What is plantar fasciitis?

The commonest cause of pain in the heel is plantar fasciitis. The plantar fascia is a thick fibrous band of tissue in the sole of the foot. It is attached to the heel bone (calcaneum) and fans out as it passes forwards towards the toes (attaching to the bases of the toes). It functions as the ‘soft tissue’ part of the arch in the foot.

In some people the plantar fascia becomes painful and inflamed. This usually happens where it is attached to the heel bone, although sometimes it happens in the mid-part of the foot.

What causes it?

Plantar fasciitis may follow a period of prolonged walking or running, often when the individual is unaccustomed to such activity. The problem occurs when part of the inflexible fascia is repeatedly placed under tension. Repetitive impact causes an overload that produces microscopic tears and inflammation at the point where the fascia is attached to the heel bone. Sometimes it is provoked by poor or inappropriate footwear. A tight calf muscle is often implicated, and commonly revealed on clinical examination. Other risk factors include obesity, flatfeet, high arch feet and diabetes.

How it is diagnosed?

The symptoms from plantar fasciitis often give away the diagnosis. The pain is typically worst first thing in the morning and when getting up having been sat down for a while. The location, under the foot and usually on the inside of the heel is very typical. However, the diagnosis is often confirmed with either an ultrasound or MRI scan.

How is is treated?

Plantar Fasciitis is a condition which subsides in approximately 95 per cent of affected people spontaneously. The condition is very unpredictable however and symptoms can persist for 18 months. It is considered a self-limiting problem, however it generally responds to a tailored treatment plan made specific to each individual and based on the suspected cause of the problem. This often speeds up the recovery. Mr Amin will coordinate your treatment, which is often multi-disciplinary, and which very rarely, if ever requires surgery.

Common treatment modalities include:

•  Activity modification: Rest and avoidance of sport is very important. Pain should guide and limit the level of activity. It is very important to avoid activities which aggravate the problem
•  Anti-inflammatory medication (eg Ibuprofen / Diclofenac): Non-steroidal anti-inflammatory medication can be helpful in treating the pain. Daily “icing” of the painful area can be helpful. Your physiotherapist can guide you further.
•  Physiotherapy: This is a very important part of treatment for this condition with techniques to reduce inflammation. Stretching the calf musculature to try and reduce the load on the plantar fascia is very important. Your overall biomechanics may be playing a role in the cause of the pain, and Mr Amin works with specialist physiotherapists, and will recommend a colleague conveniently located to your home or work.
• Orthotics: A cushioned heel, from over-the-counter is a good start. If you have a foot deformity, then you may benefit from a custom made insole, specific to your foot. A night splint (which holds the foot up – stretching the calf) can also be helpful. Mr Amin work’s with specialist podiatrists in London and will refer you on accordingly.

What are my options if physiotherapy fails?

There are two options at this point.

• Ultrasound guided injections (guided corticosteroid injections): These injections are given by a Consultant Radiologist or Sports Doctor and are guided directly to the site of the problem. In the majority of patients these injections provide relief from pain, although the longevity is unclear.
•  Shockwave therapy (ESWT): This is a newer option, where focussed pressure waves are applied to the painful plantar fascia. The theory is that these pressure waves incite a healing response and ‘kick start’ the body’s natural healing process. The treatment is undertaken in the out-patient clinic and takes 10 minutes. Three sessions are required leaving 7-10 days in between cycles. The response tends to occur 2-3 months after the final session. Physiotherapy during this treatment remains vital, and studies have shown benefits of ESWT and physiotherapy over ESWT alone.

Mr Amin’s initial preference is to try shockwave therapy, however not all insurance companies cover this treatment, and this can be discussed during the consultation.

Are there any surgical options?

In a very small number of cases, surgery is considered for patients who have more than 12 months of persistent pain. The operation involves release of the plantar fascia and the small nerves which can be trapped in this region. Occasionally a tight calf muscle persists despite focussed physiotherapy, and a gastrocnemius release is required, which helps take the tension of the plantar fascia. Fortunately, this is very rarely required.

What about the heel spur? Will this be removed too?

Studies have conclusively shown that the heel spur is not responsible for the pain in plantar fasciitis. A recent study evaluated 1000 people randomly and found 132 to have a heel spur. Of these on 6 patients described a history of heel pain. A heel spur can be considered an incidental finding, and I do not personally remove it, in the small group of people undergoing surgery for this condition.