Topic of the Month: Plantar Fascitis

"…I'm having pain on the bottom of my heel that hurts worse in the morning when getting out of bed, or after sitting for awhile…"

This is one of the most common complaints we see in our office due to a condition called Plantar Fascitis. This is a common overuse injury, with estimates suggesting that more than 2 million Americans seek treatment for this problem annually. Plantar fascitis is believed to be an overuse injury due to repetitive stress on the ligament supporting the foot, leading to the development of micro tears. It can be seen in conjunction with a flat or high arched foot, a tight Achilles tendon, limb length discrepancies, fat pad atrophy, unsupportive shoegear, walking on hard surfaces, prolonged standing and obesity.

Most patients describe pain on the bottom of the heel, sometimes extending into the arch area. The discomfort is usually worse in the morning or after periods of inactivity (driving in the car, sitting, etc), which often gradually goes away after some activity and worsens again by the end of the day. The pain can be aching, stabbing, and throbbing. The patient will often limp after brief episodes of sitting. It is usually a slow, gradual process with no recollection of any trauma or change in activity.

Initial visit

On the initial office visit, radiographs and diagnostic ultrasound may be performed in the office. The x-rays will often reveal a heel spur resulting from tension at the origin of the plantar fascia. A heel spur can be present or absent with plantar fascitis. If an ultrasound is performed, the ligament can be easily visualized. With this condition, quite often, the proximal fascia is thickened due to the repetitive trauma. The ultrasound can also rule out other possibilities such as a calcaneal fracture, partial tear of the fascia, or tumor. The doctor will also exam your foot. An area of pinpoint tenderness can be localized on the plantar medial aspect of the heel. There is less pain when pressing the heel from side to side. Often, there is limited ankle joint dorsiflexion range of motion available.

Treatment

Luckily, conservative treatment is usually adequate in relieving the pain. These include a combination of modalities for optimal results. To reduce the local inflammatory process, often a cortisone injection will be recommended. One injection may resolve the pain, or a series of 3 to 4 injections. Too many injections over a short period of time may cause weakness of the ligament and to potential for a partial tear or rupture. A stretching program is usually instituted on the first visit to reestablish foot function. We often use a night splint, which is a device that can be worn while sleeping that keeps the foot at 90 degrees to the leg. The initial steps in the morning are usually less painful. Nonsteroidal anti-inflammatory medication such as Motrin or Celebrex is also often utilized during the acute, painful stages and well as ice or ice baths. Physical therapy is also an option, but usually reserved for the more difficult cases.

Once the acute symptoms are subsiding, we can now address your foot function by reestablishing proper biomechanics. Custom made, functional orthotics work well by limiting excessive pronation of the foot, and supporting the arch and medial plantar fascia. Orthosis have long been considered to be a reliable method for treating plantar fascitis. Heel cushions and heel cups appear to provide immediate pain relief by offering shock absorption. Athletic shoes should be worn during treatment because they offer motion control and stability.

What if months of conservative treatment fail?

Most patients do improve with conservative care (estimated 90%), but there are some instances where it seems like nothing helps (the remaining 10% of patients). At Main Street Foot and Ankle, we offer a state-of-the-art treatment called ESWT (extra corporeal shockwave therapy). This is a fairly new treatment option, which is noninvasive, and an alternative to surgical release of the plantar fascia. It is rapidly gaining popularity because of the convenience of the procedure and the effectiveness of this therapy. The mechanism of ESWT is not fully understood, but it is thought to influence pain receptors, stimulate blood flow and healing, and stimulate growth factors to the injured tissues.

The benefit of ESWT is that it is noninvasive and minimally risky. It can be performed at our office and only requires local anesthesia to numb the heel. It allows patients to return to daily activities, regular shoe gear, and return to most occupations within one to two days. Unfortunately, all insurance carriers do not recognize ESWT and many patients need to self-pay for the treatment. At our office, we have had great success with ESWT, and only in rare instances do we now perform any surgery for plantar fascitis.

The good news is most heel pain can be treated successfully by conservative means. Addressing your heel pain early can get you back to your daily activities and lifestyle!

Drs. Majeski and Paukovitz look forward to helping you!