One of the most common conditions encountered by the podiatric physician is plantar fasciitis and other forms of heel pain that may present as plantar fasciitis. In fact, one study suggested that up to a third of all Americans will experience this form of heel pain at some point in their adult lives.
The plantar fascia describes a tough band of fibrous material found at the plantar surface of the foot. This structure allows for integrity of the foot, and helps to contain the deeper structures within the foot. It functions to assist in gait and maintain integrity of the musculature of the foot, and is therefore subjected to high levels of stress, particularly in the athlete or in the non-athlete that is on their feet for extended periods of time.
Plantar fasciitis is classically described as heel pain at the bottom of the foot, which may extend into the arch or even into the toes. It is a chronic inflammatory condition, which some suggest is more appropriately described as plantar fasciosis, which indicates the chronic nature of the condition, rather than an acute inflammatory process. Other causes of heel pain include stress fractures of the calcaneus, entrapment of the medial and/or lateral calcaneal nerves, tarsal tunnel syndrome, and certain forms of inflammatory arthritis. It is very possible and quite likely that some cases of heel pain may be multi-factorial, and have elements of more than one of these causes of heel pain.
Symptoms of plantar fasciitis include pain in the heel after long periods of rest, particularly in the morning. This is often referred to as “first-step pain”, and describes the sudden stretching of the plantar fascia band after it is allowed to contract some during rest. The pain may be relieved somewhat as the plantar fascia is “loosened”, but will return with increased activity.
Conservative therapy for plantar fasciitis revolves around exercise and stretching, corticosteroid injections, anti-inflammatory medications, icing, rest, and the use of orthotic devices. Newer advancements in technology have led to ultrasound and shockwave therapy, platelet-rich plasma therapy, and other high-tech therapies.
However, conservative therapy can often fail, and surgery becomes an option. Surgical management is traditionally performed as an open procedure, with a small incision made into the medial foot and a resection of some of the plantar fascia, or a simple release. Historically, the entire plantar fascia was commonly released. However, this was found to destabilize the lateral foot, and would lead to pain in this area. In fact, this complication was often more debilitating than the original plantar fascia pain. This realization led to a more judicious release of the plantar fascia, usually only involving the medial one-third of the structure. This led to much less instability and greater results.
Another historical approach to plantar heel pain was the resection of a bone spur on the calcaneus. For a long time it was believed that this was the source of the plantar fascia pain, and resection would lead to improvement. Research into “heel spurs” as the cause of heel pain would later disprove this as an etiology of the pain. Resection of heel spurs, or infracalcaneal exostoses, is not commonly performed as a result of this information.
With a greater understanding of plantar heel pain, as well as advancements in surgical technique and technologies, the use of endoscopic methods of plantar fascia release became a popular option in the 1990’s. With endoscopic plantar fasciotomy, one or two small incisions are made in the side of the foot, and a small camera is used to visualize this plantar fascia. Then, a specialized blade is inserted and the plantar fascia is released. This minimally invasive technique causes less damage to the surrounding tissues, and can lead to a faster recovery.
Post-operatively, however, a period of non-weight bearing or partial weight bearing is still recommended. With the initial development of endoscopic plantar fasciotomy, the idea of a faster recovery led to a quicker return to normal shoes. However, it was realized that this quick return to normal shoes led to increased instability and recurrence of pain. It is now recommended that the patient remain non-weight bearing in a surgical boot until healing occurs.
The endoscopic plantar fasciotomy remains a popular option for foot and ankle surgeons in the treatment of plantar fasciitis. Advancements since its initial inception make it easier to operate and lead to greater outcomes. Conservative therapy should be initiated and followed for some time before surgical intervention. If you are experiencing heel pain or symptoms of plantar fasciitis, consult your podiatrist for evaluation. Diagnosis can only be made after proper examination and evaluation.
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