Plantar fasciitis is the number one cause of heel pain, and Podiatrists are experts in the lower limb who treat this condition everyday. Anecdotallys speaking, it represents 50% of our clinic’s musculoskeletal pain cases in Singapore.
Not entirely; 50% of patients who suffer from plantar fasciitis have heel spurs, but the bone spurs are also present in people without any pain. This means that you could have a heel spur, without it causing you any pain.
Heel spurs are osteophyte formations (growths of bone tissue) on the calcaneus (heel bone); they form as the body’s reaction to inflammation and chronic local soft tissue traction. In other words, heel spurs appear from repetitive tension of connective structures at their insertions on the heel bone, e.g. Achilles tendon or plantar fascia.
Heel spurs may be symptomatic (painful) or asymptomatic (no pain). Most patients are diagnosed with a heel spur through X-ray testing for other conditions such as plantar fasciitis, calcaneal stress fracture, bone cyst or seronegative arthropathies.
Pain with heel spurs are often associated with runners, but can also affect the general population who may not exercise regularly. Heel pain is predominantly due to plantar fasciitis pathology, but it still tends to have the associated misnomer of heel spur pain or heel spur syndrome. With medical advances, we now know that heel pain is due to an overuse injury, whereby the plantar fascia and other soft tissue structures become inflamed. The pain is not a direct result of the bony growth.
Plantar fasciitis is a painful condition which is frequently under-treated; sufferers go for months or even years before seeking help from lower limb specialists such as Podiatrists. As Podiatrists, we take an interest in educating our patients and the general public in understanding this condition. We promote early intervention, before complications such as tears or ruptures can arise; the debilitating complications will often lead to surgery.
“1 in 10 people will suffer from plantar fasciitis in their lifetime.”
Anatomically, the plantar fascia appears as a triangular sheet of tough, inelastic fibrous tissue which extends from the heel bone to the base of the toes. It forms a connective tissue layer which fans into 5 distal slips that attach to the base of the 5 toes. It plays an important role during gait, facilitating forward momentum through the propulsive phase (toe-off) and maintaining the foot’s longitudinal arch. The plantar fascia absorbs 100% of our body weight at heel strike and 200% when we are running.
The plantar fascia can become inflamed (acute or chronic) due to microtears. These microtears at the attachment to the heel bone are a response to repetitive tensile forces, overuse, or degeneration of the tissue (see diagram below). Flat feet (overpronation), cavoid feet (high arches) and leg length differences all can predispose individuals to this condition. Factors such as obesity, prolonged standing, inappropriate footwear and running also put individuals at risk to developing this condition.
Plantar Fasciitis is characterised by recurrent pain in the proximal, central or distal part of the plantar fascia. It is most commonly centered at the heel.
Common characteristics of plantar fasciitis:
Stabbing pain in the bottom of the heel after physical activity.
Affects one foot, but it may occur in both feet.
Morning pain with first step on the ground (post-static dyskinesia).
Does not require any initial injury to foot.
Common secondary conditions to plantar fasciitis are achilles tendinitis, tibialis posterior tendinitis and knee pain. Due to the compensatory forces in the foot when sufferers try to avoid the painful area during gait, other structures and soft tissue become at risk of injury.
If conservative treatment fails after 6 months to 1 year, then surgical intervention should be considered. An endoscopic release of the plantar fascia is the common method for patients with a severe presentation of plantar fasciitis. But any surgery carries its own risks of surgical wound infection, prolonged swelling, increased pain, prolonged rehabilitation time, and altered biomechanics of the foot. The pros and the cons of any surgical treatment should always be weighed and considered; your surgeon would always inform you.
“Women are 6 times more likely to suffer from plantar fasciitis.”
Conservative treatment is the mainstay of treating plantar fasciitis and heel spur, with an array of modalities available to treat these conditions.
Common techniques include:
Injections such as corticosteroids or PRP
Lifestyle and shoe changes