Plantar Fasciitis - Heel Pain

‘Hey Doc, I have a spur la’, said my buddy and hockey devil Avtar. ‘What makes you think so huh?’ I asked worried. ‘I have pain over my heel. What else can it be la?’ he retorted.

That started me on a long lecture about how not all heel pain is caused by a spur. Well, I concede that while plantar fasciitis is the most common cause of heel pain, other causes need to be ruled out by the treating doctor for effective and accurate care. These include  stress fractures of the calcaneum, tendonitis of the tendo Achilles or foot flexors, arthritis of the foot joint and nerve irritation being the more common differential diagnoses.

Once other causes have been ruled out, getting rid of that irritating pain of Plantar Fasciitis is a logical end goal!

So… The million-dollar question - How do we do that? To treat plantar fasciitis one must understand the condition well.

What Is Plantar Fasciitis?
The plantar fascia is a band of tissue attached to the heel and extends to the toes - specifically from the medial calcaneal tubercle to the bases of the proximal phalanges. It functions to maintain the longitudinal arch of the foot and is important in the dynamics of proper foot function. In plantar fasciitis, the fascia  becomes inflammed due to repeated injury-irritation resulting in heel pain. This can be as a consequence of a poorly treated acute injury or the end result of overuse.

Causes
The most common cause of plantar fasciitis relates to faulty structure of the foot whether congenital or acquired:

1.                   Reduced flexibility at the ankle especially that due to a tight Achilles tendon is a independent risk factor for fasciitis

2.                   Poor footwear especially with hard heel regions place an undue stress to the region of the plantar fascia. This coupled with job descriptions that require prolonged standing and walking predispose to plantar fasciitis.

3.                   Obesity may also contribute to the development of plantar fasciitis.

Symptoms
The symptoms of plantar fasciitis are:

• Pain on the bottom of the heel. This is worse upon rising in the morning and usually subsides with activity. There may remain  a residual dull ache in the heel. The pain returns or is worsened by long periods of immobilization.

Diagnosis
Accurate diagnosis requires a detailed history and clinical examination. Other causes of heel pain should be ruled out systematically. Pain to pressure over the medial part of the heel is pathognomonic. Palpation of the fascial band is essential to not miss a rupture or tear of the fascia. Associated assessment of the tendoachilles for tightness is essential for optimal care.

Although diagnosis is essentially via clinical evaluation, diagnostic imaging studies such as x-rays or other imaging modalities may be used to distinguish the different types of heel pain.

Sometimes heel spurs are found in patients with plantar fasciitis, but these are rarely a source of pain. When they are present, the condition may be diagnosed as plantar fasciitis/heel spur syndrome.

Non-Surgical Treatment
Treatment of plantar fasciitis begins with first-line strategies, which you can begin at home:

• Stretching exercises. Exercises that stretch out the calf and toe flexor muscles help ease pain and assist with recovery. These concentrate of stretching the Achilles tendon
• Shoe modifications. Wearing supportive shoes that have good arch support and a slightly raised heel reduces stress on the plantar fascia. This aids in the acute phase. Prevention of recurrence circles around continuance of optimum footwear.
• Medications. Oral nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, may be recommended to reduce pain and inflammation.

If these methods fail or if symptoms worsen, it is good to get an expert opinion from your Orthopaedic Surgeon. You may be then advised on these methods:

• Orthotic devices / Splints. Custom orthotic devices that fit into your shoe help correct the underlying structural abnormalities causing the plantar fasciitis. Splints are usually used as an adjunct to stretching exercises and are usually prescribed for night use.
• Injection therapy. In some cases, corticosteroid injections are used to help reduce the inflammation and relieve pain. Newer options such as platelet rich plasma to restart the healing process are currently popular in recalcitrant cases.
• Extracorporeal Short Wave Therapy. The use of ESWT is gaining popularity as a therapy in chronic symptomatic cases.

When Is Surgery Needed?
Although most patients with plantar fasciitis respond to non-surgical treatment, a small percentage of patients may require surgery.  The decision for surgery is usually taken in the group of patients who remain symptomatic in spite of compliance to a structured stretching and rehabilitation programme. Post surgery, rehabilitation has to be continued to obtain optimum benefit.

Long-term Care
It is important to understand that the causative elements of plantar fasciitis may often remain. This underlines the need for continued preventive measures. Appropriate supportive shoes, properly done stretching programmes and using orthotic devices where appropriate are the mainstay of long-term treatment for plantar fasciitis.