Heel pain (plantar fasciitis)

Extracorporeal shockwave therapy

This is a procedure whereby shockwaves are passed through the skin to the affected heel. The shockwaves are mechanical and not electrical and work by increasing blood flow to the injured area to accelerate the body’s healing process. NICE have deemed the procedure as safe but, again, report that there is limited evidence of it effectiveness. A recent review of research has suggested that it is effective for treating chronic plantar fasciitis (over three months).

Surgery

Surgery involves releasing part of the tight fascia band from the heel bone. There is conflicting evidence for the success of surgery, some reporting good outcomes and long complications whilst others reporting poor surgical outcomes with multiple complications. Therefore you should only consider surgery if all other treatments have failed.

How successful will my treatment be?

Most patients will have an improvement in pain and function after 12 weeks of conservative treatment. Patients who have tight calf muscles at presentation are four times more likely to respond to stretching. Patients who suffer with plantar fasciitis for a longer time (over six months) are less likely to respond to initial treatment. Therefore, patients are advised to commence treatment as quickly as possible after suffering with heel pain.

What causes heel pain?

Plantar fasciitis is one of the most common causes for heel pain. The plantar fascia is a fibrous tissue band that runs along the bottom of the foot. It supports the arch and provides vital shock absorption. Plantar fasciitis is an overuse injury where micro tears develop in the tissue.

What are the symptoms?

Patients with plantar fasciitis often present with:

• severe pain in the heel on first step in the morning or after a rest period
• pain in the heel after a long period of weight bearing activity
• pain on palpation of the heel bone.

Diagnosis is made if a patient presents with these symptoms.

What causes Plantar fasciitis?

Common causes of plantar fasciitis include:

• high BMI
• tight calf muscles with reduced movement at the ankle
• high arch and low arch feet
• runners or people who spend long periods of time standing on hard floors.

How can I treat plantar fasciitis?

Initial treatments include:

footwear – a supportive shoe that has a fastening (lace, Velcro, buckle) should be worn. There should be a thumb width from the end of your longest toe to the end of the shoe. Ideally, the shoe should have a detachable insole to allow plenty of room for an orthoses or arch support.

Arch support – evidence has found that a simple arch support or orthoses is effective to treat plantar fasciitis. These can be purchased over the counter or may be prescribed by a podiatrist.

Stretching — Achilles tendon and plantar fascia stretch – Before you get out of bed, loop a towel around your foot, and pull it with the knees straight, bringing your foot towards you. Hold this position for one minute. Repeat three times for each foot. Wall push-up or stretches for the Achilles tendon – Place both hands (at shoulder height) on a wall, with staggered feet (one foot in front of the other). With the front knee bent and the back knee straight, lean towards the wall until a tightening is felt in the calf of the back leg. Hold for 1 minute. Repeat three times for each leg.

Stair stretches for the Achilles tendon and plantar – Stand facing upstairs using the stair-rail for support. Your feet should be positioned so that both heels are off the end of the step, lower the heels, keeping the knees straight, until a tightening is felt in the calf. Hold for one minute before raising back to neutral. Repeat the exercise three times, twice a day.

Dynamic stretches for the plantar fascia – while seated, roll the arch of your foot over a rolling pin or a tennis ball. You should allow the foot and ankle to move in all directions as it rolls over the object. Continue the exercise for a few minutes or until there is some discomfort.

If initial treatment fails after 12 weeks then you could consider:

steroid injections – evidence suggests that corticosteroid injections can reduce pain, improve function and reduced plantar fascial thickness in patients with plantar fasciitis. This effect has been shown to last for up to three months in patients. Steroid injections can risk heel pad atrophy and plantar fascial rupture. Therefore they are only to be used in patients who have failed two months of conservative treatment.

Autologous blood injection – This involves injecting autologous whole blood or platelet-rich plasma into the plantar fascia to promote healing. The National institute of clinical excellence (NICE) have also deemed this as safe but report that there is limited evidence of its effectiveness.