Plantar Fasciitis and the Gastrocnemius New Data and Clinical Implications

This refers to the heel pain occurring at the plantar fascia’s point of origin on the calcaneus. Histopathological studies reveal that this pain, historically referred to as plantar fasciitis, does not involve inflammation. Rather, the pain stems from a chronic degenerative process and an overloaded healing response.2 Affecting both runners and sedentary people, incidence peaks between ages 40 and 60.3 Stretching the interconnected complex of the gastrocnemius, Achilles tendon, and plantar fascia serves as a proven component of physiotherapy for plantar fasciosis. 4

However, the exact role played by tightness in these structures has not previously been quantified. Enter Christopher Pearce and his colleagues from Singapore’s National University Health System. They recently published the first study to quantify the association between gastrocnemius tightness and severity of heel pain in “plantar fasciitis” diagnoses.5 Gastrocnemius tightness is measured by subtracting the difference in ankle dorsiflexion between bent-knee and straight-knee tests.6 Researchers demonstrated a very strong correlation between gastrocnemius tightness and pain severity.

For instance, a tightness of 10° difference correlates with a pain severity of three out of ten. A tightness of 20° difference correlates with a pain severity of eight out of ten. That’s asking for a rating of the worst pain the patient experienced in the previous week. As the difference approaches zero with treament, pain also approaches zero. Of the 33 patients in the study, one had gastrocnemius tightness that proved recalcitrant to physiotherapy, and that patient also did not achieve symptom relief. The patient subsequently received proximal medial gastrocnemius recession, and achieved complete symptom relief. These associations strongly suggest that gastrocnemius tightness plays a strong and correlated role in plantar fascia pain severity. Clinical Implications: A continuation of fibres connects the medial head of the gastrocnemius—via the Achilles tendon—to the plantar fascia.

However, this continuation is not seen in elderly cadaveric specimens.7 This age-related anatomical difference may explain the decreasing prevalence of plantar fasciosis after age 60. Elderly patients with heel pain have a higher index of suspicion for other pathologies, such as calcaneal stress fractures. Furthermore, this revelation of the strong role played by gastrocnemius tightness may optimise care planning. All care planning for plantar fasciosis should include an evaluation of gastrocnemius tightness.

The data in this study contradicts a popular misconception that if the ankle can dorsiflex beyond neutral, there is no gastrocnemius contracture. Similarly, there is a misconception that isolated gastrocnemius tightness can be evaluated solely by the limitation of ankle dorsiflexion.8-10 In fact, evaluating gastrocnemius tightness requires measuring the difference between ankle dorsiflexion with a bent knee and then with a straight knee.4,6 A difference of roughly three degrees correlates with no pain, on average. Pain reaches one out of ten at only a five degrees difference.

Additionally, it may be safe to assert that any treatment plan that does not directly address gastrocnemius tightness can be considered incomplete. Authors sometimes refer to plantar fasciosis as self-limiting, leading to a wait-and -see approach. However, one in five cases is still symptomatic after a year, and high recurrence rates have been reported.11,12 Moreover, patients may average as much as eight months of symptoms before seeking medical attention. Prescribing wait-and-see on top of that is connected with lesser clinical outcomes and patients harbouring the mistaken belief that healthcare has little to offer.13 While the scientific literature has yet to elucidate the most effective combination of conservative treatments, one thing we know is this: programmes supervised by a physiotherapist achieve better results than programmes that patients conduct independently after initial consultation.14 

References

1. Gupta R, Malhotra A, Masih GD, Khanna T, Kaur H, Gupta P, Kashyap S. Comparing the role of different treatment modalities for plantar fasciitis: a double blind randomized controlled trial. Indian Journal of Orthopaedics. 2020 Feb;54(1):31-7.

2. Ramamoorthy EN, Daniels JM, Kukkar N. Challenges in Diagnosis of Plantar Fasciosis (Fasciitis). Ann Sports Med Res. 2016;3(7):1086.

3. Riddle DL, Pulisic MA, Pidcoe PE, Johnson RE. Risk factors for plantar fasciitis: a matched case-control study. JBJS. 2003 May 1;85(5):872-7.

4. Gupta R, Malhotra A, Masih GD, Khanna T, Kaur H, Gupta P, Kashyap S. Comparing the role of different treatment modalities for plantar fasciitis: a double blind randomized controlled trial. Indian Journal of Orthopaedics. 2020 Feb;54(1):31-7.

5. Pearce CJ, Seow D, Lau BP. Correlation between gastrocnemius tightness and heel pain severity in plantar fasciitis. Foot & Ankle International. 2021 Jan;42(1):76-82.

6. Baumbach SF, Braunstein M, Regauer M, Böcker W, Polzer H. Diagnosis of musculus gastrocnemius tightness-key factors for the clinical examination. JoVE (Journal of Visualized Experiments). 2016 Jul 7 (113):e53446.

7. Ballal MS, Walker CR, Molloy AP. The anatomical footprint of the Achilles tendon: a cadaveric study. The Bone & Joint Journal. 2014 Oct 1;96(10):1344-8.

8. Barouk P, Barouk LS. Clinical diagnosis of gastrocnemius tightness. Foot and Ankle Clinics. 2014 Dec 1;19 (4):659-67.

9. Henricson A, Larsson A, Olsson E, Westlin N. The effect of stretching on the range of motion of the ankle joint in badminton players. Journal of Orthopaedic & Sports Physical Therapy. 1983 Sep 1;5(2):74-7.

10. Rabin A, Kozol Z, Finestone AS. Limited ankle dorsiflexion increases the risk for mid-portion Achilles tendinopathy in infantry recruits: a prospective cohort study. Journal of Foot and Ankle Research. 2014 Dec;7 (1):1-7.

11. Ramamoorthy EN, Daniels JM, Kukkar N. Challenges in Diagnosis of Plantar Fasciosis (Fasciitis). Ann Sports Med Res. 2016;3(7):1086.

12. Carcia CR, Martin RL, Houck J, Wukich DK, Altman RD, Curwin S, Delitto A, DeWitt J, Fearon H, Ferland A, MacDermid J. Achilles pain, stiffness, and muscle power deficits: achilles tendinitis: clinical practice guidelines linked to the international classification of functioning, disability, and health from the Orthopaedic Section of the American Physical Therapy Association. Journal of Orthopaedic & Sports Physical Therapy. 2010 Sep;40(9):A1-26.

13. Orchard J. Plantar fasciitis. BMJ. 2012; 345: e6603. 14. Almubarak AA, Foster N. Exercise therapy for plantar heel pain: A systematic review. International Journal of Exercise Science. 2012;5(3):9.