The term heel spur often conjures
up images of a sharp bony prominence on the bottom of the heel that
pokes and prods us with every step. But that image couldn't be further from the truth.
Heel spur syndrome is not a bone problem at all. Heel spur syndrome is actually a soft
tissue problem. Confused? We'll explain.
spurs, heel spur syndrome and plantar fasciitis refer
to the same condition. Although hard to pronounce, plantar fasciitis is
rapidly becoming the most commonly used term to describe this
condition. 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.
Pain associated with plantar fasciitis is specific to the plantar heel as seen
in red in the accompanying image.
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
tension (load) applied to the plantar fascia is greater than what the fascia can tolerate,
the fascia will become inflamed.
Treatment of Plantar Fasciitis
Treatment of plantar fasciitis is based on four
broad categories of care; biomechanical methods, anti-inflammatories
methods, surgery and other methods. Let's take a closer look at each of these four categories and
see how they can often work together.
The leg, ankle and foot functions as a lever. This lever is
called the CT band.
Levers consist of three parts; an effort arm, a fulcrum and a
resistance arm. In the CT band, the leg is the effort arm or source of
force coming primarily from the calf muscles. The ankle is the fulcrum or
hinge of the lever. And the foot is the resistance arm of the lever.
The resistance arm of the lever is where the force creates action.
The lever action of the leg, ankle and foot is to deliver force from the
strongest muscle in our body (the calf) to the ball-of-the-foot. The
action created is what we know as walking. Plantar fasciitis is the
result of an imbalance in the lever mechanics of the leg ankle and foot.
This imbalance results in force from the effort arm (calf) that overwhelms the
resistance arm (the foot).
The first step in treating plantar fasciitis is to try and restore
the balance between the effort arm and the resistance arm of the CT band.
To do so, there are three simple steps;
Avoid going barefoot or wearing a shoe with a low heel.
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 to change the biomechanical properties of the
CT band and for complete resolution of symptoms of plantar fasciitis.
Arch supports can be used on a daily basis to maintain good support of the arch
and help to decrease recurrence of plantar fasciitis.
The second category of care is the use of anti-inflammatories. 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-inflammatories, bear in
mind that we are treating a problem that we know is mechanical in nature.
Plantar fasciitis is caused by mechanical overuse or
overloading of the CT band. Anti-inflammatories help with the dull ache common
in cases of plantar fasciitis. Anti-inflammatories typically do not help
with the sharp tearing pain found with that first step out of bed or when
initially standing during the day. That's why it's important to combine
mechanical methods of care (above) with the use of an anti-inflammatory. The two methods
work in conjunction with each other to address the two different types of pain that are
common in cases of plantar fasciitis.
The third category of care includes surgery and what we describe
as other methods (below). Surgery becomes indicated when a course of
conservative care has failed. Endoscopic surgical
methods have become the standard of care for the treatment of plantar fasciitis.
The surgical procedure used today to treat plantar fasciitis is called an
endoscopic plantar fasciotomy. The
older methods of surgical correction included resection of the heel spur or
partial resection of the heel bone. With an endoscopic plantar fasciotomy, we
release, or make a cut through the fascia, leaving any spur in place. It's
important to recognize that we are treating a soft tissue problem (plantar
fasciitis) and not a bone problem (heel spur).
The following video shows the steps used to perform an endoscopic
plantar fasciotomy. This procedure is performed at a surgery center or hospital and is
completed with sedation and local anesthesia. The procedure takes
approximately 15 minutes to complete. Patients are able to walk the very
same day on the foot and return to most activities within 3-4 weeks.
Heel spur surgery, whether performed endoscopically or with a traditional
method, is not without problems. While 90% 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. The complications of LCS occur not in the first week or two after surgery but
rather 2-4 month after a plantar fasciotomy. As
a patient reaches status 4 weeks post surgery, they start to feel
more able to return to their normal activities. As they progressively
increase their activities they begin to add an increase of 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 is not complete for 4-6
months following the 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.
