PLANTAR FASCIITIS (heel spur syndrome) What is it? Plantar fasciitis is a condition wherein the plantar fascia is pulling on the periosteum at the calcaneus therefore causing inflammation and pain. The plantar fascia is connective tissue that acts as a stabilizer and maintains the integrity of the arch of the foot. It originates at the plantar aspect of the calcaneus and is attached to the metatarsal heads and continues forward to insert on the proximal phalanges as well as forming the fibrous flexor sheath in each toe. What are the common symptoms/complaints? Patients complain of severe pain felt in the heel at the hindfoot (plantar surface of the calcaneus) particularly when they take their first few steps of the day, or after they have been off their feet for a prolonged period of time. Pain after rest! How is it caused? The plantar fascia is repeatedly over-torqued because the calcaneus in the hindfoot is stable while the forefoot is over-pronating. This shearing force causes the Plantar Fascia to become inflamed. Because the weakest part of the plantar fascia is the attachment to the periosteum (fibrous membrane covering the bone) at the calcaneus. When the plantar fascia is repeatedly twisted, it pulls the periosteum away from the calcaneus and causes the pain and inflammation. If this happens often enough, the calcaneus will eventually grow toward the plantar fascia in an effort to re-attach itself. That bone growth is called a heel spur. The pain is felt during the first few steps of the day because during the night, the fibres of the fascia try to heal themselves by forming fragile new fibre, and when the person puts weight on the foot, renewed tearing takes place and the pain becomes severe. How is it treated? Since the problem is caused by over-pronation, the patient should be fitted with orthotics and will likely experience pain relief within weeks and complete recovery within months (generally 2 - 3 months). When foot pain and tenderness occurs in the bottom of the heel, most commonly the podiatry problem is related to an inflammation of the Plantar Fascia. This discussion will focus on pain to the bottom of the heel and not to the ankle joint or the rear of the heel. Besides plantar fasciitis, there are a few other conditions that need to be considered in diagnosing heel pain. These conditions include ruling out the presence of a calcaneal stress fracture, an entrapment of the nerve going to the inside or outside of the heel, radiating pain from sciatica from the hip or back and / or an nerve compression in the ankle called tarsal tunnel syndrome. In teenagers, there is also a common condition with the growth plate causing bottom of the heel pain called Sever's Disease. PLANTAR FASCIITIS AND HEEL SPUR SYNDROME The Plantar Fascia is a strong inelastic band of fibers which begins at the heel and extend into the toes. When the Plantar Fascia becomes inflamed, the pain is mainly in the arch of the foot. Medically, this condition is called Plantar Fasciitis. When the Plantar fascia becomes inflamed and the pain is mainly in the heel, medically this condition is called Heel Spur Syndrome. The usual cause of Plantar Fasciitis or Heel Spur Syndrome is excessive pulling on the Plantar Fascia from either excessive exercise, poor fitting shoe gear or poor foot alignment while running or standing. Plantar fascia pain usually begins as a mild pain to either the arch area or the bottom of the heel. The discomfort in the foot is usually most noticeable with the first step in the morning and seems to improve after a period of "warming up" the foot. If untreated, the pain can become intolerable. In some individuals, actual heel spur formation can occur at the site of where the Plantar Fascia is connected to the heel. The heel spur is actually a ridge of bone which forms to reinforce where the Plantar Fascia attaches to the heel. The ridge of bone is not the main problem unless a small nerve under the Plantar fascia becomes entrapped. The Plantar Fascia is the primary pathological anatomical structure that is causing pain to the patient. If the pulling on the plantar fascia is corrected, it is important to understand that the heel spur that formed from the pulling is not important and does not need to be removed with surgery. There are many doctors who get the heel spur confused and tell the patient that a heel spur is causing their pain when in fact it is the injury to the Plantar Fascia that needs to be medically treated. Home care for either Plantar Fasciitis or Heel Spur Syndrome primarily consists of resting the foot, applying ice to the affected area three times a day for ten minutes, and using a supportive athletic shoe for most activities during the day. Sometimes stretching the arch by rolling the foot on an empty soft drink bottle in the morning helps relieve some of the pain. In addition, using a heel pad or a padded insole can be helpful in relieving the pain in the heel. If these home treatments do not relieve the pain, treatment by a foot and ankle specialist is warranted. In treating heel and arch related foot pain, an X-ray of the foot is usually obtained to rule out a rare heel stress fracture and to document if a heel spur has occurred. Once a diagnosis is made of either Heel Spur Syndrome or Plantar Fasciitis, initial treatment usually consists of anti- inflammatory medications, the use of a night splint and functional foot orthotics. A night splint is required to hold the foot in the correct position during sleep to allow the Plantar Fascia to heal in the correct length as when standing and walking. A functional orthotic is required to control the amount of pulling that is occurring in the Plantar Fascia with weight bearing by controlling the position of the foot in the shoe. In some cases a cortisone shot is placed into the area of the origin of the Plantar Fascia to rapidly reduce the amount of pain that is present. However, in many cases, a cortisone shot results in only a couple of weeks of pain relief and the problem is back with the same intensity of pain or even worse than before the cortisone shot. Surgical intervention of either Heel Spur Syndrome or Plantar Fasciitis is rarely indicated and should be considered only after use of the night splint and / or the functional foot orthotic has failed. The surgery is warranted if the Plantar Fascia band has become too short due to repeated injury to where the Plantar Fascia or the nerve under the Plantar Fascia has become entrapped. The surgery should only be performed by an experienced surgeon. The primary purpose of the operation is to lengthen the Plantar Fascia and remove the excessive bone formation where the Plantar Fascia is anchored to the heel bone. In many surgical cases, there is also a adventitious bursa that must be excised. Over the last five years, a procedure has been advertised for heel spur surgery using a scope with claims to have a better recovery time and less associated pain compared to traditional procedures. However, to date this procedure has not demonstrated any better advancement over traditional methods and has actually been associated with a higher rate of complications than traditional procedures. Because Heel Spur Syndrome and Plantar Fasciitis is an inflammatory condition, early intervention is essential to stop the repeated scarring of the Plantar Fascia that can lead to irreversible shortening of the Plantar Fascia, nerve entrapment and the formation of a painful adventitious bursa. .
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