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Heel pain fasciitis


Suffering With Plantar Fasciitis | Heel Pain Symptoms & Treatment

Are you suffering from heel pain? It might be caused by plantar fasciitis. Our sports injury clinic specialises in the diagnosis and treatment of plantar fasciitis.

WHAT IS PLANTAR FASCIITIS?

Plantar fasciitis is a painful inflammatory heel condition affecting the large ligament-type structure in the base of the foot that can cause arch pain and heel pain. The plantar fascia can become thick and inflamed due to the irritation at its attachment, at the base of the heel bone. In some patients, small tears can develop and these people suffer from acute pain that can be excruciating. Sometimes, on x-ray, heel spurs (bone spurs) can be seen, but these are not usually the cause of the patient’s heel pain.

It should be noted that “heel spurs” is a misleading diagnosis that has been used by podiatrists and doctors for many years. More and more practitioners today are open to the fact that heel spurs are not the problem and that these bone spurs don’t cause pain. Instead, the source of pain is the inflammation within the plantar fascia surrounding the spur itself.

What Does it Feel Like?

Patients with plantar fasciitis usually feel pain under the ball of the heel and it can represent a stone bruise sensation. Arch pain is less common but is also a key symptom of the condition. The heel pain is common first thing in the morning when climbing out of bed and after periods of rest, such as driving or being seated. The pain in the heel can be erratic and often, there are pain-free periods when the person feels like they are healing. If there is a very sudden onset of pain, as opposed to a gradual onset, this may be due to tearing of the plantar fascia.

Correct Diagnosis

It is important that the podiatrist differentiates between regular plantar fasciitis, and plantar fascia tearing as the treatment is different. Your podiatrist will also be able to exclude the possibility of a stress fracture, which sometimes leads to similar symptoms. Ultrasound imaging may be necessary to accurately diagnose the cause of the patient’s heel pain.

At Sydney Heel Pain, our podiatrists are highly experienced and skilled in the diagnosis and treatment of heel pain.

THE STAGES OF PLANTAR FASCIITIS

INITIAL STAGES OF PLANTAR FASCIITIS

Initially, these heel pain patients may feel a dull ache in the base of the heel. There may be an awareness of a problem in the afternoons, or after they have been weight-bearing for long periods of time. It is possible that they feel some pulling in the plantar fascia, which they describe as a tightness in the arch or the sole of the foot.

Early treatment or intervention at this stage is crucial and may inhibit the development of a more chronic heel pain condition. Unfortunately, many patients ignore the early symptoms, presuming or hoping that the tightness or the dull ache in the heel will settle down and dissipate. In some people, this is the case, but others can develop severe heel pain and/or chronic P. F.

As sports podiatrists, the typical symptoms that we hear in these early stages, are the feeling of a pebble in the shoe or a stone bruise sensation. Patients with mild P.F sometimes inform us that they felt like they had stepped on a small pebble or stone.

In these early stages that we describe above, the condition does not always induce heel pain throughout the daytime. The symptoms may only be present in the morning when getting out of bed and can be very sporadic. Some patients are asymptomatic for a day or two only to find the pain returning.

In the early stages, there can also be some heel pain in the morning when the foot hits the floor, but this is usually mild and is often little more than a feeling of tightness.

CHRONIC PLANTAR FASCIITIS

When the condition is fully developed, the symptoms of plantar fasciitis heel pain are more acute. The condition will become chronic if the strain on the plantar fascia goes on for long enough and remains untreated.

The pain in the heel is more consistent and patients will usually report pain, not just stiffness, each morning when hopping out of bed. Most patients hobble for at least 5 minutes after getting out of bed due to extreme plantar fasciitis heel pain.

The pain in the heel usually subsides within 15 minutes and patients are usually more comfortable after taking a hot shower. Walking throughout the day isn’t always a problem as the inflammatory change in the plantar fascia is less consistent and the heel pain isn’t always present.

However, mid-afternoon, after several thousand steps the foot fatigues, and the heel pain returns. Patients will sometimes report pain when getting out of their car after a drive home from work. They hobble again for the first few minutes and find some relief after walking a short distance.

