Plantar fasciitis

Plantar fasciitis is a common cause of heel pain. The plantar fascia is a thick band of connective tissue which supports the arch of your foot and runs from the heel to the base of your toes. The function of the plantar fascia is to provide tension across, and therefore support the arch of your foot.

Due to repeated excessive mechanical stress, for example standing long periods of time that put your foot in huge stress, the fascia can be inflamed. This results in pain and is called plantar fasciitis.

Plantar fasciitis is more common in runners. In addition, people who are overweight and those who wear shoes with inadequate support have an increased risk of plantar fasciitis.

Under normal circumstances, your plantar fascia acts like a shock-absorbing bowstring, supporting the arch in your foot. If tension and stress on that bowstring become too great, small tears can arise in the fascia. Repetitive stretching and tearing can cause the fascia to become irritated or inflamed, though in many cases of plantar fasciitis, the cause isn't clear.

Symptoms are typically at their most severe first thing in the morning, with the first steps of the day, after the plantar fascia has developed stiffness overnight. Pain normally settles as the morning progresses.

Plantar fasciitis typically causes a stabbing pain in the bottom of your foot near the heel. The pain is usually the worst with the first few steps, although it can also be triggered by long periods of standing or rising from sitting. The pain is usually worse after exercise, not during exercise.

 

Plantar fasciitis can be reliably diagnosed by your doctor or physiotherapist by taking a history of your condition and by conducting a physical examination. The main feature on examination is often pain with direct palpation over the heel bone or the plantar fascia itself as it runs under the arch of the foot.

X-rays and scans are not routinely required.

  • Age. Plantar fasciitis is most common between the ages of 40 and 60.
  • Certain types of exercise. Activities that place a lot of stress on your heel and attached tissue, such as long-distance running, ballistic jumping activities, ballet dancing and aerobic dance can contribute to an earlier onset of plantar fasciitis.
  • Foot mechanics. Being flat-footed, having a high arch or even having an abnormal pattern of walking can affect the way weight is distributed when you're standing and put added stress on the plantar fascia.
  • Obesity. Excess pounds put extra stress on your plantar fascia.
  • Occupations that keep you on your feet. Factory workers, teachers, policeman and other occupations who spend most of their work hours walking or standing on hard surfaces can damage their plantar fascia.

This condition is easily diagnosed clinically and does not routinely require any special tests.

An X-ray has a certain specific feature to support the diagnosis and an MRI is occasionally carried out to rule out other causes of heal pain.

Management

This condition can often be successfully self-managed in the following ways:

  • Avoidance of aggravating activity. Plantar fasciitis is commonly triggered by excessive weight bearing activity and reducing the time and duration of standing will help the condition improve.
  • Footwear. Lack of adequate support from footwear is another cause. It is important to wear footwear with a firm sole and adequate support to the arch, especially if the arch is flattened. Flip flops offer very little support and change to a more supportive shoe can help.
  • Weight reduction. Reducing weight will reduce forces across the plantar fascia and assist recovery.
  • Exercises. Exercises that stretch the plantar fascia and improve flexibility of the calf and plantar fascia are a mainstay of treatment.

The Arthritis Research UK website has a particularly good exercise leaflet.

5×30 second holds, 2x per day

5×30 second holds, 2x per day

  • Podiatrist. If the above measures are unsuccessful, referral to a podiatrist for advice and consideration of an insole is worth considering, especially if there are biomechanical issues. There is no evidence to suggest that custom made insoles are any more effective than those bought over the counter.
  • Physiotherapy. local treatment or taping may be helpful and can be accessed via you GP or by self-referral.
  • Night splints. although cumbersome there is some evidence that they can improve symptoms. They can be bought online
  • Time. The plantar fascia lacks blood supply and is a thick fibrous tissue. As a result, time is needed for symptoms to resolve. Do not be in a hurry to move onto invasive treatments as it is a condition that will normally resolve with time
  • Corticosteroid injection therapy. For individuals with plantar fasciitis who continue to suffer disabling symptoms in spite a course of non-surgical management, a corticosteroid injection can be offered as the next line of treatment. This injection is a very painful procedure. Its success rate is variable and often of short-term benefit. There is a small risk of tendon rupture and atrophy of the plantar fat pad so a fully informed consent is necessary before performing the procedure. You can read more about local corticosteroid injections here.

Treatment options

An injection into the plantar fascia either with steroid or PRP (plasma rich protein) does give pain relief, although these can sometimes be temporary pain relief.

Surgery

If adequate conservative measures fail to resolve the condition a surgical release procedure can be offered, although this is rarely necessary.

Useful Links

NHS choices

Arthritis Research UK

Surgery is carried out as a daycase under anaesthesia. You will walk with surgical shoes for 2 weeks and will be invited to attend a follow-up appointment. You may need crutches for the first few weeks.

What are the risks of surgery?

There are some risks associated with surgery, however these are small.

There is a small risk of wound infection, developing clots in your leg or lung, swelling of your foot and ankle for up to to 3 months or more, over sensitivity of scar, injury to any of major nerves or blood vessels around the area of surgery, temporary or permanent numbness around the area of surgery.

In very rare occasions, you may have chronic pain as a result of surgery (CRPS), loss of limb and anaesthetic risk. However these risks are very rare. Please discuss this further with your surgeon.

You should get back to most of your normal activities, including driving at 2-4 weeks. It is normal to have some discomfort and swelling for up to 3 months.

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