The most common cause of heel pain is plantar fasciitis. The plantar fascia, also called the heel fascia, is made of fibrous connective tissue and its main task is to passively stabilize the longitudinal arch of the foot. The aponeurosis attaches to the lower part of the calcaneus tumor, runs on the plantar side in three strands (medial, central and lateral) and ends at the phalanges of all of the toes. With each step, the longitudinal arch is lowered and the plantar fascia under tension to absorb the stresses. The aponeurosis, as part of the fascia tape, is also responsible for the transfer of force from the Achilles tendon to the forefoot when the heel is raised and dislodged from the big toe.
Plantar fasciitis causes pain on the plantar side of the heel, making it difficult to walk. It is now believed that the heel spurs visible on X-rays are not the primary cause of heel pain and that their presence is independent of the tendon inflammation. Treatment of plantar fasciitis consists mainly in resting, appropriately targeted rehabilitation and wearing orthopedic insoles that relieve the aponeurosis. Surgery is the last resort and is performed when conservative treatment is unsuccessful.
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How does plantar fasciaitis happen?
The cause of plantar fasciitis is an overload of the proximal attachment of the plantar fascia at the calcaneus tumor. This leads to microcracks and secondary degeneration of the fascia structure. The term "plantar fasciitis" suggests an inflammatory background of the disease, but recent studies show that degeneration and necrosis of the aponeurosis collagen fibers are at the root of the problem. People who are overweight, workers who spend most of the day standing and runners training on a hard surface are at increased risk of developing the condition. "Inflammation" of the aponeurosis often coexists with excessive tension in the calf triceps and ischio-shin muscles that form a single myofascial continuum. In people with a squamous-valgus foot, there is an uneven distribution of tension within the aponeurosis with an overload of its medial band, which also predisposes to the development of the disease.
Are heel spurs responsible for heel pain?
The calcaneus spur is a characteristic bone growth at the base of the calcaneus tumor and is often seen on x-rays in the lateral view. Patients mistakenly attribute the main role to the heel spur as a pain-inducing structure in the course of plantar fasciitis. The heel spur is formed at the site of the attachment of the proximal short flexor muscle of the fingers next to the attachment of the plantar fascia on the calcaneus and constitutes a degenerative-productive lesion. The exact influence of the spur on the "inflammation" of the aponeurosis has not been fully elucidated so far. Most orthopedic surgeons believe that the presence of a heel spur is not directly related to the pain associated with plantar fasciitis. Not all patients with fasciitis have a heel spur, and a heel spur is also present in people who do not complain of heel pain. Therefore, treatment of the heel spur aimed at its removal may be ineffective.
Plantar fascia diagnosis
Symptoms of plantar fasciitis include pain in the foot from the medial side of the heel, which is strongest in the morning when taking your first steps after getting out of bed. The feet appear stiff and painful only after the feet have "parted" or massaged in the feet, the patient is able to walk more freely. During rest (when the feet are not loaded with body weight), the tension in the triceps muscle of the calf and the aponeurosis increases. When the foot is suddenly loaded without first loosening these structures, pain is released.
Diagnostics is mainly based on an interview and clinical examination. Palpation tenderness of the aponeurosis is observed at its attachment to the calcaneus. Ultrasound examination allows the assessment of the course of the aponeurosis fibrils and the size of their swelling. Bilateral plantar fasciitis is an indication for the diagnosis of systemic diseases, e.g. rheumatoid arthritis, Reiter's syndrome, ankylosing spondylitis (AS), systemic lupus erythematosus. This is especially true for men between 15 and 35 years of age.
It is worth remembering that there are many causes of heel pain. Fasciitis should be distinguished from conditions such as:
- Heel fat pad atrophy - it is a mechanical destruction of the fatty lining under the heel, which results in impaired natural cushioning and the formation of soft tissue overload injuries, and even periostitis of the calcaneus,
- Calcaneus fracture - traumatic fracture most often occurs as a result of jumping onto the heels from a height.
- Tarsal canal syndrome - compression of the posterior tibial nerve or its branches.
