Plantar fasciitis with heel pain, often referred to as Heel Spur Syndrome, is due to tearing of the rigid fascia. Limiting over-pronation by orthotics can provide relief, and NSAIDs and cortisone injections if necessary may be useful. Infrequently, surgery is necessary. Endoscopic release of this connective tissue band, followed by a stretching regime, is a surgical method currently used for treatment of this problem.
Heel pain is a common problem in individuals of middle and older age. It occurs in both men and women regardless of body weight, occupation, etc. Many individuals suffer from heel pain that is so debilitating that it interferes with daily activities.
One of the most common types of heel pain is plantar fasciitis. Often referred to as heel spur syndrome, this condition can be easily misdiagnosed and incorrectly treated.
In most cases, patients describe pain in their heel(s) when first standing, especially in the morning. They do not generally complain of walking or resting pain. Heel pain usually subsides after the initial 20 steps, until the patient rests and then stands again. Patients also note prior over-use, e.g. walking extensively while on vacation or walking 18 holes rather than using a golf-cart.
A careful history and physical examination of the lower extremities is required to determine if a patient is suffering from plantar fasciitis. Radiographs that exhibit subcalcaneal spurs are of little significance, since many people who suffer from plantar fasciitis do not exhibit heel spurs and vice versa. Heel spurs do not cause pain; their existence and size hold very little significance. Their existence only signifies that pulling of the plantar fascia has been present for many months or years.
Most of the population over-pronates (an imbalance of the foot towards the medial aspect). This mechanical imbalance causes the feet to lengthen when walking or when standing. The plantar fascia courses the entire plantar aspect of the foot, inserting in the calcaneus proximally and the digits distally (Fig.l). Unlike muscles, tendons and ligaments, the fascia is unique in that it cannot stretch. Consequently, when the foot over-pronates and lengthens, the fascia pulls at its calcaneal insertion, most notably at the medial calcaneal tuberosity. This constant pulling over time causes heel spurs, an out pocketing of the calcaneal cortex. After the presence of longstanding stress at the calcaneus, the fascia can exhibit micro trauma in the form of a partial avulsion. This micro trauma is caused by overuse and represents the acute stage of plantar fasciitis.
If the practitioner palpates the medial calcaneal tubercle, with the patient's digits and foot dorsiflexed, pain is usually elicited, indicating plantar fasciitis. Rarely do other pathologies such as tarsal tunnel syndrome, calcaneal nerve entrapment or other enthesopathy* elicit this pain on palpation of the area of the medial plantar fascia insertion. Physical examination includes gait/stance analysis, neuromuscular evaluation, vascular examination and footwear observation.
If plantar fasciitis is diagnosed and is present without evidence of systemic disease such as the sero negative spondyloarthropathies or other local abnormalities, then conservative treatment should be initiated as soon as possible. Conservative management of plantar fasciitis is successful in approximately 95% of patients, and surgical intervention is considered in the remaining 3-5%.
Cortisone injections, non-steroidal anti-inflammatory drugs (NSAIDs), acupuncture and physiotherapy provide temporary relief, since they only target the resultant inflammation but do not address the fascial microtrauma. Unless the fascial avulsion is treated by reducing the pull of the fascia at the calcaneal tubercle with orthotics, plantar fasciitis can become chronic and debilitating. I tend to reserve the above temporary treatments (i.e. injection, NSAIDs, etc.) until absolutely necessary. Contrary to popular belief, stretching exercises are contraindicated, because the fascia cannot stretch and exercise creates more trauma to the area due to overuse.
The mainstay of treatment is aimed at mechanically altering foot function using prescription orthotics to limit over-pronation; this releases the stress and pulling of the plantar fascia at the calcaneal insertion. This allows the fascial avulsion to heal. Healing does not occur immediately. Most cases, on average, resolve within 12-16 weeks following the initiation of orthotic therapy.
To provide temporary relief for patients awaiting should consist of prescription orthotics with local orthotics (about 3 weeks), we administer laser therapy about the medial calcaneal tuberosity in conjunction with orthopedic taping techniques such as a low dye configuration. Generally, if physiotherapy is not proving helpful within 3-4 treatments, there is little chance additional treatments will prove effective.
For elderly patients, a semi-flexible orthotic comprised of polypropylene or sorborthalon with EVA* is prescribed. We provide a deep heel seat with poron cushion and over-correct the number of rotational degrees required. The more rigid the orthotic, the less patient tolerance will be seen. The patient's shoewear, weight, activity level and foot architecture must be carefully considered when prescribing an orthotic device. A complete biomechanical assessment must be performed to accurately prescribe an orthotic. Computer gait analysis may determine pressure points but does not evaluate dynamic movement or rotational degree analysis.
In a small percentage of patients who continue to have plantar fasciitis, where conservative therapy has failed, surgical intervention may be considered. In 1993, the author introduced endoscopic plantar fasciotomy (EPF) to Canada. This procedure uses an endoscope to visualize the fascia and lengthen it by severing a portion of the fascia, usually the medial band. Utilizing a very tiny incision and minimal trauma, EPF allows for less risk over traditional surgery and immediate patient ambulation. A 6-week plantar fascia stretching regime is mandatory post-operatively, to allow the fascial separation to heal with weaker fibrous tissue. If this stretching is not followed, the fascia will appose the calcaneus and heal in the original shortened position.
There is a small failure-rate with traditional and EPF surgical procedures. However, EPF has a superior functional outcome, lower morbidity and faster ambulation/recovery.
There are some myths surrounding plantar fasciitis, especially the need for stretching exercises as a treatment. Furthermore, at times, treatments are initiated unnecessarily without an accurate diagnosis. However, with a careful history and examination, a proper diagnosis of plantar fasciitis can be made. Other systemic seronegative spondyloarthropathies and enthesopathies should be ruled out. Treatment should consist of prescription orthotics with local physiotherapy modalities. NSAIDs and cortisone injections should not be used initially, but are reserved as an adjunct to other therapies. Surgical intervention of plantar fasciitis should only be considered when lengthy conservative therapy has proven to be less than perfect.
*EVA is a rubber-like compound used in almost all athletic shoes to provide the highest degree of shock absorption.
*Enthesopathies are a classification of seronegative spondyloarthropathies, i.e. Reiter's syndrome, reactive arthritis, ankylosing spondylitis; all can affect the heel area.
MATURE MEDICINE CANADA
December 1999 by Hartley Miltchin, D.P.M