Other non-conservative methods of care include shock wave therapy, Topaz surgery
growth factor injections and neuroablation. These methods of treating plantar
fasciitis focus on the difference between the terms plantar fasciitis and
plantar fasciosis. Plantar fasciitis is an acute inflammatory condition of
the plantar fascia. But after several months, the inflammatory nature of
plantar fasciitis changes. Studies that have used tissue biopsy of long
term plantar fasciitis show that over time, there become less of an inflammatory
response by the body within the plantar fascia. So the acute inflammatory
condition of plantar fasciitis changes to a non-inflamed case of plantar
fasciosis. This finding is the basis for several other techniques used to
treat plantar fasciitis.
Extracorporeal shock wave therapy is used
as a tool to break the re-injury cycle associated with plantar fasciitis. 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
fascia. 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.
Topaz surgery is used to treat plantar fasciosis. To
complete Topaz surgery, a patient is taken to surgery, sedated and anesthetized.
A Topaz wand is used to place a series of small holes or defects within the
fascia. The Topaz wan creates this defect by using radio frequency
ablation. Patients are able to bear weight and walk immediately following
Growth factor injections are also used to treat cases of plantar
fasciitis/plantar fasciosis that have failed conservative care. Growth
factor is isolated from the platelets in a patient's blood. This technique
can be completed in the doctor's office. A 50cc sample of blood is drawn
from the patient and spun down in a centrifuge. The platelets are then
re-injected into the most symptomatic area of heel pain. Patients are able
to walk immediately following this procedure.
Neuroablation is a technique used to treat heel pain that doesn't
focus on treating inflammation, but instead focuses
on deadening nerve pain in the plantar heel. 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.
What's the best method of care for you? That decision
should be made by you and your doctor as a team. Consider conservative measures
of care as a means to help your body heal itself. Surgery on the other hand is
the physical change. The first consideration in determining a treatment plan is
the duration of your symptoms of plantar fasciitis. How long has your plantar fasciitis been present?
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 surgery or other care.
Plantar Fascial Tears
Plantar fascial tears are a relatively uncommon injury.
There are no precipitating factors (age, weight, smoker, etc) that would tend to
one patient more susceptible to a plantar fascial tears. Plantar fascial
tears occur in men within the 20-50 year age range who are engaged in aggressive
activities such as sports or physical labor. The onset of a plantar
fascial tear is abrupt and typically secondary to a fall or sports injury.
Sharp pain with weight bearing, along with bruising specific to the plantar heel
and arch are found. Treatment include, rest, ice, compression and partial
weight bearing to tolerance. Surgical repair of a torn plantar fascia is
unnecessary. The fascia will heal over the course of 4-6 weeks to be fully
functional. Plantar fascial tears should be evaluated with an x-ray to
rule out a stress fracture of the heel.
The terms heel spur syndrome 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 load to the foot,
the arch drops and the plantar fascia becomes tight. Plantar fasciitis
occurs when the load that is applied to the foot is so great that the
plantar fascia begins to pull away from the heel bone. The painful symptoms of plantar
fasciitis do not result from standing on a sharp heel spur, but
rather from the result of the overwhelming tension that occurs in the
plantar fascia as we stand (apply load). The plantar fascia becomes so
tight that it is literally being torn from the bottom of the heel.
When discussing biomechanical properties of heel spur syndrome, 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 symptoms of plantar fasciitis classic. The symptoms
develop slowly and insidiously over the period of a week or two. As the pain becomes progressively worse,
the pain 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 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.
Gout- deposition of
monosodium urate crystals (hyperuricemia)
Retrocalcaneal bursitis (Albert's Disease) - this is the formation and inflammation
of a bursa at the back of the heel
between the heel bone and Achilles tendon
Sero-negative arthropathies such as Reiter's Syndrome
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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