Plantar fasciitis refers to an inflammation of the plantar fascia, a thick, fibrous band running along the sole of the foot. Such inflammation results from direct injury to the plantar fascia, usually, repeated trauma to the tissue where the fascia attaches to the calcaneus or heel bone. The plantar fascia is critical in maintaining the foot’s complex arch system, also playing a role in balance and fine control of certain phases of the athlete’s gait. Injury to the plantar fascia is particularly painful and disabling for runners and can often prove stubbornly resistant to treatment. Rehabilitation is frequently a lengthy and frustrating process. For these reasons, care should be taken where possible to avoid such injury by means of preventative exercises and sensitivity to early warning signs.
Plantar fasciitis can be confused with a condition called tarsal tunnel syndrome. In tarsal tunnel syndrome, an important nerve in the foot, the tibial nerve, is trapped and pinched as it passes through the tarsal tunnel, a condition analogous to carpal tunnel syndrome in the wrist. This may cause symptoms similar to the pain of a plantar fasciitis. There are also other less common problems such as nerve entrapments, stress fractures, and fat pad necrosis, all of which can cause foot pain. Finally, several rheumatologic conditions can cause heel pain. These syndromes such as Reiter’s syndrome and ankylosing spondylitis can cause heel pain similar to plantar fasciitis. If your symptoms are not typical for plantar fasciitis, or if your symptoms do not resolve with treatment, your doctor will consider these possible diagnoses.
The condition typically starts gradually with mild pain at the heel bone often referred to as a stone bruise. You’re more likely to feel it after (not during) exercise. The pain classically occurs right after getting up in the morning and after a period of sitting. If you don’t treat plantar fasciitis, it may become a chronic condition. You may not be able to keep up your level of activity, and you may develop symptoms of foot, knee, hip and back problems because plantar fasciitis can change the way you walk.
During the physical exam, your doctor checks for points of tenderness in your foot. The location of your pain can help determine its cause. Usually no tests are necessary. The diagnosis is made based on the history and physical examination. Occasionally your doctor may suggest an X-ray or magnetic resonance imaging (MRI) to make sure your pain isn’t being caused by another problem, such as a stress fracture or a pinched nerve. Sometimes an X-ray shows a spur of bone projecting forward from the heel bone. In the past, these bone spurs were often blamed for heel pain and removed surgically. But many people who have bone spurs on their heels have no heel pain.
Non Surgical Treatment
About 90% of plantar fasciitis cases are self-limited and will improve within six months with conservative treatment and within a year regardless of treatment. Many treatments have been proposed for the treatment of plantar fasciitis. First-line conservative approaches include rest, heat, ice, calf-strengthening exercises, techniques to stretch the calf muscles, achilles tendon, and plantar fascia, weight reduction in the overweight or obese, and nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin or ibuprofen. NSAIDs are commonly used to treat plantar fasciitis, but fail to resolve the pain in 20% of people. Extracorporeal shockwave therapy (ESWT) is an effective treatment modality for plantar fasciitis pain unresponsive to conservative nonsurgical measures for at least three months. Corticosteroid injections are sometimes used for cases of plantar fasciitis refractory to more conservative measures. The injections may be an effective modality for short-term pain relief up to one month, but studies failed to show effective pain relief after three months. Notable risks of corticosteroid injections for plantar fasciitis include plantar fascia rupture, skin infection, nerve or muscle injury, or atrophy of the plantar fat pad. Custom orthotic devices have been demonstrated as an effective method to reduce plantar fasciitis pain for up to 12 weeks. Night splints for 1-3 months are used to relieve plantar fasciitis pain that has persisted for six months. The night splints are designed to position and maintain the ankle in a neutral position thereby passively stretching the calf and plantar fascia overnight during sleep. Other treatment approaches may include supportive footwear, arch taping, and physical therapy.
If treatment hasn’t worked and you still have painful symptoms after a year, your GP may refer you to either an orthopaedic surgeon, a surgeon who specialises in surgery that involves bones, muscles and joints, a podiatric surgeon, a podiatrist who specialises in foot surgery. Surgery is sometimes recommended for professional athletes and other sportspeople whose heel pain is adversely affecting their career. Plantar release surgery. Plantar release surgery is the most widely used type of surgery for heel pain. The surgeon will cut the fascia to release it from your heel bone and reduce the tension in your plantar fascia. This should reduce any inflammation and relieve your painful symptoms. Surgery can be performed either as, open surgery, where the section of the plantar fascia is released by making a cut into your heel, endoscopic or minimal incision surgery – where a smaller incision is made and special instruments are inserted through the incision to gain access to the plantar fascia. Endoscopic or minimal incision surgery has a quicker recovery time, so you will be able to walk normally much sooner (almost immediately), compared with two to three weeks for open surgery. A disadvantage of endoscopic surgery is that it requires both a specially trained surgical team and specialised equipment, so you may have to wait longer for treatment than if you were to choose open surgery. Endoscopic surgery also carries a higher risk of damaging nearby nerves, which could result in symptoms such as numbness, tingling or some loss of movement in your foot. As with all surgery, plantar release carries the risk of causing complications such as infection, nerve damage and a worsening of your symptoms after surgery (although this is rare). You should discuss the advantages and disadvantages of both techniques with your surgical team. Extracorporeal shockwave therapy (EST) is a fairly new type of non-invasive treatment. Non-invasive means it does not involve making cuts into your body. EST involves using a device to deliver high-energy soundwaves into your heel. The soundwaves can sometimes cause pain, so a local anaesthetic may be used to numb your heel. It is claimed that EST works in two ways. It is thought to, have a “numbing” effect on the nerves that transmit pain signals to your brain, help stimulate and speed up the healing process. However, these claims have not yet been definitively proven. The National Institute for Health and Care Excellence (NICE) has issued guidance about the use of EST for treating plantar fasciitis. NICE states there are no concerns over the safety of EST, but there are uncertainties about how effective the procedure is for treating heel pain. Some studies have reported that EST is more effective than surgery and other non-surgical treatments, while other studies found the procedure to be no better than a placebo (sham treatment).