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Plantar Fasciitis

What Is Plantar Fasciitis?

Before describing the condition, you may wish to read about the normal anatomy of the plantar fascia here.

The plantar fascia is a thin band on the sole that has a very important role in the foot, maintaining the shape and arch of the foot.

The suffix “itis” is used to describe inflammation of a part of the body, for example gastritis, which is inflammation of the stomach. The term plantar fasciitis therefore means inflammation of the plantar fascia.

However the term plantar fasciitis is strictly incorrect. Research has shown that there is actually little, if any inflammation. That is why NSAIDs (such as ibuprofen) do not work except for patients who are in the early stages of the disease (when there is a little inflammation present). In fact, plantar fasciitis is a degenerative condition and for that reason it is more appropriate to call it plantar fasciopathy. By degeneration we mean “wear and tear”. The body’s normal healing response is impaired resulting in pain. Instead of a thin strong band of tissue the fascia becomes thickened and has weaker properties.

Patients often come to The London Foot and Ankle Clinic having been told that they have a heel spur, which is the cause of their symptoms. This was in the past thought to be the cause of plantar fasciitis but has now been disproven. A large proportion of the population has a “heel spur” and it is now seen as an incidental finding and nothing else.

The plantar fascia (white arrow) Achilles tendon (red arrow) and continuous fibres (yellow arrow)

The plantar fascia (white arrow) Achilles tendon (red arrow) and continuous fibres (yellow arrow)

MRI scans of the hindfoot showing a normal plantar fascia and an abnormal plantar fascia

MRI of the hindfoot demonstrating A – normal plantar fascia and B – abnormal plantar fascia consistent with plantar fasciitis

What Can Cause It?

Risk factors for plantar fasciitis include:

  • Obesity – puts more strain on the plantar fascia
  • Prolonged standing – can damage the plantar fascia
  • Wearing unsupportive footwear on hard surfaces
  • Increasing age – is most common between the ages of 40 and 60
  • Exercise – certain sports and activities place a lot of stress on the heel such as running and dance aerobics
  • Tight calf muscles – additional strain and load on the plantar fascia
  • Abnormal foot biomechanics – very flat feet or feet with very high arches can predispose to plantar fasciitis

What Are The Symptoms?

Pain is the most common symptom of plantar fasciitis.

The characteristics of plantar fasciitis are –

  • Pain worse first thing in the morning (getting out of bed)
  • Pain worse after a period of rest or sitting and then getting up (post static dyskineasia)
  • Pain that eases with walking initially
  • Pain that gets worse the longer you are on your feet
  • Pain that initially is intermittent but then becomes chronic
  • Pain on the plantar medial aspect of the foot (inside of the heel)
  • Pain that is aching, sharp, stabbing, burning or throbbing in nature
  • Not uncommon to have pain in both feet
  • May have history of calf tightness or cramps
  • May have history of Achilles tendon pain

On clinical examination patients complain of pain at a specific point on the plantar aspect of the heel. Patients will often have tight calf muscles.

The history and examination will aim to rule out other pathology that can cause similar symptoms. Other conditions that can cause plantar heel pain include:

  • Disc prolapse and sciatica
  • Tarsal tunnel syndrome
  • Calcaneal stress fracture
  • Calcaneal stress lesion (reaction within the bone, but no fracture)
  • Nerve entrapment i.e. lateral calcaneal nerve (Baxters nerve entrapment)
  • Subtalar joint osteoarthritis
  • Fat pad atrophy
  • Infection
  • Systemic conditions such as i.e. rheumatoid arthritis, Reiters syndrome, Ankylosing spondylitis, gout
  • Overload heel pain syndrome
  • Ruptured plantar fascia
  • Soft tissue mass (tumour)

What Investigations May Be Required?

The diagnosis is based on history and clinical examination in the majority of patients with “classic” symptoms and examination findings as described above.


Radiographs

Radiographs are rarely requested unless there are atypical symptoms and other pathology needs to be ruled out.


Ultrasound

An ultrasound is a quick and pain free investigation that can confirm the diagnosis.


MRI

MRI is particularly useful in making the diagnosis and ruling out other conditions such as a calcaneal stress fracture. It is requested if there are atypical symptoms and examination findings.

