PLANTAR FASCIITIS

What is plantar fasciitis?

Pain in the heel can be caused by many things. The commonest cause is plantar fasciitis.

There are a number of strong ligaments, which run between the heel bone and the toes. One of these is the plantar fascia. The plantar fascia takes a lot of stress as you walk, or even just standing.

In some people the plantar fascia becomes painful and inflamed. This usually happens where it is attached to the heel bone, although sometimes it can affect the mid-part of the foot. This condition is called plantar fasciitis.

Causes include

Constant stress within the plantar fascia - plantar fasciitis is commoner in people who spend all day on their feet, or are overweight.
A tight Achilles tendon - this increases the stresses on the heel. Most people with plantar fasciitis have a rather tight Achilles tendon.
People who have high-arched ('cavus') feet or flat feet are less able to absorb the stress of walking and are at risk of plantar fasciitis
Occasionally plantar fasciitis starts after an injury to the heel.
People who have a rheumatic condition such as rheumatoid arthritis or ankylosing spondylitis may get inflammation anywhere a ligament is attached to bone (enthesopathy), and plantar fasciitis in these people is part of their general condition.

Usually plantar fasciitis eventually gets better itself, but this can take months or even years. If you have it once you are more likely to get it again.

Some people are told that they have a bone spur at the bottom of the heel bone. It is important to understand that this does not usually cause the pain, and is normally a coincidental. These spurs do not have to be removed in this condition.

What are the symptoms?

Patients complain of pain in the base of the heel. This is often worse first thing in the morning when getting out of bed. The pain can spread along the foot. The pain can also be worse when first standing after a period of rest and can sometimes ease with activity.

How is it diagnosed?

The diagnosis is often made on clinical history and examination.

What are the treatment options?

The vast majority of cases are treated without an operation. Usually the longer the symptoms have been present, the longer they will take to settle down. A combination of non-surgical treatments are generally required. Over 90% of patients improve with simple non-operative treatments, however it can take 3-6 months for the symptoms to settle. Simple non-operative treatments include:

Weight loss and activity modification
Painkillers and anti-inflammatories
Physiotherapy - Specific stretches and exercises can significantly improve symptoms, but need to be performed regularly as instructed
Night splints - These are used to continue stretching the plantar fascia and/or calf tendons.
Insoles/heel pads - Shock absorbing heel pads or special insoles can help with the sharp pain.

If the above simple measures do not work then you may consider more specialised treatment:

Shock wave therapy - Studies have shown reasonable success with some patients. Physiotherapy stretches must be done in conjunction with this.
Steroid injections - An injection of steroid could be considered. There is a small risk of infection, increased pain, thinning of the heel pad and plantar fascia rupture.
Further physiotherapy – it is important to continue stretches in combination with other treatments.

Only if all these treatments don’t work, and symptoms have been present for over 12 months, then surgery may be considered. This is because the majority of patients settle with these treatments and surgery is not always successful.

What are the benefits of surgery?

Surgery is approximately 70-80% successful. The aim is to relieve pain. It can take months to get the full benefit from the surgery.

Summary of surgery

The surgery is usually performed as a day case. It is usually performed under a general anaesthetic. Local anaesthetic is often given after the surgery to help with pain relief.

There are different types of surgery which can be done to treat your symptoms. This will be dependent on your examination findings and will be discussed with your surgeon. These include:

Releasing the plantar fascia - aim of an operation is to release part of the plantar fascia from the heel bone and reduce the tension in it. The small nerves nearby may be explored and released if caught up in tight bands of tissue.
Gasctrocnemius (calf muscle) release – if you have a tight calf then releasing the muscle up the back of the leg near the knee may reduce tension at the plantar fascia

After your surgery

Your wound will be in big bulky bandage. You may need crutches and a post surgical shoe to help mobilise after surgery. If there is any concern with the wound, then you may have a short resting period in a cast (usually 2 weeks). You should keep your foot elevated on a chair/pillow and take regular painkillers.

What are the risks with surgery?

The general risks with surgery include

Bleeding – rarely may there be bleeding with results in a collection of blood under the wound. Bruising is common.
Swelling – common after surgery and can take many months to eventually settle down. Elevation is key to reducing this.
Infection – infections can be treated with antibiotics. Deeper infections which are much rarer may require further surgery.
Nerve injury – this may cause some numbness in the ankle/foot.
Scarring – some scars can be prominent or dark in colour. This usually fades with time.
Clots in leg/lung – your risk of clots will be assessed prior to surgery and appropriate treatment/advice will be given.

The specific risks to this surgery include

Ongoing pain – despite surgery, some patients may still have symptoms of pain.
Deformity – if the plantar fascia is cut and released, there is a small risk of developing a flat foot which can be painful and difficult to treat.
Chronic regional pain – This is excessive pain after surgery and is a very rare complication.

Advice after surgery

The foot should be strictly elevated for the first 2 weeks to avoid excessive swelling which could compromise the wound. Aim to keep the foot elevated for 55 minutes of every hour

The dressings should not be disturbed unless there is a concern with the wound.

At around 2 weeks after surgery, you will return to the clinic to have the wound inspected and stitches removed.

You may shower after the stitches have been removed and the wound is fully healed. Keep the wound and surrounding area dry and clean.

It may take several weeks before you can drive. Please check with your insurer.

Going back to work depends on the activity undertaken at work and should be discussed with your surgeon.

There is often a lengthy recovery process following surgery. Physiotherapy is essential after surgery. It may take several months before swelling subsides. Return to recreational walking and light activities can take up to 3 months. Often a full recovery takes much longer than one would expect – up to 12 months. This is a normal recovery. If you are slower than these times do not panic, they are only averages, but let your surgeon know when you attend clinic.

If I have any questions or concerns?

These guidelines are to help you understand your operation. This level of detail may cause concern, anxiety, or uncertainty. Please let your doctor or nurse know so that we may address these issues.

We aim to see you back in the clinic at regular intervals to monitor your progress and answer any questions you may have during your recovery.

If there is concern regarding the wound, such as increased redness, pus, discharge, or pain, then seek medical attention either at your GP or nearest Emergency department.

Above all else, please do not proceed with surgery unless you are satisfied and understand all you want to know about the operation.