help against heel pain, but are less effective than tablets due to their shallow depth of penetration. Corresponding gels have a decongestant and anti-inflammatory cooling effect.

Injecting a local anesthetic into the painful heel area can also lead to a temporary relief from symptoms. Many sufferers also have positive experiences with cortisone injections (glucocorticoid injections). However, since the anti-inflammatory steroid hormone can have side effects such as a loss (an atrophy) of the plantar fat pad or tendon tears (ruptures), a maximum of two to three glucocorticoid injections should be administered according to experts.

To date, little research has been carried out into newer drug treatment methods such as the injection of botulinum toxin (botox) or platelet rich plasma (PRP) – the patient's own blood plasma, which is enriched with platelets and is therefore said to contain highly concentrated growth factors for wound healing.

Relieving therapies:

All measures that reduce the chronic overload of the plantar fascia fall into this category, for example:

  • Weight loss in those with pre-obesity or obesity
  • regular elevation of the affected foot
  • Provision of individually adjusted, corrective shoe insoles, with which the arch of the foot is supported in the event of deformities (pressure reduction)
  • (Long-term) wearing a so-called night splint (orthosis), with the help of which the tip of the foot is stretched towards the shin, can stretch the tendon plate and accelerate the healing process
  • Reduction of sporting activities where the plantar fascia is likely to be overloaded
  • Training only in the pain-free interval.
  • the choice of suitable, well-padded shoes for every sport / activity
  • changing positions with standing professional activity

Stimulating therapies:

Regular stretching and isometric training for calf muscles and plantar fascia are recommended. According to studies, good results can be achieved in the short as well as in the long term (up to complete freedom from pain). Professional instructions from a specialized physiotherapist or orthopaedist make sense.

The same applies to exercises to strengthen the foot muscles.

Regular cooling of the painful tissue can also effectively relieve the inflammation.

Low-dose X-ray radiation (low-dose radiotherapy) is said to promote blood circulation in the inflamed tissue and thus help to reduce inflammation and pain. However, long-term effects of radiation over a period of more than eight years have not yet been investigated.

The procedure of extracorporeal shock wave therapy (ESWT), in which pressure waves destroy electromagnetically generated, precisely aligned pressure waves, such as a heel spur, can represent another therapy option.

(Dry) Needling is a physiotherapy method in which fine needles are placed in the sole of the foot and then moved gently to trigger a reaction in the muscle. Some patients perceive it as painful.

In-house treatments such as foot and heel massages that promote blood circulation, acupressure or taping (instructions are available online) can do good and relieve the pain.

Home remedies for plantar fasciitis

Various home remedies for inflammation in the heel are also recommended, but their effects have not been scientifically proven, for example:

When is an operation to relieve the plantar fascia necessary?

Overall, plantar fasciitis only needs to be operated very rarely because multimodal conservative therapies generally work well.

If, despite conservative treatment and diagnostic exclusion of other causes, the heel pain persists for more than twelve months and significantly reduces the quality of life, those affected should weigh up with their orthopedic surgeon whether a surgical intervention could be useful. A second medical opinion can be helpful in this case.

Surgery is performed on approximately one in 100 people with plantar fasciitis. However, the procedure is no guarantee of permanent freedom from symptoms: According to studies, around 70 to 90 percent of all operated patients are satisfied with the result.

There are different surgical techniques for containing heel pain. The question of which leads to the best results is controversial among experts.

One possible procedure is fasciotomy, which involves a partial separation of the inflamed tendon. The goal is to relieve the pressurized part of the plantar fascia directly on the heel bone, because the tissue here is often abnormally thickened, calcified, scarred, stiffened or torn due to stubborn inflammation.

A fasciotomy can now be performed arthroscopically over small incisions using an endoscope and a tiny cutting instrument (keyhole technology). The minimally invasive procedure should lead to a faster recovery compared to an open procedure: Studies have shown that endoscopically operated patients with plantar fasciitis can return to their workplace much earlier.

Another possible surgical procedure is the relieving mobilization of the (possibly shortened) two-bellied calf muscle (gastrocnemius muscle) by indenting this muscle fascia. If necessary, this procedure can be combined with a fasciotomy.

A heel spur usually does not need to be surgically removed. However, if it is so pronounced and localized that it actually causes painful damage to the surrounding tissue, it can be removed endoscopically.

Due to the high risk of injury, all corresponding interventions should only be performed by highly specialized foot and ankle surgeons.

How does plantar fasciitis typically go?

Specialists speak of the "creeping character" of the inflammation: the pain in the heel initially occurs only sporadically and disappears in phases of rest. With constant stress or irritation of the plantar tendon, the complaints occur more frequently and with increasing intensity.

Since people with heel pain often move to other positions when walking – i.e. instead of stepping on the heel or walking on tiptoe (relief limp) – chronic plantar fasciitis can permanently overload and further areas of the body such as the spine, knees, hips or ankles / or be damaged.

The careful posture leads to strong and painful muscular tension in the long term. If left untreated, plantar tendinitis can endanger mobility.

The prognosis for plantar fasciitis is generally very good, since measures such as relief, cooling, compresses and other home remedies as well as conservative medical therapies effectively relieve the inflammation until it finally disappears.

If surgery is required, follow-up care can take a long time, depending on the surgical procedure: The tissue must be protected and protected for four to six weeks, which means that the foot should be kept as calm as possible and not stressed.

As a rule, the treating doctor then prescribes a gradual reloading and movement, which is accompanied by physiotherapy. It takes an average of six to twelve months for the foot to fully recover after the procedure.

How long the patient is on sick leave after an appropriate operation depends on the healing process and occupation. The same applies to sick leave for a conservatively treated plantar fasciitis. Sedentary activities can usually be resumed much faster (with feet up) than standing or physically demanding jobs.

How can plantar fasciitis be prevented?

Since inflammation of the plantar tendon usually arises from an overload, the risk of illness can be significantly reduced by the following preventive measures:

  • The BMI should be in the normal range. Weight loss is recommended for pre-obesity or obesity.
  • The entire foot should be well supplied with blood. In addition to regular exercise and muscular training, foot massages (for example using a hedgehog ball or a fascia roller) and cold water stimuli (Kneipp treatments) are therefore also useful. Cigarettes should be avoided because smoking constricts the blood vessels and inhibits the oxygen supply to the tissue.
  • To relieve the feet, they should be raised in the event of muscular exhaustion.
  • Callus calluses on the heel and sole of the foot can be prevented by caring foot baths, softening creams and, if necessary, podiatry removal of the cornea. Regular medical foot care is recommended for problem feet.
  • Shoes for work and leisure should be flat and comfortable (well padded) and should be changed more often.
  • It is advisable to change your standing position frequently when you are standing.
  • Recreational athletes who tend to have tendon problems should avoid high-risk sports such as running, tennis, dancing, basketball and soccer and switch to alternatives such as cycling and swimming, as there is little or no pressure on the heel and sole of the foot.
  • In general, individually adjusted special footwear should be worn during sport (many specialist shops offer foot and running analyzes).
  • In running disciplines in particular, care should be taken to increase training slowly, otherwise overload situations can occur quickly.
  • Regular stretching and strengthening exercises for muscles and tendons keep the feet robust and healthy and effectively prevent plantar fasciitis.

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