Plantar Fasciitis

A Patient's Guide

Plantar fasciitis (or fasciopathy as it should ideally be termed since tissue is degenerate rather than inflamed) is one of the most common causes of heel pain, affecting millions of people each year. It occurs when the plantar fascia, a thick band of tissue that runs along the bottom of the foot from the heel to the toes, becomes worn out and thickened. This condition typically results in pain at the bottom of the heel and can interfere with daily activities, making walking or standing uncomfortable. While it is often self-limiting, treatment is crucial to help alleviate pain and prevent it from becoming a chronic issue.

Symptoms and Signs

The hallmark symptom of plantar fasciitis is pain at the bottom of the heel, which is usually worse in the morning or after periods of rest. Other common signs and symptoms include:

Sharp, stabbing pain: Most people describe the pain as sharp, especially with the first steps taken in the morning after getting out of bed. The pain may decrease after walking around for a bit but can return after prolonged standing or after exercise.
Pain after physical activity: The pain may not be as noticeable during activity, but it often worsens once the activity stops, especially if there is excessive standing or walking involved.
Stiffness: Many people with plantar fasciitis experience stiffness in the foot, particularly in the morning. This stiffness may gradually improve after walking or stretching.
Swelling: Though not always present, some individuals may notice mild swelling around the heel or the arch of the foot.
Tenderness at the heel: Focal pain that is made worse when the heel is pressed upon is an extremely finding in more that 90% of patients.
Tight calf muscles: There is a strong association between a 'tight posterior chain' and plantar fasciitis, since fascial tissues extend from the spine to the thighs down to the calves and eventually into the soles of feet.

It’s important to note that plantar fasciitis can develop gradually, often beginning as mild discomfort that worsens over time. The pain can be intermittent or persistent, and it may become more severe if left untreated.

Investigations

Accurate diagnosis involves a combination of clinical evaluation and imaging studies. The following investigations are commonly employed:

Ultrasound (USS): USS is a widely used imaging modality providing real-time images, allowing assessment of fascial thickness, structure, and the presence of any tears or fibromas.
Magnetic Resonance Imaging (MRI): MRI is another valuable tool. It offers detailed images of both the fascia and surrounding structures, helping to identify the extent of fascial thickness, localised bone spurs, and any associated soft-tissue or bone abnormalities.
X-rays: While not typically used to diagnose plantar fasciitis directly, X-rays can help rule out other conditions that might mimic foot pain, and assess for ectopic bone growth.
Blood Tests: In certain cases, blood tests may be conducted to rule out systemic conditions like psoriatic or rheumatoid arthritis, or ankylosing spondylitis which are associated with plantar fasciitis.

Accurate diagnosis through these investigations is crucial for formulating an effective treatment plan tailored to the severity and specific characteristics of the fasciiopathy.

Conservative Treatment

Treatment aims are to relieve pain, promote healing, and restore normal function. A combination of conservative and, in some cases, surgical interventions is employed based on the severity of the condition. Conservative treatments include:

Rest and Activity Modification: Reducing or modifying activities that exacerbate symptoms is the first step in treatment. This may include switching to low-impact activities like swimming or cycling.
Medications: Simple analgesics such as paracetamol can help manage pain. However, long-term use should be limited to avoid potential side effects.
Exercises: Stretching exercises for the calf muscles, Achilles tendon, and plantar fascia itself can help reduce tension and improve flexibility. A common stretch involves sitting with one leg extended, using a towel to gently pull the toes toward the shin, and holding for 15-30 seconds. Strengthening exercises for the foot and lower leg muscles can also help improve foot mechanics and provide long-term relief.
Orthotic Devices: Shoe inserts or orthotic devices can help reduce pressure on the heel and providing better foot support and cushioning. Night splints that keep the foot passively stretched overnight whilst asleep can reduce early morning pain.
Extracorporeal Shock Wave Therapy (ESWT): This non-invasive treatment uses high-energy sound waves to stimulate healing within the fascia. ESWT has been found effective in reducing pain and improving function in chronic cases where symptoms last more than six months.

Invasive Treatment

In cases where conservative treatments fail to provide relief after several months, invasive intervention may be considered. Options include:

Corticosteroid Injection: This procedure involves injecting the thickened fascia. It is often performed under image guidance to ensure accurate placement. Rupture of the plantar fascia is a known risk so strenuous exercise after the injection should be avoided for six weeks, although stretching exercises are encouraged whilst pain has been improved to prevent recurrence.
Botulinum Toxin Injection: Injections of therapeutic agents that relax the calf muscles and intrinsic muscles of the foot have been used to reduce the forces being acted upon the heel.
Gastrocnemius Lengthening: Since tight calf muscles can contribute to pain, lengthening the gastrocnemius muscle surgically can help reduce strain on the origin of the plantar fascia.
Plantar Fascia Release: Incising the plantar fascia is a recognised treatment for plantar fasciitis, although is rarely performed in the UK for the complications which have been historically identified. These include wound complications, collapse of the arch of the foot, and nerve injury.

Post-surgical rehabilitation is crucial to ensure a successful recovery and return to normal activities.

Summary

Plantar fasciitis can be a painful and limiting condition, but with appropriate care and early intervention, most people can recover and return to normal activities. Treatment typically involves rest, stretching, and proper footwear, with more advanced options like physiotherapy, shockwave therapy or corticosteroid injections reserved for chronic cases. By understanding the causes, recognising the symptoms early, and following a comprehensive treatment plan, you can manage plantar fasciitis effectively and prevent long-term complications. If you're experiencing persistent heel pain, it's important to consult with a healthcare provider like Shelain Patel to develop a plan and get back on your feet with comfort and ease.