Do you experience a stabbing pain towards the heel of your foot when you place your feet to the ground, from the bed, when you wake up in the morning? Plantar fasciitis is the commonest cause of heel pain and anti-inflammatories and stretching exercises work well in almost all cases, says Dr Biswajit Dutta Baruah, consultant orthopaedic surgeon, KIMS Oman Hospital.
Continuing our discussion on heel pain from last week, when compared to Achilles tendinitis, plantar fasciitis is a more common cause of lower heel pain. About 15% of all foot pain relates to this painful condition. Often the condition is self-limiting and pain resolves in 90% of the cases in about 10 months. However, for most patients this long interval of wait time can be very frustrating and make them approach a physician. In Achilles tendinitis the pain is located on the back of the heel, while in plantar fasciitis it mostly arises at the bottom of the heel – the sole side of your foot.
The plantar fascia is a strong thick fibrous band of tissue that starts from the heel bone (calcaneum) at the back. As it runs forwards, it fans into three or more bands that meet the bones (phalanges) that make up the toes. Our feet are not flat but shaped like an arch due to the way the bones of the foot are stacked against one another. While standing the bones are loosely propped up against each other, but when walking the fascia tightens up pulling the toes closer to the heel bone. This pushes the stack of bones tightly against each other and in an upward direction thus raising the arch of the foot and providing a stable platform for us to propel our body forwards.
So what happens in fasciitis leading to pain? It is commonly thought to involve inflammation and degeneration of the fascia. The most common site is its attachment to the heel bone. It is a general understanding among physicians that there is mechanical overload and excessive straining of the fascia leading to microtears – tears so tiny that they are not visible to the common eye. This eventually leads to inflammation. Repeated heel strikes as it happens during walking or running hinders or prevents healing at the site of inflammation leading to a chronic condition and ultimately degeneration or wear & tear of the fascial attachment.
First thing in the morning, when patients place their foot on the ground, most patients have a sharp, stabbing type of pain towards the heel side of the foot. Many patients hobble around in pain. As the person is immobile during sleep, fluid accumulates at the site of inflammation leading to this type of ‘start-up’ pain. Swelling in the heel is not readily apparent from the outside in spite of fluid accumulation due to the thick skin that makes up the sole of the foot. As the day progresses, and the patient continues walking, the fluid build-up waxes and wanes leading to dissipation of pain. A dull aching or throbbing type of pain persists in many towards the end of the day. This may at times radiate to the arch or towards the toe end of the foot. Resting, elevating or massaging the foot often relieves this type of pain.
Key risk factors
Studies have shown that three important risk factors are strongly related to development of fascial degeneration. One group consists of those individuals who stand the majority of their time including homemakers. Second would be those with a very high body mass index (BMI – higher weight for the same height) and the third would be those with difficulty in raising their foot in the upward direction at the ankle joint indicating a tight achilles tendon. Although joggers are commonly thought to develop this condition, running is not the cause of the condition. It may become apparent in those who run or walk, due to the repetitive nature of heel strike during such activities uncovering the inflammation rather than actually causing it. Other factors like advancing age, incorrect foot posture or poor footwear also contribute to the development of this condition.
Diagnosis and treatment
Plain x-rays are often ordered by family physicians revealing a bony outgrowth from the heel bone, called a bone spur. As the fascia is not visible on the x-ray, many patients (including several physicians) are distracted by the spur. Its relevance to fasciitis has not been established yet. Ultrasound is a good way to assess the thickness of the fascia and determine the exact site of inflammation.
Fascia is about 2-4 mm thick in normal individuals while in fasciitis this may increase to 7-8 mm in thickness, which is why many physicians prefer to call it fibromatosis (fibrous thickening) rather than fasciitis (inflammation). MRI scans are rarely ordered when patients fail to respond to regular treatment.
As the first line of treatment most physicians will prescribe a course of anti-inflammatories with prefabricated (readymade) soft insoles to be placed inside of their shoes or sandals. Stretching exercises for the fascia have been helpful at this early stage. Often stretching of the plantar fascia is combined with stretching of the achilles tendon. Most sportsmen and women will be familiar with these stretching techniques as a part of their warm-up exercises.
Night and day relief techniques
Night time splinting may be helpful. During sleep, the foot is normally bent downwards at the ankle joint. Splinting keeps the foot in a more straight (neutral) position, preventing shortening and thickening of the fascia. However, most patients find splinting cumbersome and rarely comply with instructions.
During the day time, prefabricated or custom made-to-order orthoses such as heel cups and arch supports may be prescribed as well. If this line of treatment fails, cortisone shots (corticosteroids) have often been employed to overcome inflammation as a second line of treatment.
Steroids, shockwaves, surgery
After reading last week’s article, a few astute readers inquired about the ill-effects of steroids. Steroids are often employed as potent anti-inflammatory agents directed at the site of inflammation. Studies have shown effective short term relief from pain. However, steroids can be like a double-edged sword proving beneficial at one end while proving harmful at the other end.
In cases of tendinitis especially, injection into the tendon itself can lead to weakening and subsequent tears in the tendon. Repeat injections therefore, must be avoided and the potential risks of infection and subsequent tears in the tendon or fascia must be balanced against the benefits of pain relief. In other words, not all patients may be candidates for cortisone shots. Instead, platelet-rich plasma injections may be helpful in the healing of this condition.
Shock wave therapy by the physiotherapist is also known to be beneficial in treating this condition. Fasciotomy or surgical release of the fascia is often reserved for a small minority of patients who have not responded well to medicines and physiotherapy. This is often combined with excision of the calcaneal spur, excision of inflammatory tissue and decompression of the branches of the plantar nerve.
In summary, plantar fasciitis is the commonest cause of heel pain. It is often self-limiting and the diagnosis is usually made without resorting to x-rays or scans. Anti-inflammatories and stretching exercises work well in almost all cases. Shockwave therapy can be helpful and rarely is surgical release required.
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