Treatment of the inflammation of the aponeurosis
Most patients ask the question "how to treat heel spurs?" It is worth noting that the forming heel spur is not the primary cause of the tendon inflammation. Treatment should focus on improving the structure of the aponeurosis rather than breaking down or removing the bone spur of the heel tumor.
Conservative treatment
Treatment of plantar fasciitis is a long-term process - symptoms of varying intensity may last for several months. The mainstay of treatment is the elimination of the factor that overloads the aponeurosis. In the acute period, it is advisable to rest, i.e. avoid prolonged standing, and for runners, temporarily replace running with another form of activity, e.g. swimming or cycling. It is worth analyzing running shoes in terms of its wear and adaptation to the type of foot (shoes for excessively pronating, neutral or supination feet). In the event of severe heel pain, it is recommended to use anti-inflammatory drugs and insert pads to raise the heel approx. 2 cm in the shoes. At night, it is recommended to use an orthosis that keeps the foot in dorsiflexion, which prevents sudden changes in the tension of the plantar fascia. In the case of diagnosed flat valgus deformity of the foot, special insoles should be provided to correct the defect and relieve the plantar fascia.
Due to the accompanying increased tension of the posterior band (myofascial band), rehabilitation including manual therapy of the fascia and muscles of the posterior group of the lower leg and thigh is very helpful. The obligatory point of rehabilitation are exercises to stretch the plantar fascia and the calf triceps muscle. Initially, the exercises are performed under the supervision of a physiotherapist, and then should be regularly continued by the patient at home.
Shock wave therapy (ESWT) is a modern method of treating chronic overload of the plantar fascia. The therapy uses the effect of a pressure surge with a gradual decrease and a delayed phase of a slightly negative pressure. The pressure impulse is transmitted to the tissues through an applicator applied to the area of the heel fascia attachment. Shock wave therapy dissolves calcifications, creates new blood vessels (stimulates angiogenesis), improves local metabolism and stimulates tissue repair processes. The structure of the aponeurosis is rebuilt, thanks to which it becomes more resistant to loads.
Treatments in the field of regenerative medicine are a modern form of treatment. If you want to read more about how we treat it in our hospital, click here.
In case of severe symptoms that persist, a steroid blockade may be considered, consisting in injecting the fascia with a drug with strong anti-inflammatory and analgesic properties. However, it is not recommended to repeat this procedure too often as it may lead to local tissue necrosis. A rare but real complication of blockage is complete rupture of the plantar fascia.
Surgery
If, despite many months of conservative treatment attempts, the pain persists, surgeons perform a partial incision of the aponeurosis to decompress it (reduce tension). This procedure can be performed with a small skin incision from the medial side of the heel or with a less invasive endoscopic technique. The importance of excision of the heel spur for the relief of heel pain remains unclear, therefore he does not currently perform this type of surgery.
Frequently asked questions about plantar fasciitis:
It is now believed that the heel spurs visible on x-rays are not the primary cause of heel pain. Heel pain is most often caused by plantar fasciitis at the site of its attachment to the calcaneus. Treatment should focus on reconstructing the fascia structure, rather than breaking down or removing the calcaneus bone spur. In most cases, conservative treatment is sufficient, which includes regular exercises to stretch the plantar fascia and calf triceps, wearing orthopedic insoles, and shock wave therapy. Treatments in the field of regenerative medicine are a modern form of therapy. If you want to read more about how we treat it in our hospital, click here. Surgical treatment is the last resort and involves a partial dissection of the aponeurosis (fasciotomy).
A typical symptom of plantar fasciitis is pain in the medial area of the heel, which is strongest in the morning, especially during the first steps after getting out of bed. The feet appear stiff and painful, only after the feet “part” or massaged, the heel discomfort slightly diminishes. Palpation tenderness at the heel is also observed, and there is often increased tension in the calf muscles.
Prophylaxis of plantar fasciitis consists in limiting the factors leading to contracture and overload of the fascia. The treatment includes regular stretching of the aponeurosis and triceps muscle of the calf, self-massage of the plantar part of the foot, weight reduction, wearing insoles correcting possible valgus of the feet and selection of comfortable footwear. The above-mentioned treatments help to reduce the risk of the disease recurrence.
