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Plantar Fasciitis (Policemans Heel)

Plantar Fasciitis

This is a common cause of heel pain. It can affect people at any age but is most common in middle-aged women.
The plantar fascia arises from the lower inner aspect of the heel and spreads out in a fan shape across the sole of the foot. It sends slips into all the toes. It is a strong sheet of tissue that helps to maintain the arches of the foot but is also important during normal walking.

What is the cause?

The cause is not fully understood but it is thought small tears in the fascia cause inflammation and swelling. The normal fascia is approximately 3mm thick but in severe plantar fasciitis the swelling can increase this to 15mm. These tears can be caused by repetitive traction on the fascia during activities such as walking or running.

There are many factors that will increase the risk of getting these tears. These include being overweight, inappropriate footwear that does not support the foot adequately, jobs where most of the day is spent standing, tight calf muscles or achilles tendon, structural abnormalities of the foot.

Other diagnoses that can cause similar symptoms include, lateral plantar nerve compression (tarsal tunnel syndrome), tibialis posterior inflammation or dysfunction, subcalcaneal bursa or fat pad pain, calcaneal stress fracture.

Investigations

An X-ray may be requested especially if a stress fracture of the calcaneum is suspected. Often a spur of bone is found that projects forwards from the calcaneum. This has in the past been thought to be a cause of plantar fasciitis but we now know that this is not the case and if there is a spur present it is not associated with a diagnosis of plantar fasciitis.

Isotope bone scan may be used if a stress fracture is suspected if the X-rays are normal but a MRI scan is probably a better investigation in this scenario.
Nerve conduction studies may be used if there is a suspicion of nerve compression.

Treatment

Night splints are aimed at reducing the pain in the morning when first getting out of bed. Plastic splints are not always tolerated. An alternative is a Strasburg sock and these are available from many pharmacists and online retailers.

Steroid injection may be offered if symptoms don’t respond to the other treatments.

Surgery is a last resort and is only used if the symptoms have not responded to twelve months of proper conservative treatments. Surgery is only successful in 50 – 60% of cases.

A new non operative treatment is now available called shockwave therapy and further details can be found in the shockwave section

What are the symptoms and examination findings?

Pain is usually on the inner border of the foot towards the heel but it can be felt over a wide area. The onset of the pain is gradual and classically the pain is said to be worse in the morning especially the first few steps as you get out of bed. This is because during the night when asleep the foot and the fascia relaxes and the fascia will tend to shorten. The first steps of the day will stretch the fascia out to a more normal length and this is why it is very painful. After a few steps the symptoms may improve but with increasing activity throughout the day the symptoms may deteriorate. If you sit down during the day the pain can be severe after you get up and the reason for this is the same as after getting out of bed first thing in the morning. If you get pain during the night this might indicate a different diagnosis such as a trapped nerve. Plantar fasciitis can be bilateral in up to 15% of cases.

The examination findings include swelling on the anteromedial aspect of the heel, tightness of the achilles tendon is a common finding, which will limit ankle movements. Tenderness should be at the calcanealtuberosity where the plantar faciitis originates. If the tenderness is not in this area then an alternative diagnosis should be considered.

Treatment

The condition is generally regarded as being self-limiting and if treatment is initiated within three weeks of the onset of symptoms then recovery is much quicker.

Insoles may be used to support the foot and take the pressure and strain off the plantar fascia, especially if you are flat footed.
Footwear advice maybe appropriate as shoes with little support especially under the arches may aggravate symptoms. Barefoot walking should be avoided.
Anti inflammatory drugs or topical creams can be effective.

Physiotherapy to stretch the achilles tendon is aimed at reducing the work that the plantar fascia has to do. (SeeAlfredson regime file)

Physiotherapy to stretch the Achilles Tendon is aimed at reducing the work that the plantar fascia has to do