The term heel spur
up images of a sharp bony projection on the bottom of the heel. But that image couldn't be further from the truth.
Heel spur syndrome isn't a bone problem at all. It's actually a soft
tissue problem. Confused? We'll explain.
spurs, heel spur syndrome and plantar fasciitis are synonymous terms that refer
to the same condition. Although hard to pronounce, plantar fasciitis is
rapidly becoming the most commonly used term to describe these
conditions. By breaking the term plantar fasciitis into its' root form, it's
much easier to understand. Plantar is a geographic term that refers to the bottom of
the foot (dorsal on top/plantar on bottom). Fascia is a tough, inelastic
band. And 'itis' always refers to something that's inflamed (bronchitis, arthritis,
etc.). When the root words are combined they describe is an inflammatory
condition of a fascial band on the bottom of the foot; plantar fasciitis.
How do we develop plantar fasciitis?
Plantar fasciitis is an overuse syndrome that is the result of
excessive and repetitive loading of the plantar fascia. When we stand, load is applied to the
arch of the foot causing the height of the arch to drop. This drop
in the height of the arch places tension on the plantar fascia. If the
load applied to the plantar fascia is greater than it can support,
the fascia will become inflamed.
Treatment of Plantar Fasciitis
Treatment of plantar fasciitis is based in four
broad categories of care; biomechanical methods, anti-inflammatories
methods, shock wave therapy
and surgery. Let's take a closer look at each of these four categories and
see how they work.
We spoke earlier of load and how a change or increase in load may
contribute to the onset of plantar fasciitis. The primary load that
contributes to the onset of plantar fasciitis is the load generated by the calf.
Therefore, the primary focus of treatment becomes finding ways to weaken the
function of the calf. This can be accomplished by using a
firm 3/8 heel lift or wearing shoes with a wedged sole or higher heel.
Calf stretches will also help to weaken the
CT Band hence decreasing the power of
the calf and tending to 're-balance' the normal biomechanics of the foot and
leg. The most effective calf stretches are done by standing on the edge of
a stretching block
for 60 seconds. Repeat this stretch 6 times each day.
Taping the arch,
heel cushions and a host of other 'devices' have been used successfully to
treat plantar fasciitis. All of these devices focus on changing the
biomechanical properties of the CT Band. Remember, the key to
treating plantar fasciitis is addressing the entire CT Band and not just the
plantar fascia. Stretches and heel lifts
are quite often all that is needed for complete resolution of symptoms.
Arch supports can be used on a daily basis to maintain good support of the arch
and help to decrease recurrence of plantar fasciitis.
Anti-inflammatory medications can be used to help control the pain
associated with plantar fasciitis. Anti-inflammatories include steroid injections, oral anti-inflammatory
medications such as aspirin, prescription strength medications called NSAID's,
topical medications and a host of other methods to reduce
inflammation. When using anti-inflammatory to treat plantar fasciitis, bear in
mind that plantar fasciitis is a mechanical problem. Knowing this fact, it's
important to recognize that anti-inflammatories alone cannot cure plantar
fasciitis. Anti-inflammatories are only helpful in treating
inflammation. Anti-inflammatories will not typically address the sharp tearing
pain we call post dystatic pain but rather address the pain we
develop as the day progresses (see the symptoms tab for more information
on symptoms of plantar fasciitis). That's why it's important to combine
mechanical methods of care with an anti-inflammatory medication. The two methods of
treatment work together to address the two different types of pain that are
experienced with plantar fasciitis.
Extracorporeal shock wave therapy has been used
recently as a tool to break the re-injury cycle associated with plantar
fasciitis. The initial studies on shock wave therapy were performed on
renal (kidney) and biliary (gall bladder) stone patients. Due to the
initial success of treating renal and biliary stones, researchers began to look
for new applications for shock wave therapy. Animal experiments began in
1986 to study the effects on bone growth when stimulated by shock wave therapy.
In 1991, High Medical Technologies (HMT) of Switzerland developed and clinically
tested the OssaTron®. The OssaTron® is the first shock wave therapy
device designed for orthopedic/podiatric use. The OssaTron® received FDA
approval for treating plantar fasciitis in 2000. Other applications
for shock wave therapy, which are now under investigation, include tennis elbow,
non-healing bone and tendonitis.
Shock wave therapy employs an acoustic wave that
results in an explosion of energy at the point of focus. Shock waves
differ in amplitude and are 'tuned' for a specific purpose based upon the
desired amplitude and medium that is crossed to reach a target tissue. The
effect of the shock wave in cases of plantar fasciitis is not fully understood.
