A niggling pain under the heel that begins gradually, makes the sufferer hobble with uncomfortable stiffness on rising from bed and throbs after a long day on the feet is most likely to be caused by plantar fasciitis. This condition is sometimes called heel-spur syndrome or policeman’s heel.
The plantar fascia is a broad, thin band of gristle that runs from beneath the heel bone to the bases of the toes. It is considered to be an extension of the achilles tendon which runs from calf muscle to the heel bone, wraps around this bone, stuck very tightly to it, and then continues – as the plantar fascia – under the arch of the foot. In the arch it serves to keep the bones of the instep in place.
The achilles tendon and the plantar fascia are made from thousands of fibres of collagen. Minor damage can be repaired by the body’s natural ‘daily maintenance’.
If, however, a few too many fibres are torn then the repair process cannot keep up. The fibres become knotted, instead of smoothly aligned and regular, and the plantar fascia becomes swollen and pain intensifies. At this stage, the acute inflammatory response to a fresh injury is replaced by chronic low-grade inflammation and is sometimes termed a failed healing response.
Plantar fasciitis is more common in middle to older age groups, probably because the fibres become more brittle with age.
Pain that persists throughout the day, or even night, maybe a stress fracture (especially if osteoporotic or e.g. marathon training). Burning and tingling are unusual symptoms and may indicate a nerve condition from entrapment at the ankle or even in the lumbar spine.
Most cases of plantar fasciitis resolve in a few weeks. There is, however, no ‘quick-fix’ miracle cure. Listed below are some first-line treatments. These will help 8/10 patients to get better within three months. More stubborn cases may benefit from physiotherapy interventions. Symptoms persisting beyond six months may require specialist assessment.
Rest is important. Runners should swim or cycle to avoid aggravating the situation. Commuters should stand on the escalator and not march up the stairs. The overweight should try and recognise that their high body mass index is unhelpful. Weight loss aids healing.
Stretching exercises are perhaps the most valuable and yet under-rated means of improving symptoms. Long, slow stretches for the calf muscle and achilles tendon, combined with stretching the arch of the foot, is extremely effective. It takes time though. Too many people give up on these stretches too easily.
A night splint holds the toes and ankle up during sleep and (for those people who can tolerate wearing it overnight) reduces the pain of first steps in the morning.
Insoles come in different shapes and sizes. A simple heel cushion gives some padding to the sore area. Orthotics designed to support the arch of the foot may be beneficial too. People with very high arches or flat feet are reported to be more prone to plantar fasciitis.
Anti-inflammatory medication or gel is rarely of any use because, as noted above, the acute inflammatory phase is over by the time the patient seeks help.
The underside of the heel bone commonly has a small ‘spur’ that can be seen on x-ray pictures. This is not the reason for the pain (in 99.9% of cases) and so x-rays are not necessary, except in truly stubborn cases.
Rolling the heel over a golf ball or bottle of frozen water is commonly recommended. Although soothing for the foot there is no benefit in terms of healing the condition.
“I need an MRI”. Imaging studies are only required after several months of proper stretching. An ultrasound scan is usually a better choice of investigation if a scan is needed.
“A steroid injection will fix it”. This is not supported by medical evidence. A carefully placed injection may provide relief, but this often wears off. There are potential side-effects from steroid injections. Repeated injections should be avoided because of the risks of fat pad atrophy or plantar fascia rupture.
“My friend/relative was cured by shockwave therapy”. This (sometimes painful) therapy is useful in stubborn cases. It works by stirring up fresh damage in the injured part. It may make the condition worse if used too early in the natural history.
“There must be an instant cure”. Unfortunately, this is just not true at present.
Patients presenting with pain and stiffness under their heel (rather than on the back of the heel) should be advised to: rest, wear supportive shoes and heel cushions; perform calf/achilles stretching exercises.
It is important to paint a realistic picture of the time that recovery will take. Antiinflammatory medication is seldom useful.
The contributor, Dr Matthew Solan, is a consultant orthopaedic foot and ankle surgeon.
This article also appears in the August issue of Pharmacy Business.