Symptoms, diagnosis and treatment of plantar fasciitis (heel pain)

Contents

• Anatomy
• Symptoms
• Who is at risk?
• What causes plantar fasciitis?
• Diagnosis
• Heel spurs
• Non-operative treatment
  • Self-treatment
  • Stretching
  • Orthoses
  • Nocturnal dorsiflexion splints
  • Anti-inflammatory medication
  • Extracorporeal shockwave therapy (Lithotripsy)
• Surgery to relieve plantar fasciitis
• Summary

Plantar fasciitis is a common cause of heel pain. It is often also known by the colloquial name of Policeman’s heel. Fortunately it is a self-limiting condition and in most patients (80-90%) the symptoms will get better within ten months.

Anatomy

The plantar fascia is a strong fibrous band of tissueA group of cells with a similar structure and a specialised function. in the bottom of the foot which helps support its shape. It arises from the heel bone (calcaneus) and inserts into the toes. The heel bone is protected by a specialised pad of fatOne of the three main food constituents (with carbohydrate and protein), and the main form in which energy is stored in the body. that cushions it when we stand. This also protects the attachment of the plantar fascia. 

Symptoms

With plantar fasciitis start-up pain is common. This is a sharp or stabbing sensation in the region of the heel typically when getting out of bed in the morning or from getting up from a chair after a period of rest. Start-up pain often resolves but may be replaced by a dull constant aching or throbbing pain at the end of the day. 

Who is at risk?

Patients who are overweight or who spend the majority of their day standing are at increased risk. Advanced age and a tight Achilles tendonThe tendon that connects the heel to the muscles of the lower leg. as well as outside factors such as poor shoes also increase the risk. Recreational jogging does not increase the risk of plantar fasciitis.  

What causes plantar fasciitis?

There are several theories as to the cause of plantar fasciitis but the most likely is that mechanical overload and excessive strain results in micro-tears in the tissue of the heel that in turn give rise to an inflammatory response. Repeated overload may hinder or prevent normal healing and this may result in chronicA disease of long duration generally involving slow changes. inflammationThe body’s response to injury. and degeneration of the tissues.  This causes pain when the area is compressed.

Diagnosis

In the majority of cases your doctor will be able make the diagnosis from the symptoms and medical examination findings alone. Occasionally it is necessary to perform investigations to confirm the diagnosis or exclude other causes of the pain. Sometimes X-rays are used to rule out breaks (fractures) in the bone or very rare causes such as infectionInvasion by organisms that may be harmful, for example bacteria or parasites. and tumours. Bone scans can also be used to exclude stressRelating to injury or concern. fractures. Ultrasound may be used to confirm the diagnosis, as it is very sensitive at measuring the thickness of the plantar fascia. Thickening of the plantar fascia is a firm sign of the condition. MRIAn abbreviation for magnetic resonance imaging, a technique for imaging the body that uses electromagnetic waves and a strong magnetic field. scans are very sensitive at diagnosing a large number of conditions and also confirming the diagnosis of plantar fasciitis

Heel spurs

Plain X-rays often pick up spurs of bone that are close to the attachment of the plantar fascia on the heel bone. These are very common and are not related to plantar fasciitis.

Non-operative treatment

There are a number of possible non-operative treatments and these are:

1. Self-treatment

Rolling your foot on a plastic bottle of hot or cold water is often very effective at reducing acuteHas a sudden onset. symptoms. It is best to experiment with hot and cold to find which you find most effective.

2. Stretching

Stretching of the plantar fascia and Achilles tendon, often supervised by a Physiotherapist, is very effective at relieving acute pain.  There is some evidence that it may reduce the length of symptoms. 

3. Orthoses

Soft rubbery orthoses, also known as heel-cups, are also effective at reducing the acute symptoms of plantar fasciitis when walking. There is also some evidence that they may reduce the duration of the condition. 

4. Nocturnal dorsiflexion splints

A nocturnal dorsiflexion splint is a brace worn overnight holding the ankle at 90° and forcing the toes towards the shinbone.  There is good evidence that these reduce start-up pain first thing in the morning and reduce the length of duration of symptoms. They can however be uncomfortable to wear.

5. Anti-inflammatory medication

Anti-inflammatory medication can either be taken in tablet form, an example being Ibuprofen, or in the form of a steroid injection. Oral anti-inflammatories can be very effective particularly early on in the disease. However, it appears that their effect is often limited to the first month only. Injections of steroidsCompounds with a common basic structure, which occur naturally in the body. The term may also refer to man-made drugs administered because they act like hormones. such as cortisone and local anaestheticA medication that reduces sensation in a part of the body. also have a significant effect in reducing pain in the short-term but do not appear to reduce the length of symptoms. 

6. Extracorporeal shockwave therapy (Lithotripsy)

Extracorporeal Shock Wave Therapy involves passing shock waves from a probe through the tender area.  This has a short-term effect of reducing pain and may reduce the duration of symptoms. Currently there are several studies being performed to measure its effectiveness in the long term. 

Surgery to relieve plantar fasciitis

In addition to the non-operative treatments listed above, surgery can also be used to alleviate heel pain. Surgery to release the plantar fascia can be performed by either open or minimally invasive surgical techniques. Some surgeons also release the nervesBundles of fibres that carry information in the form of electrical impulses. in the region at the same time. This is reserved for patients that have severe limiting symptoms that are persisting beyond six months. This is effective in approximately 50% of patients but does have some associated risks. These include failure to relieve pain, infection, nerveBundle of fibres that carries information in the form of electrical impulses. injury resulting in numbness of the foot or a tender wound, bleeding, flattening of the foot, stiffness, wound tenderness, deep vein thrombosisObstruction of one of the deep veins, often in the calf, by a blood clot. Often abbreviated to DVT. (DVTAn abbreviation for deep vein thrombosis: the obstruction of one of the deep veins, often in the calf, by a blood clot.) and pulmonary embolismObstruction of the pulmonary artery by a blood clot. (PEpulmonary embolism). Complex regional pain syndrome is a rare condition of pain and swelling that can occur post operatively and is poorly understood. It is treated with physiotherapyThe use of physical therapies such as exercise, massage and manipulation. and pain medication. It may lead to chronic disability and pain if severe.

Summary

Plantar fasciitis is one of the most common orthopaedic conditions affecting the foot. In the vast majority of cases conservative, non-surgical treatment will be successful over a period of time although surgery may become necessary if the condition does not improve. A number of interesting studies are currently taking place into the effectiveness of shockwave therapy as a treatment for plantar fasciitis.