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Heel Pain

Plantar Fasciitis

Plantar Fasciitis is the most common cause of plantar heel pain, accounting for 80% of heel pain. It is estimated that 1 in 10 will suffer at one point in the UK in their lifetime.

Although no estimates could be found for the cost to the UK, the estimated cost of treatment of plantar fasciitis in 2014 in the USA was $284 million, where over 2 million individuals received treatment.

Plantar fasciitis is a term used interchangeably with Plantar fasciopathy, but it should be used to describe the acute or inflammatory stage of plantar fascia degeneration by overuse, or onset by other systemic inflammatory pathology like inflammatory arthritis. The term Plantar fasciosis describes the chronic degeneration of Plantar fasciitis. Plantar fasciopathy is the broad umbrella term for injury to the plantar fascia. Another less common etiology under this umbrella is Plantar fibroma, which is a mid portion fascia thickening associated with trauma, and subsequent scar tissue formation.

Causes

For most Plantar fasciopathies are caused by doing too much too soon, after too long doing too little. Every tissue has a load capacity, and for most this has been exceeded causing injury. I see two distinct groups who suffer. The sedentary individual, who decides to lose their holiday weight and begins to significantly increase their activity, or the seasoned conditioned athletic type, who decides they want to run a marathon and steps up their training accordingly.

Diagnosis

Pain is usually localised to the plantar heel, is unilateral, gradual in onset with pain worse on first step each morning, and following activity. Bilateral onset is associated with systemic conditions. Sudden onset should be suspected for more serious injury, and associated with mid portion tear. Whilst diagnosis is primarily made clinically based of history and symptoms, imaging is a fantastic adjunct, aiding insight into the condition. Ultrasound scans can be performed quickly, in clinic, are inexpensively, with no risk of radiation or complications.


On ultrasound imaging, changes in the plantar fascia can be seen. Most usually appear thickened and darkened at the proximal attachment to the calcaneus, indicating a chronic weakening of the collagen fibres that make up its structure. This is known as plantar fasciosis. However, thickening in the midportion is more likely a diagnosis of plantar fibroma. Plantar fasciitis is best used to describe the acute phase usually at onset of symptoms, or that of heel pain caused by systemic conditions, often associated with inflammatory arthropathy. It should be noted there are at least fifteen other causes of plantar heel pain.


Treatment

Best treatment involves identifying a correct diagnosis, also identifying the chronicity of the fasciopathy. Whilst an acute fasciitis will respond well to rest, a chronic fasciosis should not be rested. Ultimately for any fasciopathy, increasing load tolerance should be the long-term goal. Load tolerance is the amount of work a tissue can cope with before becoming injured. This is done with strengthening rehab, not stretching.

Adjuncts to rehab include custom orthoses, which aim to improve foot function to allow repair of the injured tissue, or correct biomechanic traits known to cause increased stress to the plantar fascia. Injections represent a very good way to manage pain to enable rehab to take place. These show good results at least in the short term, and better for acute onset of symptoms, if rehab is not completed, recurrence of symptoms is high. Shockwave therapy works differently to injections (and should not be mixed) with reported success rates of 77-80%, it stimulates the fascia to repair itself. This has proven longer lasting results than injections, however, anecdotally is not as well tolerated in acute cases.

In Plantar fasciopathy remember, REHAB IS KING!

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