Plantar Fascia Rupture

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The diagnosis, treatment and prevention of a rupture of your plantar fascia.

By Ben Herring, MD

The plantar fascia is a tough band of connective tissue that fans out across the bottom of the foot from the heel bone and attaches to the base of the toes. It has three important functions. The plantar fascia maintains the arch of the foot, allowing the foot to flex and return to its original shape when loaded. It also represents the final link of tough chain of connective tissue organizing the toes, heel, calf, and knee into a flexible chain for absorbing impact during walking and running. Finally, it protects the flexor tendons and muscles, nerves and vessels of the bottom of the foot.

Plantar fascia rupture diagnosis criteria includes some or all of the following items: feeling a pop with pain in the arch during exercise, a palpable mass under the arch, moderate to severe arch pain, bruising at the focus of pain, and inability to perform a single leg toe raise. Since the foot is a complex structure- fracture, muscle strain, or dislocation should also be considered. Typically the history and physical findings are sufficient to diagnose plantar fascia rupture. A complication that must not be missed is an avulsion fracture of the calcaneus, where the origin of the fascia breaks away with a piece of the heel bone. A foot Xray will usually identify this fracture. For the competitive athlete an MRI may be help to determine the severity of injury and plan treatment.

The plantar fascia ruptures when weakened disorganized fibers of the plantar fascia give way under dynamic flexion of the forefoot. Although runners and jumpers suffer this injury fairly frequently, it is uncommon among all people with foot pain (less than 2% in a recent study). Predisposing factors include plantar fasciitis and possibly plantar fascia steroid injections. Plantar fasciitis is an extremely common cause of foot pain in both athletes and sedentary folks. The condition essentially weakens the fascia through tiny tears and repetitive trauma. Steroid injections are known to weaken connective tissue, yet have been a mainstay for treatment of stubborn plantar fasciitis. A recent study of elite athletes with plantar rupture demonstrated all had pre-existing plantar fasciitis and 20% had preceding steroid injections. Among sedentary individuals obesity, sudden increase of activity, and flat feet are risk factors for plantar fascia rupture.

Unfortunately for the driven triathlete, plantar fascia rupture will take a serious bite out of a race calendar. A good recent study of treatment for plantar fascia rupture included 2-3 weeks of non-weight bearing status in a boot cast with advancement to weight bearing when the athlete was able to stand without pain. The boot was worn for one week past complete resolution of pain with walking. Physical therapy began 1-3 weeks after the injury. Return to activity was guided by patient’s pain and exercise tolerance. Return to full training and competition was gradual. Most athletes benefited from orthotic insoles. So until you are out of the boot, you will be limited to weight training, core work, and swimming with a pull buoy if you do not do flip turns.

Prevention of plantar fascia rupture should focus on avoiding plantar fasciitis or managing the condition if you already have it. Increase mileage and intensity of training gradually.  Maintain ankle, calf, hamstring, and hip abductor flexibility. Consider sport specific orthotic supports. Treat symptoms of plantar fasciitis early and aggressively with mileage reduction, stretching, ice, massage, and correction of strength imbalances. I would not recommend plantar fascia steroid injection unless it was followed by rest and significantly reduced training volume and intensity.

Sincerely,

Ben Herring, MD

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date: June 28, 2012