It is believed that the effect of the shock wave stimulates an intense focused
inflammatory reaction that promotes healing at the insertion of the plantar
Shock wave therapy can be painful to perform and
therefore requires that the procedure be performed in an outpatient setting with
deep sedation. The procedure takes about 15 minutes to complete and does
not require a local anesthetic (only sedation). Patients are able to walk
on the foot the same day. Complication are minimal. Most doctors
will require continued stretching and limited activity for 4 weeks following
shock wave therapy. The long term success or failure of shock wave therapy
is yet to be seen, but recent studies have had short term success rates of
65-95%. For additional information on shock wave therapy refer to The
International Society for Musculoskeletal Shock Wave Therapy.
Neuroablation is a technique used to treat heel spur syndrome that focuses
on deadening nerve pain. Neuroablation doesn't actually treat the
mechanical component of heel spur syndrome, but instead destroys nerve that
supplies sensation to the bottom of the heel. Neuroablation can be
performed with a cold probe (cryoablation, thermoablation) with a hot probe
(radiofrequency surgery) or with injectable chemicals (alcohol, phenol).
Neuroablation is an appropriate procedure for select patients who have not
responded to conservative care.
correction for plantar fasciitis has come a long way over the past several
decades. Although the intent of the procedure has remained
the same, the methods of
completing the surgery have changed dramatically. Endoscopic surgical
methods have become the standard of care for plantar fasciitis. The
procedure, called an endoscopic plantar fasciotomy, or EPF for short, was
developed by Steve Barrett, DPM. Dr. Barrett developed
instrumentation that enabled the procedure to be performed through two small
1/4 incision. Most patients are able to return to their shoes in
just a matter of days. Dr. Barrett deserves credit for making
such improvements in not only the knowledge pertaining to plantar fasciitis but
also revolutionizing the ways in which the procedure is performed. The
older methods of surgical correction included resection of the heel spur or
partial resection of the heel bone. We now merely release, or make a cut
through the fascia, leaving any spur in place. Once again, it's important
to realize that we are treating a soft tissue problem. Dr. Barrett's
efforts have resulted in a vast improvement in surgical care, sparring many
patients the complications and disability associated with the older surgical
Another recent theory regarding heel spur syndrome is that of
plantar fasciitis vs plantar fasciosis. Several papers in the literature
have shown that over a period of several months, plantar fasciitis changes from
an acute inflammatory condition to a non-inflammatory condition. Tissue
biopsy actually shows a decrease in the total count of inflammatory cells at the
insertion of the fascia. As a result of these findings, a school of though
has arisen that suggests that treating plantar fasciitis necessitates restarting
the inflammatory process at the insertion of the plantar fascia. A number
of methods have been used to accomplish this. These techniques include
needling the fascia, injections of medications and
The fasciitis vs fasciosis argument is still fresh, therefore many doctors will
opt for EPF surgery as a procedure with a more definitive or proven track
So what's the best method of treatment for your heel pain? That
decision should be made by you and your doctor together. Essentially, the most
important issue is the duration of your symptoms. How long has your plantar
fasciitis been present? The use of the biomechanical methods of care and
anti-inflammatories may help and are a necessary part of a complete treatment
plan but do not always work. If your symptoms have been present for more than a
year or if you've tried 4 months of conservative care with no change in your
symptoms, you are probably a good candidate for EPF surgery. Consider the conservative measures of care as a
means to help the body heal itself or make the necessary change to become pain
free. Surgery on the other hand is the physical change required when
conservative care has failed.
of EPF cases are completed without complication, 10% do have
problems that can vary in severity. One complication specific to plantar fasciotomies,
regardless of how they are performed, is later column syndrome (LCS). LCS
is sometimes a very difficult complication to understand, diagnose and treat.
If we think of other endoscopic surgical procedures, such as a cholecystectomy
(gall bladder) we tend to think of the first week or two as the time when we
would have complications. The surgery is completed, we heal and move on.
The complications of LCS do not occur in the first week or two after surgery but
rather 2-4 month after a plantar fasciotomy. As
a patient gets 4 weeks or so out on their plantar fasciotomy, they start to feel
more able to return to their normal activities. As they progressively
increase their activities they begin to add an increase in load to the foot.
Although the surgical site no longer is sore from the surgery, the biomechanical
impact, or change to the joint structure of the foot requires 4-6
months to heal following surgery. Early symptoms of LCS are a dull ache of the
lateral (outside) of the foot and the top of the arch. This ache is a
stiffness that if left untreated will result in small stress fractures if the
lateral and dorsal aspects of the foot. LCS is a manageable complication
of this procedure and should be thoroughly discussed before surgery so that
patients are aware of the symptoms of LCS and can make their doctor aware should
they experience problems.
