plantar fasciitis
Ross Hauser, M.D. Marion Hauser, M.S.,R.D.

An athlete presenting to the physician with plantar fasciitis characteristically complains of a pinpoint, knife-like pain in the plantar aspect of the heel pad at the base of the fascial insertion to the calcaneous. Pain is generally worse when the athlete first arises in the morning, as the plantar fascia is cold, contracted, or stiff. Pain is due to the stretching of the damaged tissues. For the same reasons, the athlete is generally symptomatic during the initial stages of exercise, with improvement as exercise continues, presumably because the warm-up increases the pliability of the fascia. The onset of plantar fasciitis is generally gradual and often flares only with exercise. As the problem continues interference with walking becomes a common problem. This entity accounts for about 10 percent of all running injuries.(1)

Plantar fasciitis is classified as a syndrome resulting from repetitive overload to the plantar fascia at its insertion into the calcaneous. The development of plantar fasciitis, as in other repetitive overload injuries, can be related to several factors, including repetition of the athletic activity, improper biomechanics, improper training programs, abnormal anatomy, muscle strength imbalances, and range-of-motion deficits. Typically what occurs is that, for whatever reason, a weakness develops in the plantar fascia and it becomes inflamed, hence the name fasciitis. The inflammation is due to the fascia trying to repair itself. At this point, modern medicine says the athlete needs some NSAIDs (anti-inflammatory medications) and a cortisone shot to stop the inflammation. This is exactly what occurs, causing the fasciitis, which is an active process of the body trying to heal itself, to become a dead process with the end result being tendinosis. There is no inflammation present in tendinosis, indicating that the tendon or fascia is no longer trying to repair itself. There is evidence of degeneration to the collagen with no evidence of inflammatory cells repairing the tissue in tendinosis.

Long-term cases of plantar fascia problems, shown in this pathologic picture (biopsy), exhibit degeneration of collagen and cell damage, which are signs of tendinosis. (2,3)

Dr. W. Clancy showed, by taking biopsies of the plantar fascia, that cellular degeneration was the picture in plantar fascia problems, not inflammation. (Clancy, W. Tendonitis and plantar fasciitis in runners. Prevention and Treatment of Running Injuries, Thorofare, Charles B. Slack, 1982, pp. 84-85.) This is quite disconcerting because this means the tendon or fascia has lost the ability to repair itself. Only Prolotherapy can start the soft tissue proliferation of new collagen and begin the repair process. This tendinosis problem is also another reason why the use of NSAIDs and cortisone shots for treatment of these cases makes no sense. There is absolutely no inflammation present in these cases of tendinosis.

1. Chandler, T. A biomechanical approach to the prevention, treatment and rehabilitation of plantar fasciitis. Sports Medicine. 1993; 15:344-352.
2. Leadbetter, W. An introduction to sports induced soft tissue inflammation. In Leadbetter et al. (eds.) sports induced inflammation, American Academy of Orthopaedic Surgeons, 1990.
3. Leadbetter, W. Physiology of tissue repair. In Athletic training in sports medicine. American Academy of Orthopedic Surgeons, 1991.)

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