WHAT IS PLANTAR FASCIITIS?
The plantar fascia is a ligament like structure that is attached to the bottom (plantar) aspect of the heel bone (calcaneous). It begins as a narrow band in the center of the heel and then widens as it extends and fans to
through the bottom of the foot and arch and on into the long bones and toes. It is an extension of the Achilles tendon at its superficial fibers that is attached to the back of the heel. It lies just under the skin and fat. Its purpose is to support the arch and the muscles of the arch during gait. It acts as a “rubber band” that stretches back and forth with each step as force is put through the arch. When there is an injury to the fascia and it becomes inflamed this is called plantar fasciitis.
The fascia can also suffer larger tears or partial rupture if there is a significant injury to the area.
WHAT IS A HEEL SPUR?
Plantar fasciitis can be related to a heel spur, or heel spur syndrome. A heel spur is the formation of extra bone from the constant pull of the plantar fascia ligament on its attachment at the heel bone (calcaneous). When bone is stimulated, it grows. Extra bone can be formed in an location of the body where there is over stimulation of bone. When the plantar fascia is tight, and it constantly tugs and pulls on the heel bone, the bone will react by growing extra bone in the direction of the pull of the ligament on the bottom of the heel. A spur usually forms over a period of time. A heel spur can cause pain. A heel spur on the bottom of the heel can cause the plantar fascia to rip and tear as it disrupts the strength of the insertion of it into the heel bone. When the spur causes long term or chronic irritation to the plantar fascia insertion it begins to degenerate and become plantar fasciosis (deterioration of the plantar fascia). The spur can also push into the pain receptors in the fat pad of the heel if its become significantly large causing severe pain. Patients can have a large heel spur and no plantar fascial tear and no pain. Patients can have a very small heel spur and significant pain if they also have tearing of the fascia plantar fasciosis. The appearance of a heel spur informs the doctor that the ligament has been very tight for a long period of time, greater than 3 months. A spur on the bottom of the heel should not be confused with spur on the back of the heel called a retrocalcaneal exostosis.
WHAT ARE THE SYMPTOMS OF PLANTAR FASCIITIS?
Patients will complain of different types of pain the bottom of the heel. The pain is usually located on the bottom, inner portion of the heel, forward about an inch from the back of the heel. Description of the pain range from a deep achy pain, to a sharp knife-like pain. Most patients will complain of the most significant pain when they take their first few steps out of bed or after sitting for some time, and then walking. This pain can ease when there is more walking, and then increase again towards the end of the day. There is usually no pain at rest. Some relate a burning or numbness in the skin of the heel. Most find that being barefoot, using flat shoes or shoes without support lend to more pain. The pain usually will worsen gradually over time. There are cases when there is significant injury and tear or rupture of the fascia. The patient will note bruising to the skin, noted swelling to the heel, inability to place weight on the heel and acute pain.
WHAT CAUSES PLANTAR FASCIITIS?
Plantar fasciitis is usually caused by a recurring injury to the area over time. If there is an instance when the ligament is not able to stretch and be elastic during an activity (even walking) the fascia can suffer micro tears near its attachment to the heel bone. As the micro tears increase, there is an onset of inflammation and pain that will be felt in the heel. When the foot is at rest or under bed sheets, the foot is in a downward position; the ligaments in a shortened, relaxed state. As soon as sudden weight is put through the foot, the already damaged ligament is asked to stretch to quickly and more tears are created. This is the reason for the common increased pain in the mornings. As the ligament stretches out with more walking, it will tear less. It is seen in women and men, athletes and non-athletes.
The ligament can also suffer larger tears or partial rupture if there is a significant injury to the area. This is usually seen when there is a quick movement from a stationary state to activity, a bad step off a curb or step, or a jump activity. Also if there is a heel spur this can be the cause of tearing and ripping of the plantar fascia at its insertion.
HOW IS PLANTAR FASCIITIS DIAGNOSED?
Diagnosis is achieved by the clinical examination, x-rays, and sometimes a diagnostic ultrasound of the patient. Dr. Heath will listen to the patient’s complaints, symptoms, and goals. The examination involves a hands-on analysis of the patient’s foot and evaluating their gait. Radiographs (x-rays) of the feet will be obtained in the office and reviewed with the patient. The positions of the bones and joints evaluated on the x rays helps determine the severity of the deformity and an associated deformities. As well as help rule out a fracture of the heel or cyst in the heel bone.
