Plantar Fasciitis and Bone Spurs
Other popular names
- DeQuervain's tenosynovitis
- First Extensor compartment tenosynovitis
Who does it affect?
Plantar fasciitis (fashee-EYE-tiss) is the most common cause of pain on the bottom of the heel. Approximately 2 million patients are treated for this condition every year. Plantar fasciitis occurs when the 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.
Why does it happen?
The plantar fascia is designed to absorb the high stresses and strains we place on our feet. 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.
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:
- Tighter calf muscles that make it difficult to flex your foot and bring your toes up toward your shin
- Very high arch
- Repetitive impact activity (running/sports)
- New or increased activity
Although many people with plantar fasciitis have heel spurs, spurs are not the cause of plantar fasciitis pain. 1 out of 10 people has heel spurs, but only 1 out of 20 people (5%) with heel spurs has foot pain. Because the spur is not the cause of plantar fasciitis, the pain can be treated without removing the spur.
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
There are a number of signs that will be examined by your consultant to diagnose the problem, which include looking for:
- A high arch
- An area of maximum tenderness on the bottom of your foot, just in front of your heel bone
- Pain that gets worse when you flex your foot and your consultant pushes on the plantar fascia. The pain improves when you point your toes down
- Limited "up" motion of your ankle
It is likely that you will require and x-ray to help to make sure your heel pain is caused by plantar fasciitis and not another problem, such as fractures or arthritis. Heel spurs can also be seen on an x-ray.
Other imaging tests, such as magnetic resonance imaging (MRI) and ultrasound, are not routinely used to diagnose plantar fasciitis. However, an MRI scan may be used if the heel pain is not relieved by initial treatment methods.
More than 90% of patients with plantar fasciitis will improve within 10 months of starting simple treatment methods. Methods should include:
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 or aerobics).
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 medication (NSAID's).
Drugs such as ibuprofen or naproxen reduce pain and inflammation. Using the medication for more than 1 month should be reviewed with your GP or Consultant.
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. A number of useful stretches are described below:
- 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.
- 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 Consultant may limit your injections. Multiple steroid injections can cause the plantar fascia to rupture (tear), which can lead to a flat foot and chronic pain.
- Soft heel pads can provide extra support.
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.
- 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 sleep with, a night splint is very effective and does not have to be used once the pain is gone.
Your Consultant may suggest that you work with a physiotherapist on an exercise program that focuses on stretching your calf muscles and plantar fascia. In addition to exercises like the ones mentioned above, a physio programme may involve specialised ice treatments, massage, and medication to decrease inflammation around the plantar fascia.
- Extracorporeal shockwave therapy (ESWT).
During this procedure, high-energy shockwave impulses stimulate the healing process in damaged plantar fascia tissue.
Surgery is considered only after several months of aggressive nonsurgical treatment. There are a number of procedures that will be considered by your Consultant, which include:
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 a year of calf stretches. 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 by an arthroscopy.
Plantar fascia release. If you have a normal range of ankle motion and continued heel pain, your Consultant may recommend a partial release procedure. During surgery, the plantar fascia ligament is partially cut to relieve tension in the tissue. If you have a large bone spur, it will be removed, as well. The procedure may be performed arthroscopically or open.
You can go home soon after the operation. The anaesthetic will wear off after approximately 6 hours. Simple analgesia (pain killers) usually controls the pain and should be started before the anaesthetic has worn off. The foot should be elevated as much as possible for the first 5 days. The dressing is removed soon after your operation. The wound is cleaned and redressed with a simple dressing. Any sutures (stitches) will be removed at about 10 days. You should notice an improvement in symptoms within a few days but the final result may take upto 3 months.
Return to normal routine
Keep the wound dry until the stitches are out at 10 days.
Return to driving:
The foot needs to have full control of the pedals. You are advised to avoid driving until you have full movement and control back in your foot.
Return to work:
Everyone has different work environments. Returning to heavy manual labour should be prevented for approximately 4 - 6 weeks. Early return to heavy work may cause the tendons and nerve to scar into the released ligament. You will be given advice on your own particular situation.
Overall over 95% are happy with the result. However complications can occur. General risks (less than 1% each):
- Neuroma (nerve pain)
Reflex Sympathetic Dystrophy - RSD (<1% people suffer a reaction to surgery which can occur with any surgery from a minor procedure to a complex reconstruction).
- Failure to completely resolve the symptoms results in less than 1% of patient