Do your heels hurt first thing in the morning? Do they hurt when you stand up after sitting down for a while? You may have plantar fasciitis or plantar fasciopathy. You are not alone. Approximately 10% of the American population will have heel pain, resulting in about 1 million doctor visits annually. The key is to get the right diagnosis, and subsequently, the right treatment.
What is plantar fasciitis?
Simply stated, it is an irritating degeneration of the plantar fascia at or near its attachment to the heel bone. This is why it is more accurately called plantar fasciopathy (or plantar fasciosis). "Plantar fasciitis" is the more common term, but this implies that the fascia is inflamed, which is not often the case.
What is the plantar fascia?
The plantar fascia is a thick band of connective tissue on the bottom of the foot that connects the heel bone (calcaneus) to the ball of the foot. It is sometimes called the plantar aponeurosis. It is very important. It stretches when you stand on it, building up kinetic energy which propels you into your next step. It also supports your arch, creating stability and aiding in proper function of your foot throughout the entire gait cycle. The plantar fascia has to stretch AND support at the same time. No wonder it is so easily damaged and so problematic.
What causes plantar fasciopathy?
The cause is mechanical. It is commonly believed that there is excessive pulling of the plantar fascia at its attachment to the heel bone. This is probably true in many cases. The fascia tissue can be overstretched and microscopic tears can occur. The result is irritation, inflammation, and degeneration. But that is not the only thing going on here. When you stand, weight is transmitted down through the heel bone, crushing the structure right under it, which happens to be the plantar fascia. So the poor plantar fascia is both overstretched AND crushed. This is painful plantar fasciopathy.
What are the symptoms and signs?
- Pain when getting up in the morning, often easing up after a few steps
- Pain when getting up after sitting
- Pain in the heel right where the arch begins
How is it diagnosed?
- A comprehensive history and physical exam
This is used to rule out other causes of heel pain. A heel spur may be seen on x-ray. This is not the pain that you feel. Many plantar fasciitis patients do not have heel spurs, and many normal feet do have heel spurs on x-ray.
This is essential to measure and evaluate the plantar fascia in order to guide treatment and predict outcomes. This is "a must."
Diagnostic nerve block. This can rule in (or out) a neuritis that is often present and contributing to the heel pain.
There are a couple of reasons to order an MRI. One, if a more severe rupture is suspected. The other is if the symptoms are more neurological (pain in the toes, pain in areas not typically affected by plantar fasciopathy.) In this case we want to see if there is a lesion (like a ganglion) in an area of the foot called the tarsal tunnel.
Is there conservative (non-surgical) treatment for plantar fasciopathy?
Yes, and they all have various degrees of success and failure. Using ultrasound, we can get a better idea of the extent of the damage to the plantar fascia. Using this information, we can predict how likely you are to respond to conservative vs. surgical treatment plans. Some of the more common conservative treatments include:
- Physical Therapy
- Motrin, or other pain/anti-inflammatory medication
- Tape immobilization
- Night splints
- Immobilizing boot
- Extracorporeal Shockwave Therapy. This is the most aggressive, non-invasive, conservative treatment option.
What about cortisone injections for plantar fasciopathy?
You will certainly find that this seems to be a treatment tried early and often for this condition. It is invasive and there are varying degrees of success. I don't think one cortisone shot can cause too much harm. In fact, one single injection can actually be a diagnostic aide. It should be performed with ultrasound guidance for more accurate needle placement, allowing for reduced amount of steroid and decreasing potential error.
Other injection therapies for plantar fasciopathy include:
- PRP (platelet-rich plasma)
Your own blood is drawn from your arm, centrifuged to concentrate to platelets, and re-injected into the painful area. This can be an office procedure. Platelets have growth factor which can help heal damaged tissue.
- BMAC (bone marrow aspirate concentrate)
This is a little more invasive since it requires harvesting your own bone marrow from your hip or heel bone. Bone marrow has progenitor cells which in theory can help form new healthy tissue in areas of damage.
- Amniotic/placental stem cell allografts
- Naturopathic/Homeopathic preparations, usually containing Arnica.
- Alcohol injections
This is highly successful when there is a neuritis component, particularly in cases with pain around the "rim" of the heel.
What are the surgical options?
USGPPF (UltraSound Guided Percutanous Partial Plantar Fasciectomy) is our treatment of choice. Through a very small incision on the inside of the heel, small amounts of the degenerated tissue are removed from the plantar fascia, all visualized with ultrasound. After adequate removal of bad tissue, platelet-rich plasma or amniotic stem cells can be injected back into the area. Recovery is very quick with little restriction on activities. The plantar fascia ligament is preserved in its natural length and the mechanical function of the foot is not altered.
Other surgical techniques include:
- TOPAZ. This uses radiofrequency waves to "ablate" damaged tissue
- TENEX. This uses intense ultrasound waves to break down diseased tissue
- EPF or endoscopic plantar fasciotomy.
In general, patients should be monitored yearly after resolution of the pain. Foot orthotics may be helpful in preventing re-occurrence since they directly address the mechanical causes. Good nutrition, exercise, and maintaining proper weight are essential. Appropriate, well-fitting shoes are certainly beneficial.