An ultrasound or MRI may be ordered in cases of severe tearing or rupture of the fascia and evaluate the thickness of the fascia. It may also be needed for those patients with chronic plantar fasciitis/fasciosis. It is important to distinguish plantar fasciitis from other problems that can cause heel pain such as a tarsal tunnel syndrome.
HOW IS PLANTAR FASCIITIS TREATED?
Dr. Heath educates that early diagnosis and treatment of plantar fasciitis are the keys to successful treatment, faster recovery and increased quality of life.
CONSERVATIVE TREATMENT FOR PLANTAR FASCIITIS:
Conservative treatments rely on their ability to decrease pain, reduce inflammation, stop the tearing of the fascia and heal the fascia. Dr. Heath will sometimes order a strict 2-4-week initial home therapy protocol. Reduction of the inflammation and pain can be achieved by treating the area with a daily regimen of ice therapy and the use of anti-inflammatory medications (NSAIDS). A period of rest will be needed to reduce the constant strain on the ligament while it is trying to heal. A discussion of appropriate shoes will be advised to support the ligament. The patient will be educated on stretching regimen for the calf and the plantar fascia. Stretching of the ligament is very important to allow the ligament to be more elastic and reduce the occurrence of the micro tears. These stretching exercises will be especially important in the mornings before getting out of bed or after a period of rest. Dr. Heath may recommend a course of visits to a physical therapist. If you have already been working with another physician or treating by yourself and tried the above treatment then Dr. Heath will move forward with other treatment options.
Custom molded orthotics (insoles) are an integral part of healing and maintaining the integrity of the plantar fascia. The plantar fascia plays an important role in the support of the arch of the foot. When the fascia is
damaged and irritated, it will need to be supported by a custom orthotics to reduce the forces placed on the fascia while walking and increase activity. The orthotics control the amount of motion through the arch during gait, reduce the pressure off the plantar fascia if there is a large tear or heel spur associated with the pain a surgical removal of the spur and repair of the fascia maybe necessary.
CORTISONE (STEROID) INJECTION THERAPY FOR ACUTE PLANTAER FASCIITIS:
Those patients that experience significant acute pain, or those that are not responding to another conservative treatments may benefit from an injection. Steroids that are used in medicine are catabolic, this means that
they break down inflammation and scar tissue. When there is an acute injury with inflammation to the ligament, cortisone can be used to reduce the inflammation and break down any scar tissue within the ligament. This can reduce the pain as well as aid in more rapid recovery. Dr. Heath may recommend this therapeutic injection as an adjunct to conservative therapy; it is not meant to replace it. Cortisone injections may be helpful for some patients and may not work for others. If this fails or you have already had a cortisone injection and the pain returned, Dr. Heath may move forward with other treatment options which may include surgical release of the fascia and excision of the heel spur if present.
MINIMAL INVASIVE SURGICAL TREATMENT FOR CHORNIC PLANTAR FASCIITIS:
After a 3 to 6-month period of failed conservative therapies weather by Dr. Heath or other medical professionals or self-treatment the plantar fasciitis may have evolved into a chronic state. In chronic conditions the body’s healing factors are not trying to heal the area of concern and are busy taking care of the rest of the body. Presumably, there are less inflammatory cells around the ligament to aid in healing. In these cases Dr. Heath may offer the release of the plantar fascia, freeing up the scar tissue and nerves in the damaged area along with removal of the heel spur on the bottom of the heel in the fascia released area only. Considering surgery can be intimidating. When the skin and the soft tissues are handled with care and focus many patients experience very tolerable pain after surgery and decrease throughout the recovery period. Dr. Heath takes great care and focus to minimize the chance of post-operative pain. The goal of plantar fascial surgery is to stop the tearing of the ligament, remove the plantar heel spur, alleviate pain allow a return to normal shoes and allow to return to all activities. The procedure allows for immediate walking, fast return to work depending on what you do each day at work. Some may return in 3 days others in I -2 weeks all while wearing a special walking boot.
Dr. Heath performs the procedure in an outpatient setting at a state of the art facility and offers in office as well.