heel pain and plantar fasciitis - cambridge foot and … guide - heel pain.pdf• fracture of the...

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Cambridge

Foot & AnkleClinic

Fred RobinsonBSc FRCS FRCS(orth)Consultant Trauma & Orthopaedic Surgeon

www.cambridgefootandankle.com

Heel Pain and PlantarFasciitis

A patient’s guide

Cambridge Foot and Ankle Clinic T: 01223 518989 F: 01223 847436

Heel pain and Plantar fasciitisFred Robinson BSc FRCS FRCS(orth) Consultant Trauma & Orthopaedic SurgeonA patient’s guide

What causes pain in the heel? What is plantar fasciitis?

Pain in the heel can be caused by many things. The commonest cause is plantar fasciitis. Other causes include:

• beingoverweight

• constantlybeingonyourfeet, especially on a hard surface like concrete and wearing hard-soled footwear

• thinningorweaknessofthefat pads of the heel

• arthritisintheankleorheel (subtalar) joint

• irritationofthenervesontheinner or outer sides of the heel

• fractureoftheheelbone(calcaneum)

The function of the heel in walking is to absorb the shock of your foot striking the ground and to start springing you forward on the next step. The heel bone,orcalcaneum,iscushionedbyspecialisedfat,containedinelasticpockets,withinthethickenedskinofthe heel. It contains a strong bone (the calcaneum).

There are a number of strong ligaments,whichrunbetweenthecalcaneum and the toes. Amongst other things this ligament helps support the arch of the foot.

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Foot & AnkleClinic

The strongest of these ligaments is the plantar fascia. The plantar fascia takesalotofstressasyouwalk,orevenjuststanding.

In some people the plantar fascia becomespainfulandinflamed.Thisusually happens where it is attached totheheelbone,althoughsometimesit happens in the mid-part of the foot. This condition is called plantar fasciitis.

Causes include:• Constantstress.Plantarfasciitisis therefore commoner in people who spendalldayontheirfeet,orare overweight.

• Stiffnessoftheankleortightness of the Achilles tendon increase the stresses on the heel. Most people withplantarfasciitishavearather tight Achilles tendon.

• Peoplewhohavehigh-arched (‘cavus’)feetorflatfeetarelessable to absorb the stress of walking and are at risk of plantar fasciitis

• Occasionallyplantarfasciitisstarts after an injury to the heel.

• Peoplewhohavearheumatic condition such as rheumatoid arthritis or ankylosing spondylitis maygetinflammationanywhere a ligament is attached to bone (enthesopathy),andplantarfasciitis in these people is part of their general condition.

Usuallyplantarfasciitiseventuallygetsbetteritself,butthiscantakemonthsorevenyears.Ifyouhaveitonceyouare more likely to get it again.



Neartheinflamedplantarfasciaattachment,butnotinit,someextrabonemayform,producingasmall‘spur’.Infact,itisashelfofbone,nota sharp spur.

These ‘heel spurs’ are commoner in peoplewithplantarfasciitis,buttheycan be found in people with no heel pain. The heel spur is caused by the sameprocessastheheelpain,butthespur is not itself the cause of the pain.

I’ve been told my pain is caused by a bone spur. Is this likely?


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Youcantrytoavoidthethingsthatcause heel pain to start:

• Loseweight

• Whereyourjoballows,minimise the shock to your feet from constant poundingonhardsurfaces,both by reducing the time you spend on yourfeet,andwearingshoeswitha soft,cushionedheel(suchas training shoes).

• Reducetheshocksonyourheelby choosing footwear with some padding or shock-absorbing material in the heel. Heel pads can be bought in most chemists. These pads can be put in standard shoes to reduce the impact of walking.

• Ifyouhaveaninjurytoyourankle orfoot,makesureyouexercise afterwards to get back as much movementaspossibletoreducethe stresses on your foot and your heel in particular.

Ifyoustarttogetheelpain,doingtheabovethingsmayenablethenaturalhealing process to get underway and thepaintoimprove.

Can I do anything about heel pain myself?



Ifyourheelpainisaffectingyournormalactivitiesandnotgettingbetterwith simple self-treatment you may wish to consult your GP.

(Youmayprefertoputupwithit,knowing it will probably get better eventually.)

Your doctor will listen to your complaints about your heel and examine you to see what is causing thepain,andwhetheranythingelsehasstarteditoff.Ifthecauseofyourpainseemsobvious,yourdoctormaybe happy to start treatment straight away.However,sometestsmaybehelpful in ruling out other problems.

Blood tests may be done for arthritis. An X-ray will show any arthritis in the ankleorsubtalarjoint,aswellasanyfracture or cyst in the calcaneum. (It willalsoshowaspurifyouhaveone,but as we know this is not the cause of the pain.) Occasionally a bone scan may be used to help spot arthritis or a stress fracture.

As heel pain is basically a stress probleminthetissuesoftheheel,themain treatment is to reduce stress.

When should I take professional advice?

How will my doctor tell what is wrong?

What can be done about heel pain?


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Foot & AnkleClinic

• Yourdoctorwilladviseyouabout weight-loss and appropriate footwear.

