PODIATRIC SURGERY INFORMATION GUIDE: MANAGEMENT OF PLANTAR FASCIITIS/HEEL PAIN

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1 PODIATRIC SURGERY INFORMATION GUIDE: MANAGEMENT OF PLANTAR FASCIITIS/HEEL PAIN What is Plantar Fasciitis? Plantar fasciitis is pain in the heel and arch area of the foot. The plantar fascia is a strong band of tissue that maintains the integrity of the arch of the foot, acts as a shock absorber and aids in the toe off phase of the walking cycle. It originates on the inside of the heel bone/calcaneum, spans the arch and attaches in to the bases of the toes. Symptoms occur if the fascia becomes injured or inflamed. Pain is felt at the origin of the fascia on the inside of the heel and/or under the central part of the arch. Symptoms tend to be a dull ache/throb which is worse in the morning on first rising or after sitting for a period of rest. Gentle exercise may ease things a little as the day progresses. Occasionally patients experience a tearing sensation in the arch area and/or tingling in the arch and toes. There are two specific nerves in the region of the heel which can become irritated, the medial calcaneal nerve and Baxter s nerve. These tend to cause a burning pain around the heels periphery. In more persistent cases there may be a component of bone bruising affecting the calcaneum. Plantar fasciitis is a common condition affecting women more frequently than men. It tends to affect those over the age of 40 but can occur at any age and is common in athletes. This condition can resolve spontaneously. Investigations Diagnosis tends to be clinical, based on a classic history/symptoms and a physical examination by your clinician. Ultrasound examination is used when the diagnosis is inconclusive or symptoms are unresponsive to conservative care it can confirm inflammation/thickening of the plantar fascia and identify any tears.

2 An x- ray is often requested by general practitioners and this can reveal the presence of a calcaneal spur or bony prominence under the heel bone. This sometimes arises at the origin of the plantar fascia and is a result of tension on the fascia and inflammation causing increased bone turnover at this site. A calcaneal spur is not diagnostic for plantar fasciitis and is often seen in asymptomatic patients who have higher arched foot types in view of this an x- ray is not routinely requested by our team. MRI scans are occasionally requested in trauma cases or where patients fail to respond to conservative care and bone bruising is suspected as a component of their symptoms. If your clinician suspects a rheumatological condition, they will request some specific blood tests and an x- ray. The blood tests look for inflammatory markers and the x- ray can show bony erosions, a calcaneal spur and/or fluffy new bone formation at the painful site. Causes Obesity/Increased body mass index (BMI) Ankle equinus tight calf muscles Flat, unsupportive footwear i.e. prolonged use of flip flops in the summer Abnormal biomechanics excessive foot pronation or rolling in Trauma Inflammatory arthritis such as psoriatic arthropathy, reactive arthritis or ankylosing spondylitis Profession Sedentary job or lifestyle Increase in intensity of sporting /activity levels Referred pain from the back Local nerve irritation Home Treatments/Conservative Care 1) Calf Stretching Set up a ramp using a pile of books and a chopping board/piece of wood. The ramp should be a maximum of 15 degrees slope. Stand on the slope barefoot, at the highest height you can stand up straight. Keep your knees straight and your feet slightly pigeon toed. Stay there for 5 minutes. Do this morning and night. This is a good thing to do whilst brushing your teeth, shaving or applying make- up. In addition sit with your knees straight and use a towel to pull your feet towards your chest. Hold for 5 minutes, relax and repeat. This can be done whilst watching the television. Calf muscle tightness is one of the major causes of plantar fasciitis; it is more common in women because they wear higher heeled shoes. The calf muscle complex blends into the plantar fascia at the site of symptoms and has a direct influence on foot function.

