Heel Pain (Plantar Fasciitis)

Deep heel pain is a very common foot problem that can occur at any age and although often associated with sport often occurs after no history of high activity or trauma. The central heel pain can in some people be a minor nuisance but in others can affect their lives in making walking very painful.

Symptoms

Pain is often worse on first weight bearing in the morning and after rest. In most people the pain improves with gentle activity. The pain is often a deep aching sensation but can in some people feel very sharp. It is normally felt either under the heel or on the inside of the heel by the arch area.

Cause

In most people there is no specific cause. The pain is simply there on first bearing weight in the morning. In some people there is a mechanical cause ie the posture of their feet, or trauma. Symptoms are due to a pull on the plantar fascia (see below). Exactly why this happens is not clear.

Duration

The expectation is that the pain will go within 18 months. In many people it might last just a few weeks. It is impossible to predict how long the pain will last for each person and there are things that you can do in order to help with the pain and treat the problem.

Investigations

In the vast majority of people no investigations are required. The finding of a plantar bony spur which is seen on X Ray under the heel is irrelevant. In some people who have had heel pain for a long time an ultrasound scan or MRI might be ordered to confirm the diagnosis. Where it appears to be a standard mechanical heel pain the diagnosis is normally made in clinic. Occasionally blood tests might be arranged but this is rare.

Anatomy

The arch of the foot is supported by a large broad band of tissue called the plantar fascia or plantar aponeurosis that runs from the heel bone to the ball of the foot. It is divided into 3 bands with the central and medial (inside) portion being the strongest. With weight bearing, the foot flattens and the ligament stretches. Sometimes this overstretches and in time this can damage the insertion of the ligament into the heel bone. With continued stress on the aponeurosis it can become partially ruptured from the heel bone and this is the cause of your pain.

Treatment

This is aimed at resting the aponeurosis(fascia). The problem is that you still need to walk and carry out your daily routines. Once a thorough assessment of your foot has been made and any unusual possible causes have been ruled out the following treatment regime is usually employed.

The most important aspects of treatment are:

1/ Support of the arch of the foot and stop the foot from 'rolling in'
This is best achieved by wearing comfortable supportive shoes such as trainers and wearing insoles. These do not need to be made to measure but should have a good support to the arch. AOL or Vasyli insoles are readily found at various chemists and work well. It is important that you wear the insoles all the time in order for them to help

2/ Controlled stretching of the facia and achilles tendon
I will show you some regular calf stretching exercises that you must do every day. You can see them on
Youtube
Ehow
Make sure you do these regularly. In most people this simple regime is enough to help significantly with the pain. If however your symptoms persist the next stage would be to consider a steroid injection

3/ Steroid Injection
This can bring about dramatic relief to your heel pain. The problem is that it might not last for a long time and there are risks associated with steroid injection. The injection of steroid which is a powerful anti inflammatory into the heel reduces the inflammation and can reduce the pain. Numbing the heel before injecting the steroid significantly reduces the pain of injecting the steroid. It has been reported in the literature that the steroid can permanently thin the fat pad under the heel and this would be a major problem. I have injected the heel many times and will do this when symptoms dictate but for this reason steroids are not normally my first line of treatment

4/ Immobilisation
If the pain persists immobilising the heel might be required. This could be in a plaster cast or a removable walker boot. This could be for up to 6 weeks.

5/ Surgery
This is very rarely needed. There are numerous surgical procedures but the basic aim is to detach a portion of the fascia from the heel bone. Should this become necessary I will discuss this with you in details