• Asoftheelpadisusefultowearin your shoe to act as a shock- absorber when you walk.

• Ifyouhaveastiffankleortight Achilles tendon simple exercises can be used to stretch the heel cord. Stretching the Achilles tendon and plantarfasciaisveryeffective generaltreatmentformanypatients, howeveritisimportantthatyou undertake the exercises regularly.

1Leanyourarmsagainstasolidand secure table2 Put one leg behind the other as shown.3Bybendingthefrontknee,and keeping the back knee straight (arrow) you should feel the calf muscles (star) get tight.4 Hold this position for 30 seconds (timed). Do not rock back and forth.5Changeyourlegsover,sothatyou stretch the opposite calf. Plantar fasciitiscanaffectbothlegs,andso stretch both legs.6 Perform the exercise on both legs twice – the whole exercise takes 2 minutes.7 Repeat the exercise 4 times per day.

Self help



Self help

Simple pain-killers such as paracetamol oranti-inflammatorymedicines(forexampleBrufen,Nurofen)canhelpreducethepain.Askadvicefromyourdoctor or pharmacist before taking anti-inflammatorymedicinesastheycanhavetroublesomeside-effectsinsomepeople.

Thesimplemeasuresabovewillhelpthe majority of people with heel pain. In fact after about one year 95% of people’s symptoms settle. It is improtanttobepatient,andsticktothe treatment programme.

Ifthepaincontinues,specialisttreatment may be required. There are numerousoptions,theseinclude:

• Wearingasplintatnighttostretch yourAchilles’tendon,whileyouare asleep

• Injectionofsteroid(ananti- inflammatoryagent)intothe attachment of the plantar fascia to dampdowntheinflammation.

These measures will reduce the pain in most people who are not helped bysimpletreatment.Ifyoustillhavepainafteroneortwoinjections,yourdoctormaywanttoinvestigateyourproblem a bit further. If no other medical problem or cause of stress in yourheelisfound,anumberofothertreatments can be tried:

• Furtherphysiotherapy• Restingthefootinaplastercastto resttheinflamedtissues• Shockwavetreatment

Only if all non-surgical treatments fail would an operation be considered – this is because surgery has risks attachedtoit,andisnotalwayssuccessful.


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Foot & AnkleClinic

It is rare to need an operation for heel pain.Itwouldonlybeofferedifallsimplertreatmentshavefailedand,inparticular,youareareasonableweightfor your height and the stresses on yourheelcannotbeimprovedbymodifyingyouractivitiesorfootwear.

The aim of an operation is to release part of the plantar fascia from the heel bone and reduce the tension in it. Many surgeons would also explore andfreethesmallnervesontheinner side of your heel as these are sometimes trapped by bands of tight tissue. This sort of surgery can be done through a cut about 5cm long on the inner side of your heel. Recently there has been a lot of interest in doing the operation by keyhole surgery,butthishasnotyetbeenproventobeeffectiveandsafe,andkey hole surgery does not allow the nervestobereleased.

Mostpeoplewhohaveanoperationarebetterafterwards,butitcantakemonthstogetthefullbenefitfromthe surgery and the wound can take awhiletohealfully,forthisreasona plaster cast is often used post-operatively.

Do I need an operation?



Do I need an operation?

Surgery is between 70% and 90% successful,however,therearerisks,including a small number of patients who are worse following surgery.

The principle complications of surgery include:

• Thepainfailstosettle

• Dividingtheplantarfasciacanlead toaflatfoot,whichispainful,and difficulttotreat

• Tinglingornumbnessintheheelor foot,causedbydamagetothesmall nervesintheheel

• Infectionofthewound,slowing down healing

• Excessivebruising

• Swellingoftheankleandfoot

In the majority of cases the problems settle,butslowthehealingprocess,occasionally the damage is irreversible.Certainlyifyoudorequiresurgeryyourrecoverywillbehelpedby keeping your foot up for at least a fortnightaftersurgery,andfollowingtherecoveryprotocoloutlinedbythesurgical team.


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Wouldn’t it be better to take out my heel spur?

Asyouwillhaveseenfromreadingthesectionabove‘I’vebeentoldmypainiscausedbyabonespur’,thepainisnotcausedbythespur.Rather,both the pain and the spur are caused byinflammationintheplantarfascia.Simpleremovalofthespurhasbeenknowntobeineffectiveinrelievingthepain since the 1960s.

However,ifyouareoneoftherarepeople who do not respond to simple treatmentandenduphavinganoperationtoreleasetheplantarfascia,thesurgeonmayalsoremoveanybone spur at the same time.

FredtheFootLimited,CambridgeMedicalConsultants,WingateHouse,MarisLane,Trumpington,Cambridge,CB29FFRegisteredinEnglandNo.07700787

Cambridge Foot and Ankle ClinicSpireCambridgeLeaHospital,30NewRoad,Impington,Cambridge,CB249ELT: 01223 518989 [email protected]: 01223 847436 www.cambridgefootandankle.comMr A H N Robinson BSc FRCS (Orth) - GMC No. 3289011©Andrew HN Robinson

Cambridge

Foot & AnkleClinic

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