Podiatrists are often informed by their patients that they also limp when they stand up after being seated for dinner in the evenings or after sitting on the couch watching television. An ultrasound report will often show thickening of the plantar fascia, due to inflammatory change.

SEVERE PLANTAR FASCIITIS

If the condition comes on very quickly, during a one-off event or during a particular day/activity then the pain can feel severe/acute. Alternatively, chronic plantar fasciitis left untreated can lead to the same state.

Acute Inflammation

In these cases, the strain on the plantar fascia has been so great and so repetitive that acute inflammation develops as does extreme pain. Patients with severe P.F will usually describe to the sports podiatrist an extreme level of pain that is present for most of the day. These patients will experience throbbing when sitting or lying down and are starting to feel the psychological effects of having a condition that is both chronic and acute.

Often described as “excruciating” or “relentless”, heel pain plantar fasciitis patients experience symptoms that affect their daily lives, as they stop exercising and are often struggling to walk during day-to-day movements.

Some patients with severe P.F have developed deep surface or laminar tears in the fascia. As sports podiatrists, we arrange ultrasound scans, to help confirm or exclude torn fascia. X-rays are less helpful in the case of this soft tissue injury.

WHO SUFFERS FROM PLANTAR FASCIITIS HEEL PAIN?

Adults

Plantar fasciitis can affect men and women equally, but there is a trend in terms of the age of the patients that we treat. Fewer people younger than 30 years of age develop the condition, and the majority of patients are over 60. In between those ages, there is a large percentage of male and female patients in their 40’s and 50’s.

Sedentary people who haven’t exercised for some time, who enter a get fit health program of sorts, and those who join a boot camp, will often develop pain in the heel or Achilles tendon, namely plantar fasciitis, Achilles Tendonitis, or Bursitis.

Children

Occasionally we see juvenile-onset P.F which affects children who are engaged in sport and physical activity. It is important that we differentiate between other heel pain conditions such as Severs disease and Achilles Tendonitis.

Experienced Sports Podiatrists

Our sports podiatrists have extensive experience in these conditions and can determine which one your child has, by carrying out a careful physical examination. We will refer for x-ray or ultrasound scans if we deem them necessary.

CAUSES OF PLANTAR FASCIITIS

Multifactorial Causes

There is no single cause of plantar fasciitis. The cause is multifactorial, as is the plantar fasciitis treatment. Ultimately, there is an increased load on the plantar fascia which causes it to become pathological. Tight calf muscles and soft shoes are a big problem, as are flat feet and an increase in body weight. Biomechanical issues leading to poor foot function can also trigger the condition. Patients who suddenly increase the amount or frequency of sporting activity/exercise are also at risk.

We often hear patients saying, “I was looking to get fit after Christmas and was training several times a week, and then my heel became extremely painful…”

PLANTAR FASCIITIS TREATMENT

At Sydney Heel Pain, our objective is to provide a long-term solution to your heel pain condition, and not just quick pain relief. Our sports podiatrists have a wealth of experience in treating plantar fasciitis, as well as all other types of painful heel conditions.

Karl will select an appropriate combination of one or more treatments to suit the severity of your plantar fasciitis and your lifestyle.

Some common treatments may include:
  • Extracorporeal shockwave therapy with strapping
  • Use of an immobilisation boot
  • Footwear changes/recommendations with strapping and stretching
  • Custom-tailored prescription orthotics (gentle arches) with shockwave therapy.

Our team uses orthotics for plantar fasciitis that are specifically designed as to not push upwards against the plantar fascia. Although going against the grain of the traditional arch support theory (old science) our orthotics unload and support the plantar fascia so that injections and medications are not required, allowing the foot to heal naturally.

You can find out more about our orthotic inserts for plantar fasciitis treatment on our blog.

Written by Karl Lockett

Relevant information about plantar fasciitis:

https://www.mayoclinic.org/diseases-conditions/plantar-fasciitis/symptoms-causes/syc-20354846
https://www.health.harvard.edu/newsletter_article/easing_the_pain_of_plantar_fasciitis
https://www.webmd.com/fitness-exercise/understanding-plantar-fasciitis-basics

Plantar Fasciitis and Bone Spurs - OrthoInfo

Plantar fasciitis (fashee-EYE-tiss) is one of the most common causes of pain on the bottom of the heel. Approximately 2 million patients are treated for this condition every year.

