Heel Pain. Plantar Fascitis.

Introduction:

Plantar fasciitis is the commonest cause of heel pain. The mean age of symptoms in the late 50s. The mean age in athletes is about 10 years younger. The condition is rarely seen under the age of 20 or in extreme old age. Male:female ratio is about 1:2. It is commoner in the obese, in those standing for prolonged periods at work and working on a hard surface.

Plantar fasciitis is often said to be commoner in overpronators,(flat feet person) but most studies which have looked have found a large majority have neutral feet.

Riddle et al (2004) found that plantar fasciitis mainly affected work, hobbies and running rather than non-weightbearing and light physical activities. Obesity was the main predictor of the degree of disability.

History:

The characteristic complaint is of pain under the medial aspect of the heel, typically worst on the first step in the morning, improving as the day goes on then often getting more painful towards evening. Some patients have more weightbearing pain than first step pain. The pain may radiate across the heel or down the plantar fascia.

Tingling, electric shocks, altered sensation and rest pain should suggest nerve entrapment - tarsal tunnel syndrome, nerve to quadratus plantae, medial calcaneal nerves.

A history of trauma or recent increase in physical activity should suggest acute or stress fracture of the calcaneum. Many patients have had the problem for a long time - over a year is not unusual - and may have had a variety of treatments. However, it is rare to see a patient who has had plantar fascitis for over 3 years at presentation - whether the conditions resolves or patients adjust to it is unknown.

Patients have often had their symptoms explained to them in terms of a "spur" and may assume that they just need the spur removed and all will be well.

Examination:

Typical physical findings are localised tenderness under the medial calcaneal tubercle and sometimes in the proximal plantar fascia, sometimes worse on toe dorsiflexion (the windlass test). There is usually reduced ankle dorsiflexion due to a tight Achilles tendon - this may only be relatively reduce compared with the other side. The patient is often obese. The patient's hindfoot position and general foot shape and mobility should be noted.

Generalised heel tenderness is not typical of plantar fascitis and should usually exclude the diagnosis - the usual causes of this are plantar fat pad atrophy, previous calcaneal fracture and nonspecific pain.

Differential diagnosis:

Patients with Achilles tendon pathology may be referred as "heel pain" but the different site of pain and tenderness is usually obvious. Achilles tendonopathy and plantar fascitis coexist more often than would be expected by chance.Tenderness, hypersensitivity and a positive Tinel test should be sought over the tarsal tunnel, the nerve to quadratus plantae and the medial calcaneal nerves. Tenderness over the calcaneum itself may indicate a stress fracture. The ankle and subtalar joints should be examined - occasionally referred pain from an arthritic joint is felt under the heel. The tibialis posterior tendon should be examined. The local skin should also be searched for evidence of penetrating trauma.

Management:

The majority of patients will resolve on non-surgical management. Many non-surgical methods have been recommended, and there is no clear evidence that any modality is clearly better than others. We therefore recommend that treatment should begin simply and cheaply, using more costly and complex treatments for patients who fail initial treatment.

Initial management is aimed at symptom control and patient understanding of the problem and includes

• Explanation - usually includes explanation about insignificance of “heel spurs”
• Simple advice about obesity and shoewear
• Simple analgesia

Stretching exercises:

Most series assume these as part of general management. Stretching of the Achilles tendon is aimed to improve the range of ankle dorsiflexion, which is often deficient in patients with plantar fascitis.

Heel cups:

Intended to reduce forces on the heel and also relax the Achilles tendon.

Dorsiflexion night splint:

The rationale is that the Achilles tendon and plantar fascia normally contract at night in the relaxed equinus position, resulting in first-step pain when the tight foot hits the floor. If the ankle and toes are splinted in dorsiflexion this tightening is prevented. Some patients find the splint uncomfortable and stop using it.

Biomechanical treatment - strapping and orthotics:

The use of custom moulded orthoses derives from the concept, particularly prevalent in sports medicine and podiatry circles, that plantar fascitis is caused by overpronation, which stretches the plantar fascia. The evidence for this is equivocal, particularly as general populations with plantar fascitis (as distinct from selected athletic populations) have relatively few overpronators. Some practitioners use taping of the heel as an initial or independent step in this biomechanical approach to treatment, and a number of recent trials have suggested this has an independent effect.

Steroid injection:

Injections into the origin of the plantar fascia are intended to help resolve inflammation, although plantar fascitis is a non-inflammatory degenerative process. Steroid injection carries a small risk of plantar fascial rupture or infection. We use it only for resistant cases. If injections are carried out, the medial approach seems less unpleasant for the patient than an approach through the heel.

Casting:

The concept is of “resting” the plantar fascia; although there is only anecdotal evidence of efficacy, some resistant patients start to settle after a month in a below-knee walking cast.

Extracorporeal shockwave treatment: (ESWT). Now available at our clinic at BMI Gisburne Park Hospital.and BMI Beardwood Hospital.

This has been used in a number of degenerative soft-tissue conditions for its effects in stimulating tissue repair. Shockwave therapy appears to have different effects at different intensities and doses. NICE has recently released its guidance supporting its use in plantar fasciitis.

Surgical Management:

Surgery is rarely necessary for plantar fascitis. The usual indication for surgery is typical plantar fascitis unresolved after adequate conservative treatment. Most papers which express a view suggest that 6 months' conservative treatment is the minimum before embarking on surgery, although it may also be considered in a few patients with very severe symptoms at an earlier stage.

Plantar fascial release:

Most recent articles have described release or resection of the plantar fascial insertion from the calcaneum with removal of any spur that may be present. In view of biomechanical studies showing that partial plantar fascial release has less effect on arch stability than complete release, some surgeons have emphasised partial preservation of the attachment, while others carry out a full release or do not specify the extent of release . Spurs are often resected but no study has demonstrated that this makes a difference to the result.

Most studies describe open surgical approaches, usually medial. Brown et al described a transverse plantar approach which they claim reduces post-operative scar problems. Series of endoscopic plantar fasciotomy have been reported with increasing frequency. This is claimed to have a lower morbidity and shorter recovery time.

In what is perhaps the most realistic report of the results of surgery, Davies et al (1999) found that a combined 50% plantar fascial release and neurolysis of the first branch of the lateral plantar nerve reduced mean visual analogue pain score from 8.5 to 2.5/10, but half still had noticeable pain and restriction of activities at 1-5y follow-up. It took a mean of 8 months to reach the final outcome.

Plantar fascial release leads to slight flattening of the arch and may produce pain in the lateral column of the foot, which is commoner after a release of over 50% of the fascia.

Topaz Radiofrequency treatment:

This is a newer technique of surgical management of plantar fasciitis. It has been practiced in our clinic for the past 5 years for selected number of patients. Radiofrequency probe (Topaz, Arthrocare) is used to treat resistant cases of plantar fascitis.

Post-operative care:

Post-operatively most surgeons appear to have advised non-weightbearing for up to three weeks. However, Tountas and Fornasier allowed free weightbearing from the beginning and produced results comparable to other studies. (J L Barrie)