MRI is particularly useful in assessing:

  • Thickening of plantar fascia
  • Evidence of plantar fascia rupture or tear
  • Cartilage damage (arthritis)
  • Reactive bone changes (stress response)
  • Synovitis (inflammation and fluid in the joint)
  • Inflammation and oedema in tissues
  • Inflammation of bursa (bursitis)
  • Other pathology

Can The Problem Get Worse?

Yes the pain can become chronic in nature and more severe however this is uncommon as the condition tends to be self limiting and the majority of people get better.

Rarely the plantar fascia can rupture (partial or complete).

To ease the pain you may alter your gait pattern and therefore walk in such a way that puts abnormal pressure on other joints. As a result you may develop ankle, knee, hip or back problems.

Non-Operative Treatment Options

Non-operative management aims at relieving pain ad allowing return to normal function.

It should always be the first line of treatment. Options include:

Activity modification

A period of rest from sports and exercise that bring on symptoms. Avoiding high impact activities and sports. Reducing the amount of time standing and walking particularly on hard surfaces.


Footwear

Wearing shoes with cushioned heels.


Orthotics

Gel heel pads to cushion the heel and act as an additional shock absorber.

Orthotics with an arch support to help spread the load across the whole foot.


Splints

A night splint holds the plantar fascia and calf muscles in a lengthened position overnight and facilitates stretching.


Immobilisation

Immobilisation in a walking cast or boot for 4 weeks is sometimes indicated and may help alleviate symptoms.


Non steroidal anti-inflammatories

The use of non-steroidal anti-inflammatory drugs (NSAIDs) can decrease discomfort from plantar fasciitis in the very early stages of the condition when some inflammation is present. However usually in most patients there is no inflammation and therefore NSAIDs tend not to work.


Physiotherapy

Calf muscle stretches and plantar fascia stretches help reduce the forces going across the plantar fascia.

Intrinsic foot muscle strengthening exercise, lower limb muscle conditioning and strengthening exercise can also help ease symptoms.


Time

This is a self limiting condition in the majority of patients. It can take up to a year or more for symptoms to settle.


Extracorporeal shockwave therapy (ESWT)

Relatively new technique although evidence is coming forwards to show that it is effective in select cases. To qualify for this treatment patients should have symptoms for greater than 6 months. Patients with symptoms of less duration may find their symptoms are worse after treatment.

Shockwaves are used to create microtears in the plantar fascia, which in turn generates an inflammatory (healing) response. Three courses of ESWT are required spaced 1-2 weeks apart. Patients should avoid taking NSAIDs during treatment. The procedure is quite painful. In the majority of patients the pain is limited to the actual duration of treatment, which is about 5 minutes. We inform you of this only to forewarn rather than dissuade you of this treatment.

The complications of this procedure include bruising, swelling, pain, numbness or tingling and very rarely plantar fascia rupture. Treatment does not guarantee relief of symptoms.

Injections For Plantar Fasciitis

Injections are rarely carried out due to poor results and low efficacy. May work for a short period in some patients but generally not very effective and carries significant risk of complications such as plantar fascia rupture and fat pad atrophy (the natural cushion of the heel wastes away).


Image guided steroid injection

In very few select cases an image guided local anaesthetic and steroid injection at the plantar fascia origin is performed. This is carried out under a short general anaesthetic and under x-ray control.

Steroids act by reducing inflammation. As most chronic cases of plantar fasciitis have no inflammation these injections tend not to work.


Dry needling

Multiple small needle punctures are made in the symptomatic area under ultrasound guidance. This causes bleeding at the site of the plantar fasciopathy, and like ESWT is thought to simulate an inflammatory healing reaction. Results are unpredictable but complications minimal.

Operative Treatment Options

Surgical management is reserved for patients who have failed to respond to non operative treatment. Surgery is very rarely necessary for the treatment of plantar fasciitis.

Patients should understand that the decision to undergo surgery should not be taken lightly.

Any intervention is considered in a step wise manner, with the least invasive procedure carried out first.


Proximal medial gastrocnemius release

In patients who have failed conservative management and have tight calf muscles a proximal medial gastrocnemius release can be effective in easing symptoms in up to 80% of patients.

This operation involves making a small 2cm incision at the back of the knee and releasing the medial head of the gastrocnemius muscle. It lengthens the calf muscle and relieves the tension across the Achilles tendon and plantar fascia.