3 2) Icing Freeze a bottle of water. Roll the bottle under the arch of your foot/painful area for ten minutes every evening, whilst wearing a sock. This will massage the deep tissues and reduce inflammation. 3) Rest from weight bearing sport If you continue to exercise on a painful foot the injury will take longer to settle. Whilst the foot is symptomatic, we recommend non- weight bearing sport such as swimming and cycling. 4) Immobilisation In acute/severe cases patients may be immobilised in a cast for 3-4 weeks to rest the inflamed area. This can be useful in cases where trauma or bone bruising has been identified. 5) Loose Weight 80% of heel pain sufferers are overweight. It is essential that you loose weight if you are in this category. Many of the clinical treatments will not be offered unless attempts have been made to loose weight. Your GP may be able to refer you to a dietician for further advice and in addition you should take up some form of exercise as discussed above. 6) Insoles/Orthoses These can be purchased from Boots the Chemist. Buy a pair of Vasyli orthaheel orthoses approx 26 (not the slimfit version but the one with a structured arch). Wear these daily in your lace- up shoes. Orthoses utilising softer moulded materials and/or gel heel cushions may be more appropriate in cases of known bone bruising. Orthoses control abnormal foot function/pronation which is a common cause of plantar fasciitis.

4 7) Footwear When walking, wear the correct sized, supportive lace- up shoes/trainers with a good height heel (1 inch). If you are unsure of your size we can measure you 90% of patients wear shoes which are too short. Supportive footwear helps control abnormal foot motion and improves orthotic fit and function. Short, flat shoes cause, increased tension in the plantar fascia. Extra cushioning can be useful for bone bruising. 8) Physiotherapy This can be beneficial for the treatment of plantar fasciitis and tends to centre on calf stretching, taping to re- align the foot temporarily, ultrasound therapy and acupuncture (if the physiotherapist has the relevant additional qualification). Your GP may refer you locally for a short course of physiotherapy, which can supplement other treatments designed to correct the true cause of your symptoms. If your clinician suspects that your heel pain is referred pain associated with a back problem or tension in the long nerves running down the legs from the lower back, a referral for physiotherapy will be made. 9) Plantar Fasciitis Night Splints These can be introduced if improvement is slow. They provide a prolonged calf stretch when worn overnight in bed. Purchase online from 45 at Langer Biomechanics U.K. or Gillbert and Mellish. 10) Non Steroidal Anti- inflammatory tablets and gels (NSAID s) These can be helpful for some cases of plantar fasciitis. A one to two week s course of NSAID s such as Ibuprofen may kick start the recovery process or decrease pain in an acute episode. Prolonged use of NSAID tablets can cause irritation of the stomach lining.

5 11) A useful website with a host of ideas and treatments tried and compiled by heel pain sufferers who log on and answer some questions about their condition and current treatment regimes. Clinical Treatments 1) Steroid Injection This can be beneficial for patients as a supplement to home treatments. A maximum of three injections can be provided. Injections will not cure your heel pain; just reduce local inflammation, aiding recovery. Risks include infection, steroid flare, no benefit, fat atrophy and rupture of the plantar fascia. If a specific nerve around the heel has been irritated, a steroid injection directed around the nerve can be very effective. 2) Orthoses For those patients who have more complex mechanics or when over the counter orthoses have failed to alleviate symptoms, the hospital may provide one pair of orthoses. If footwear is inadequate this treatment will not be instigated. 3) Extracorporeal Shockwave Therapy (ESWT) Non- invasive. A machine is used to deliver sound waves to the painful area, it is not known how it works but it is thought that it may stimulate healing of the fascia. Only available privately due to expense. Surgical Treatment 1) If non surgical treatment fails to alleviate symptoms long- term, you may wish to consider surgical intervention. Surgery involves releasing the plantar fascia by cutting it. Risks include, nerve/blood vessel damage, continued symptoms/recurrence and mechanical dysfunction along the outer border of the foot. Success rates vary between 50-75% so this form of treatment is generally considered as a last resort. If you are considering surgery, please be aware we do not advise patients to undertake air travel until at least 6 weeks post surgery. You should be aware that these complications are relatively uncommon. They mostly resolve without permanent disability or pain using medications, therapy and on occasions further surgery, but even allowing for these, sometimes you may not achieve the result that you want. We do NOT advise surgery purely for cosmetic reasons. We also advise against prophylactic surgery (which is preventative surgery to avoid problems that are not yet present).