Plantar fasciitis occurs when the plantar fascia, a strong band of tissue that supports the arch of your foot, becomes irritated and inflamed.

The plantar fascia is a long, thin ligament that lies directly beneath the skin on the bottom of your foot. It connects the heel to the front of your foot and supports the arch of your foot.

The plantar fascia is a ligament that lies beneath the skin on the bottom of your foot.

The plantar fascia is designed to absorb the high stresses and strains we place on our feet when walking, running, and doing other activities like playing sports. But, sometimes, too much pressure damages or tears the tissues. The body's natural response to injury is inflammation, which results in the heel pain and stiffness of plantar fasciitis.

Too much pressure on the plantar fascia can damage or tear the tissues, causing heel pain. 

Risk Factors

In most cases, plantar fasciitis develops without a specific, identifiable reason. There are, however, many factors that can make you more prone to the condition:

  • New or increased activity
  • Repetitive high impact activity (running/dancing/sports)
  • Prolonged standing on hard surfaces (especially among nurses, factory workers, and teachers)
  • Anatomy (flat feet or a high arch)
  • Tight calf muscles
  • Obesity
  • Age (plantar fasciitis is most common among people aged 40 to 60)

The most common symptoms of plantar fasciitis include:

  • Pain on the bottom of the foot near the heel.
  • Pain with the first few steps after getting out of bed in the morning, or after a long period of rest, such as after a long car ride. The pain subsides after a few minutes of walking
  • Greater pain after (not during) exercise or activity.

After you describe your symptoms and discuss your concerns, your doctor will examine your foot. They will look for these signs:

  • A high arch or flat foot
  • An area of maximum tenderness on the bottom of your foot, just in front of your heel bone
  • Limited dorsiflexion, or "up" motion, in your ankle
  • The absence of symptoms from other conditions, such as insertional Achilles tendinitis, calcaneal (heel) stress fracture, or plantar nerve entrapment

Your doctor may order imaging tests to help make sure your heel pain is caused by plantar fasciitis and not another problem.

X-rays

X-rays provide clear images of bones. They are useful in ruling out other causes of heel pain, such as fractures or arthritis.

Heel spurs can be seen on an X-ray. A heel spur can be the result of longstanding tension on the plantar fascia insertion (the spot on the heel bone where the plantar fascia attaches). However, most people who have bone spurs on their heels do not have heel pain. Since heel bone spurs are not the cause of plantar fasciitis, plantar fasciitis pain can be treated without removing the spur.

Heel spurs do not cause plantar fasciitis pain.

Other Imaging Tests

Other imaging tests, such as magnetic resonance imaging (MRI) and ultrasound, are not routinely used to diagnose plantar fasciitis. They are rarely ordered.

An MRI scan may be used if the heel pain is not relieved by initial treatment methods or if your doctor is concerned that a different problem is causing your heel pain.

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Nonsurgical Treatment

More than 90% of patients with plantar fasciitis will improve within 10 months of starting simple treatment methods.

Rest. Decreasing or even stopping the activities that make the pain worse is the first step in reducing the pain. You may need to stop athletic activities where your feet pound on hard surfaces (for example, running, dancing, or step aerobics). Your provider may recommend that you use a walking boot and crutches for a short period of time to allow your foot to rest.

Changing your activity. Low impact exercise, such as cycling or swimming, puts less stress on your joints and feet than walking or running.

Stretching. Plantar fasciitis is aggravated by tight muscles in your feet and calves. Stretching your calves and plantar fascia is the most effective way to relieve the pain that comes with this condition.

Calf stretch

  • Calf stretch
    Lean forward against a wall with one knee straight and the heel on the ground. Place the other leg in front, with the knee bent. To stretch the calf muscles and the heel cord, push your hips toward the wall in a controlled fashion. Hold the position for 10 seconds and relax. Repeat this exercise 20 times for each foot. A strong pull in the calf should be felt during the stretch.
  • Plantar fascia stretch
    This stretch is performed in the seated position. Cross your affected foot over the knee of your other leg. Grasp the toes of your painful foot and slowly pull them toward you in a controlled fashion. If it is difficult to reach your foot, wrap a towel around your big toe to help pull your toes toward you. Place your other hand along the plantar fascia. The fascia should feel like a tight band along the bottom of your foot when stretched. Hold the stretch for 10 seconds. Repeat it 20 times for each foot. This exercise is best done in the morning before standing or walking.