The terms heel spur syndrome, heel spur and plantar
fasciitis are used interchangeably to describe a set of symptoms which
include pain in the bottom of the heel. Heel spur syndrome is the older
of the two terms but has remained as a common description of these
symptoms. Plantar fasciitis is a relatively newer term that is more
descriptive of the condition and is becoming the definition used by most
‘Plantar’ refers to the bottom of the
foot. ‘Fascia’ is a component of the musculoskeletal system that is
found through-out the body. Fascia helps to support the function of the
bones and joints and often acts as an anchor for structures such as
muscles. ‘Itis’ refers to the inflammation found in a structure and
is used in other familiar words such as arthritis (inflammation in a
The combination of plantar + fascia +
itis results in the descriptive term, plantar fasciitis, or inflammation
of the plantar fascia.
Enthesiopathy - pain that results from a ligament
or tendon pulling away from its' insertion on a bone.
EPF - endoscopic plantar fasciotomy.
Lateral column - All osseus and soft tissues of
the foot including the calcaneus, cuboid, 4th and 5th metatarsals.
Lateral Column Syndrome - a complication
post EPF surgery due to abrupt loading of the lateral column of the foot
plantar fascia is a strong, inelastic ban that originates on the bottom of the
heel and spans the length of the foot, inserting into the toes. The
plantar fascia can easily be felt in the bottom of the foot, particularly when
the toes are dorsiflexed (towards the shin). The plantar fascia consists
of three slips; a medial, a central and a lateral slip. The medial slip of
the plantar fascia is the band that most commonly becomes symptomatic in cases
of plantar fasciitis.
When we stand and apply our body weight to the foot,
the arch drops and the plantar fascia becomes tight. In cases of plantar
fasciitis, the tension applied to the fascia is so great that the fascia is
literally trying to pull off of the heel bone. Understanding this simple
biomechanical principle is at the heart of understanding plantar fasciitis.
Plantar fasciitis is not due to a sharp spur. Plantar fasciitis is due to
the fascia trying to pull away from the heel bone when load is applied to the
When discussing biomechanical properties of plantar fasciitis, it’s
important to understand the mechanical definition of load. The amount of load, the frequency of
load and the duration of load are just a few of the different loading
issues that can contribute to plantar fasciitis. Loading issues will
vary in each person affected by plantar fasciitis. For instance, for a
long distance runner, the frequency of loading may be the primary issue
that contributes to the onset of plantar fasciitis.
For a factory worker who stands for long periods of time, the duration
of load may be the primary issue. Typically, those who suffer from
plantar fasciitis don’t have just one of these loading issues but a
number of them combined.
The most important loading issue that contributes to plantar
fasciitis is the load applied to the foot by the calf. The calf is the
single most powerful muscle in the human body. With each step, the calf
delivers force via the Achilles tendon to the foot and optimally out to the
forefoot where it can most effectively be used for locomotion. Plantar
fasciitis is often the result of an imbalance between the force generated by the
calf and the flexibility of the structures that receive that load. As we
age, our tissue flexibility becomes less. Therefore, with decreased tissue
flexibility, we are less able to accommodate load. Mechanical loads that
we used to be able to accommodate and heal in a 24 hour period, become
increasingly difficult with age. The calf delivers and the foot receives.
And in plantar fasciitis, the foot just can't heal quickly enough.
The symptoms of plantar fasciitis classic. The symptoms
may be abrupt or develop insidiously over the period of a week or two. As the pain becomes progressively worse, it becomes focused in the bottom of the heel. People describe
significant pain in the bottom of the heel when they try to get up out
of bed in the morning or try to stand after a period of rest. This
post rest pain, called post static dyskinesia, is a sharp pain that seems to subside after being on the
feet for 5-10 minutes.
People will also describe a second kind of pain that
becomes worse as the day progresses. This pain is described as dull and
achy. It's often on the bottom of the heel but also seems to radiate to
the inside of the heel.
picture shows the location of pain found in patients with plantar
fasciitis. The red area on the bottom of the heel is where the plantar
fascia inserts into the medial tubercle of the calcaneus. This is the
location where patients with plantar fasciitis feel pain upon standing after a
period of rest or when getting out of bed in the mornings.
Also shown in this picture are the
areas where pain is felt with several different nerve entrapments of the
heel. The line of red dots symbolizes the path of the posterior tibial
nerve. As the posterior tibial nerve descends into the foot, it divides
into several different nerves that supply motor function to the muscles of the
foot and sensory function to the bottom of the foot. Entrapment of the
posterior tibial nerve can result in
tarsal tunnel syndrome or
Baxter's nerve entrapment.
Sever's Disease - and inflammatory condition typically found in young over weight
boys age 10 to 15 years old
Stress fracture of the calcaneus - Achilles tendonitis pain is
characteristically different from that of fractures of the calcaneus.
Fracture pain begins with the onset of activity and remains painful through the
Tarsal Tunnel Syndrome - also known as posterior tibial nerve neuralgia.
Tarsal Tunnel Syn. characteristically has pain that does not decrease with rest.
Also has numbness or 'tingling' of the toes
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