Plantar fasciitis, formerly called “a dog’s heel” in the United Kingdom, sometimes known as “flip-flop disease” among US podiatrists, is a painful inflammatory condition caused by excessive wear to the plantar fascia of the foot or biomechanical faults that cause abnormal pronation of the foot. The pain is usually felt on the underside of the heel and is often most intense with the first steps of the day. It’s commonly associated with long periods of weight bearing or sudden changes in weight bearing or activity. Obesity, weight gain, jobs that require a lot of walking on hard surfaces, shoes with little or no arch support and inactivity are also associated with the condition. This condition often results in a heel spur on the calcaneus, in which case it’s the underlying condition, and not the spur itself, which produces the pain.
The most common cause of heel pain is plantar fasciitis. The common name is “heel spur” because it’s easier to pronounce than “plantar fasciitis” and doctors are able to point to the spur on an x-ray. Many different treatments have been effective, and although it typically takes 6 to 18 months to find a favorable resolution, plantar fasciitis has a generally good long-term prognosis. The mainstays of treatment are stretching the Achilles tendon and plantar fascia, resting, keeping off the foot as much as possible, discontinuing aggravating activity, cold compression therapy, contrast bath therapy, weight loss, arch support, heel lifts and taping. Care should be taken to wear supportive and stable shoes. Patients should avoid open-back shoes, sandals, “flip-flops” and any shoes without a raised heel.
Treatment of Plantar Fasciitis
- Arch support: This is often recommended by doctors and journal articles, and is ranked number one in several medical surveys. Several fan-favorite arch supports are the $24 Powerstep and the Pinnacle Powerstep, which have more arch support than the ones seen in stores.
- Resting: The most important part of heel spur recovery is to finally learn the motto “when in doubt, don’t do it”. It takes 12 to 36 hours for many soft-tissue injuries to reach their maximum soreness, so it’s often difficult to know when you’re overdoing it or which particular activity (like squatting or climbing stairs) caused the pain to increase again. Swimming is one of the few safe alternative exercises.
- Cold Compression Therapy: Ice is a miracle cure for soft-tissue injuries. Ice is not only great for professional football players with knee or shoulder injuries, but also for “desk jockeys” who can’t seem to get rid of their heel pain. It was ranked the third best treatment by our visitors. Applying ice after activity or injury is crucial. It may be beneficial to apply it up to five times a day. The best method of applying ice seems to be freezing a can of beans and applying it for five minutes. It can be reused, it doesn’t melt and get things wet, and the metal transfers cold better than a plastic water bottle.
- Taping: Tape can be used to give the fascia rest without reducing activity. Athletic tape can be bought at all pharmacies. Tape is the cure for severe cases of plantar fasciitis that usually begins as a result of suddenly increasing weight pressure on the heel due to, say weight gain or injury. Losing weight, ice and stretching would have been enough in cases like this, but most don’t know how important ice and stretching is, so their inflammation and pain eventually turns chronic and tape becomes necessary.
- Stretching: In cases of chronic plantar fasciitis of at least ten months duration, one recent study has shown high success rates with a stretch of the plantar fascia. Pain with first steps of the day can be markedly reduced by stretching the plantar fascia and Achilles tendon before getting out of bed.
Night splints can be used to keep the foot in a dorsi-flexed position during sleep to improve calf muscle flexibility and decrease morning pain. These have many different designs, some of which may be hard and may press on the origin of the plantar fascia. Softer, custom devices, of plastizote, poron or leather may be more helpful. Orthoses should always be broken in slowly.
- NSAIDs: To relieve pain and inflammation, nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin and ibuprofen are often used but are of limited benefit. Patients should be encouraged to lessen activities that place more pressure on the balls of their feet because it increases tension in the plantar fascia. This is counterintuitive because the pain is in the heel, and the heel is often sensitive to pressure which causes some patients to walk on the balls of their feet.
- Corticosteroids: Local injection of corticosteroids often gives temporary or permanent relief, but may be painful, especially if not combined with a local anesthetic and injected slowly with a small-diameter needle. Recurrence rates may be lower if injection is performed under ultrasound guidance. Repeated steroid injections may result in rupture of the plantar fascia. This may actually improve pain initially, but has deleterious long-term consequences.
- Therapeutic Utrasound: Therapeutic ultrasound has been shown in a controlled study to be ineffective as a treatment for plantar fasciitis. More recently, however, extracorporeal shockwave therapy (ESWT) has been used with some success in patients with symptoms lasting more than six months. The treatment is a nonsurgical procedure, but is painful, and ideally should be done either under sedation or local anesthesia and either with or without intravenous sedation (twilight sedation).
Local anesthesia by injection of drugs into the area can also be painful, and may incur the risks of neuritis, bleeding and infection. ESWT re-inflames the area and in doing so increases blood flow to the area as a means to heal the area. It can take as long as six months following the procedure to see results. Like any other procedure, there are varying degrees of success. Most patients should improve within one year of beginning non-surgical treatment, without any long-term problems. A few patients, however, will require surgery. Over 95% will then be relieved of their heel pain.
- Surgery: Surgery carries the risk of nerve injury, infection, rupture of the plantar fascia and failure of the pain to improve. Surgical procedures, such as plantar fascia release, are a last resort that often lead to further complications, such as a lowering of the arch and pain in the supero-lateral side of the foot due to compression of the cuboid bone. An ultrasound guided needle fasciotomy can be used as a minimally invasive surgical intervention for plantar fasciitis. A needle is inserted into the plantar fascia and moved back and forwards to disrupt the fibrous tissue.
Symptoms of Plantar Fasciitis
The classic sign of plantar fasciitis is heel pain with the first few steps in the morning (84% of sufferers). If this symptom is not present, then the diagnosis of this condition has to be checked more carefully. The pain is usually in the front and bottom of the heel, but the definition of “plantar fasciitis” indicates it can be over any portion of the bottom of the foot where the fascia is located. Patients often report that the pain “moves around.”
The pain can be mild or debilitating. It can last a few months, become permanent, or come and go every few months or years for the rest of a patient’s life with no obvious explanation. Every year, about 1% of the population seeks medical help for this condition (one company claims it’s 2.5%). The heel may hurt when it strikes the ground, but plantar fasciitis is not caused by the heel striking the ground.
Some patients begin walking on the front of their foot because of heel pain. This may help if they have something other than plantar fasciitis, but if they have plantar fasciitis, walking on the forefoot causes more tension in the plantar fascia (which pulls more on the heel) and it can make their condition worse. Unfortunately, it can take 12 to 36 hours after harmful activity before the pain increases, so it’s not usually obvious what activity is causing an increase in pain.
Despite the claims of various product manufacturers, there is no cure-all for this complex foot ailment. Different treatments help different people. Patients need to be active in their treatment. Experimenting with several different treatments is often necessary before finding those that help.
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