Ice. Rolling your foot over a cold water bottle or ice for 20 minutes is effective. This can be done 3 to 4 times a day.

Nonsteroidal anti-inflammatory drugs (NSAIDs). Medications such as ibuprofen or naproxen reduce pain and inflammation. Using the medication for more than 1 month should be reviewed with your primary care doctor.

Physical therapy. Your doctor may suggest that you work with a physical therapist on an exercise program that focuses on stretching your calf muscles and plantar fascia. In addition to exercises like the ones mentioned above, a physical therapy program may involve specialized ice treatments, massage, and other therapies to decrease inflammation around the plantar fascia.

Supportive shoes and orthotics. Shoes with thick soles and extra cushioning can reduce pain with standing and walking. As you step and your heel strikes the ground, a significant amount of tension is placed on the fascia, which causes microtrauma (tiny tears in the tissue). A cushioned shoe or insert reduces this tension and the microtrauma that occurs with every step. Soft silicone heel pads are inexpensive and work by elevating and cushioning your heel. Pre-made or custom orthotics (shoe inserts) are also helpful.

Soft heel pads can provide extra support.

Avoid unsupportive and worn-out shoes. Make sure to replace your old athletic shoes before they wear out and no longer support your feet. 

Night splints. Most people sleep with their feet pointed down. This relaxes the plantar fascia and is one of the reasons for morning heel pain. A night splint stretches the plantar fascia while you sleep. Although it can be difficult to get used to, a night splint is very effective at reducing heel pain from plantar fasciitis.

Other Treatments

Your healthcare provider may recommend the following procedures if you remain symptomatic after several months of conservative treatments.

Casting. Wearing a cast for a short period of time can be extremely helpful in the treatment of plantar fasciitis because it provides an immobilized (no movement) environment for healing. Since a cast is custom-molded to your foot and cannot be removed, it is often a better option than boot immobilization.

Cortisone injections. Cortisone, a type of steroid, is a powerful anti-inflammatory medication. It can be injected into the plantar fascia to reduce inflammation and pain. 

Your doctor may limit this treatment or avoid it altogether because steroid injections can weaken the plantar fascia and lead to a rupture (tear), which can lead to flattening of the foot and chronic pain.

Platelet-rich plasma (PRP) injections. PRP is obtained from your own blood and can be injected into the plantar fascia to promote healing. PRP injections do not have the same risk of leading to plantar fascia rupture. However, this treatment can be expensive, and more research is needed on the effectiveness of PRP injections.

Extracorporeal shockwave therapy (ESWT). During this procedure, high-energy shockwave impulses stimulate the healing process in damaged plantar fascia tissue. ESWT has not shown consistent results and, therefore, is not commonly performed.

ESWT is noninvasive — it does not require a surgical incision. Because of the minimal risk involved, ESWT is sometimes tried before surgery is considered.

Ultrasonic tissue repair. This is a minimally invasive treatment for patients with persistent (ongoing) plantar fasciitis. Ultrasound imaging is used to guide a probe toward the injured plantar fascia. The tip of the probe then vibrates to break up and remove damaged tissue.

Surgical Treatment

Because more than 90% of patients with plantar fasciitis recover with nonsurgical treatment, surgery is generally reserved for people who have not seen improvement after 12 months of aggressive nonsurgical treatment.

Gastrocnemius recession. This is a surgical lengthening of the calf (gastrocnemius) muscles. Because tight calf muscles place increased stress on the plantar fascia, this procedure is useful for patients who still have difficulty flexing their feet, despite extensive efforts at calf stretching.

In gastrocnemius recession, one of the two muscles that make up the calf is lengthened to increase the motion of the ankle. The procedure can be performed with a traditional, open incision or with a smaller incision and an endoscope, an instrument that contains a small camera. Your doctor will discuss the procedure that best meets your needs.