The operation is carried out under local anaesthetic and a short sedation. It is a day case procedure so you can expect to go home the same day. As the wound itself is small and the operation involves cutting fascia and not muscle most patients are able to walk out of hospital without crutches and are able to drive within 4 to 5 days. Calf stretching exercises are recommended for 2 weeks post surgery to help maintain the increased length obtained by surgery.

Expect to feel the benefit of the operation 6 to 8 weeks post surgery.

A typical wound following a proximal medal gastrocnemius release

A typical wound following a proximal medal gastrocnemius release

 


Plantar fascia release

Plantar fascia releases are rarely performed at The London Foot and Ankle clinic due to potential complications such as plantar fascia rupture, loss of foot arch and chronic pain.

Potential Complications

It should be borne in mind that complications can result from a condition with or without surgery.


Potential complications of non-operative treatment include:

  • Worsening pain
  • Plantar fascia rupture
  • Abnormal gait – altered kinetic chain with resulting problems in ankle, knee, hip or back

Complications can occur as with any type of surgery. Please see Complications for more detailed explanation of post surgical complications.

Potential general complications of any operative treatment include:

  • Risks and complications of anaesthesia
  • Bleeding
  • Infection (superficial and deep)
  • Blood clots
  • Need for further surgery
  • Complex regional pain syndrome
  • Wound healing problems
  • Painful scar
  • Persistent pain

Potential specific complications of proximal medial gastrocnemius release include:

  • Saphenous nerve injury

Note – these complications are not exhaustive and are meant as a guide

Post Operative Period & Recovery

Please read the information regarding what to expect post surgery on this website.

Remember that below is a guide to recovery and that everyone heals at different rates and some people do take longer. Use this information to help you understand your condition, possible treatment and recovery. The timeframes given below are a minimum, it is important that you appreciate this when considering surgery as your healing and recovery may take longer.


Immediate post operative period

Following a proximal medial gastrocnemius release –

You will have a small waterproof dressing applied to the back of the knee. It is advised not to remove this until seen at clinic by Mr Malik at the 2 week follow up.

For 2 weeks following surgery it is recommended that you keep the area dry. You may wish to get a Limbo bag which will stop the wound getting wet.

Most patients are able to walk comfortably without any aids after the operation. If both legs have been operated on then crutches maybe necessary. A physiotherapist will guide you before your discharge from hospital. Please ensure someone is able to drive you home after the operation. It is important that you commence calf stretching exercises as soon as possible after the operation. Activities can be gradually increased as pain allows.


Two weeks post operatively

You will be reviewed at the clinic and your dressings removed. Your wound will be checked and if completely healed you will be given advice regarding soft tissue massage and scar desensitisation. Scar desensitisation should start as soon as the wound has completely healed. You can do this by massaging cream (E45 for example) into the scar and around the wound area. You may shower and get the area wet only if the wound has completely healed and is dry.

You may be referred at this stage for physiotherapy for early rehabilitation – calf and  plantar fascial stretches and intrinsic foot muscle strengthening exercises.


Six weeks post operatively

At this stage if your healing is progressing satisfactorily swelling and bruising should have subsided considerably. You should start noticing an improvement in pain levels.


Three months post operatively

Final clinical examination. Discharge if satisfactory.

FAQs

How long does the operation take?

This is probably the most common question asked of surgeons. Total operation time is different from the actual total surgical time. For example a flight involves not just the flying time, but the time checking in, going through security and boarding the plane for example.

The time given below is only a guide to the actual surgical time.

For a proximal medial gastrocnemius release 

15 minutes


When can I drive?

Following a proximal medial gastrocnemius release – 

Most patients are able to drive within a week or two. Please see guidance below.

Please see guidance above and information here. Ultimately it is the responsibility of the patient to decide if they are safe to drive. A good way of knowing is if you can stamp your right foot heavily on the ground to mimic an emergency brake. If you have any hesitation or pain then it should suggest you are not safe to drive. Remember prolonged driving involves keeping your feet in a dependant position. This will worsen the post operative swelling.


When can I return to work?

Following a proximal medial gastrocnemius release – 

Most patients are able to return to work within 3 to 5 days.


What should the final outcome be?

Following a proximal medial gastrocnemius release – 

Excellent pain relief and return to sports by 3 to 6 months in approximately 80% of patients.

 

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