Complication rates for gastrocnemius recession are low, but can include sural nerve damage and calf weakness.

Partial plantar fascia release. Often performed at the same time as a gastrocnemius recession, a partial plantar fascia release involves making an incision on the bottom or side of the heel. The surgeon identifies the plantar fascia insertion at the heel (the spot where the ligament attaches to the bone) and makes a partial cut to relieve tension in the tissue. If there is a large bone spur, it can also be removed.

Although the surgery can be performed endoscopically, it is more difficult than with an open incision. In addition, endoscopy has a higher risk of nerve damage than open surgery.

  • Complications. The most common complications of release surgery include incomplete relief of pain and nerve damage.
  • Recovery. A short period of protected weightbearing is recommended after surgery to allow the incision to heal.

Most patients have good results with surgery. However, because surgery can result in chronic pain and dissatisfaction, it is recommended only after all nonsurgical measures have been exhausted.

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Information on this topic is also available as an OrthoInfo Basics PDF Handout.

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Treatment of plantar fasciitis in the department of physiotherapy

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Department of Physiotherapy

/ Diseases

/ Plantar fasciitis

Plantar fasciitis is an inflammation of the ligament that supports the arch of the foot and connects the heel to the toes.

Plantar fasciitis is the most common cause of heel pain, which is especially severe at the beginning of walking (in the morning with the first steps). In addition, plantar fasciitis can cause pain in the arch of the foot and ankle.

Against the background of the inflammatory process in plantar fasciitis, the appearance of a bone spike-like growth - a heel spur is possible. Another common complication of this disease is tendonitis (inflammation) of the Achilles tendon.

In the presence of hallux valgus, plantar fasciitis contributes to the accelerated development of this disease, an increase in deformity with increased inflammation and pain.

How to treat plantar fasciitis?

Plantar fasciitis responds well to shock wave therapy (SWT). Particularly fast and lasting results are achieved by combining SWT with other physiotherapy procedures used in our clinic:

  • relieves heel pain and other symptoms of plantar fasciitis,
  • relieves tension in the ankle, redness, inflammation and swelling disappear,
  • disease complications are prevented,
  • in the presence of a heel spur, it disappears without surgery, valgus deformity decreases, inflammation of the Achilles tendon is removed,
  • the lameness disappears, the gait improves, the quality of life increases.

The main effect of using shock wave therapy for plantar fasciitis is achieved due to the anti-inflammatory and anti-edematous effect of acoustic waves of infrasonic frequency. These waves are concentrated in the focus of inflammation and act on the border of the plantar fascia and calcaneus, increasing the blood supply to the tissues of the aponeurosis and Achilles tendon, improving metabolic processes and stimulating recovery processes.

Thanks to this complex effect of shock wave therapy, it not only quickly relieves pain and inflammation, but also strengthens the ligamentous apparatus, increasing its resistance to physical stress.

In the presence of bone growth, acoustic waves contribute to its destruction and the natural excretion of calcium salts from the body.

Why does plantar fasciitis occur?

The main reasons why plantar fasciitis occurs are prolonged, regular overstrain of the ligament that supports the arch of the foot and multiple microtraumas (ligament microtears). Therefore, this disease is called "runner's heel".

Plantar fasciitis most often affects people whose daily life involves running, jumping (eg professional athletes), long walking, carrying heavy loads, standing on their feet.

Factors contributing to the development of plantar fasciitis also include being overweight, having flat or high arched feet, and wearing improper, tight shoes.
The use of non-steroidal anti-inflammatory drugs (NSAIDs) for plantar fasciitis can only temporarily relieve pain and is not a true cure for the disease. Traditional medicine methods and other types of self-treatment, as a rule, are also ineffective.

Really stable and fast results in the treatment of plantar fasciitis are achieved through the complex use of physiotherapy, primarily shock wave therapy. An important advantage of this procedure is that it not only eliminates pain and inflammation, but also improves metabolic processes and the condition of tissues, strengthening ligaments and tendons and increasing their endurance.

This serves as the best prevention of the recurrence of plantar fasciitis and other inflammatory and degenerative-dystrophic diseases of the ankle, heel and foot.


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