George Morris Physio Wigan
Say goodbye to plantar fasciitis heel pain for good
Plagued by plantar fasciitis? Heel pain is extremely common, but that doesn't make it any less debilitating.
We speak to Mr Suresh Chandrashekar, consultant foot and ankle surgeon at London Sports Orthopaedics and London Bridge Hospital (part of HCA Healthcare UK), and Tony Gavin, podiatrist and founder of OSGO Healthcare, for their advice about the causes of heel pain and plantar fasciitis treatment:
What is plantar fasciitis?
Plantar fasciitis is caused by inflammation at the attachment of the plantar fascia (the band of thick tissue running from the toes to the heel bone), and is a very common cause of heel pain.
Typical plantar fasciitis symptoms include:
✔️ Plantar fasciitis causes pain in the bottom of your foot towards the inside point of your heel.
✔️ It hurts to put your foot flat on the ground, especially first thing in the morning when you first get up and take your first few steps.
✔️ It can make you limp and walk on the ball of your foot.
✔️ You find that with continuous periods of standing or walking your foot starts to ache and you start putting more pressure on the outside border of your foot.
✔️ Your regular shoes or running shoes may start to show wear on the outside aspect the sole.
✔️ The severity of this condition can range from mild discomfort to constant severe pain, and regular limping and a super-sensitive heel.
Who is at risk of plantar fasciitis?
In my practice, I am seeing a lot more patients being referred with this condition in and around the London area, both privately and in the NHS. This condition can affect the young although it seems to affect older people more.
While the scientific literature estimates that around 7 to 10 per cent of the population may at some stage suffer some degree of plantar fasciitis, in my day-to-day practice this figure seems like an underestimation and as if it is just the tip of the iceberg.
Plantar fasciitis risk factors include:
➡️ Being middle-aged or overweight (or both).
➡️ People with common foot problems, like flat feet or high arches, or tight Achilles’ tendons or calves, are more prone to develop plantar fasciitis.
➡️ Wearing ill-fitting shoes, or those with thin soles, or no support, can make you more susceptible, as can excessive running or standing.
How does plantar fasciitis pain start?
We commonly hear patients tell us stories such as “Doc, a few months ago I was out on a city tour / did some serious walking and standing on my feet, which I thought was not really strenuous. The next day I felt like someone has ‘kicked’ me on my heel and I felt a deep bruise, and I started limping”.
This is usually related to the fact that the plantar fascia attachment to the heel was not accustomed to the ‘out of routine’ or excessive activity that was undertaken prior to the onset of the symptoms.
This can be put down to the fact that this area was not ready to a sudden amount of tensile loading or, in plain speech, stretching. Undue stress at the site where the plantar fascia attaches to the heel bone can lead to inflammation, and hence the area becomes sensitive (ie painful) to pressure and load that it was otherwise previously fine with. This tends to spiral down and lead to increasing symptoms over the course of the following few weeks or months.
⚠️ Periods of pain can last anywhere between a few months to more than a year in severe cases.
Can fit people get plantar fasciitis?
The answer is: there’s a good chance that you may not, but your fitness routine does not make you immune.
A common trend that is seen is that plantar fasciitis often arises in patients who have pre-existing issues with their lower limb musculature, including calf tightness, mechanical alignment problems or arch abnormalities.
How do you diagnose plantar fasciitis?
The diagnosis is mostly clinical. As most clinicians do, with a detailed history and having listened to your story we will most likely have narrowed down the list of potential diagnoses. We may still order some investigations, and these can include weight-bearing X-rays of your feet.
More often than not, your X-rays may show a bony spur at the heel, which can be labelled as the cause of your symptoms: but we now know that the spur may well just simply be inconsequential.
Ultrasound scan is a more reliable investigation, both for confirming the diagnosis and for planning potential management.
How do you treat plantar fasciitis?
There are different ways to approach this problem. Most of the roads lead to ROM! ‘Range of motion’ exercises, regular stretches of the calf and exercising appropriately is definitely the way to go.
Physios and therapists swear by eccentric stretches of the calf muscles, and this allows the attachment point of the plantar fascia to the heel to feel less under tension with the day-to-day stresses of walking and running, and it can help calm the inflammation over a period of time.
If your heel pain is due to sudden unaccustomed increased loading or a spike in your gym / running / sport schedule, then gait analysis and gait re-training can be very useful.
When in the acute phase of pain, taking the pressure of the affected heel with supports and heel cushions or orthoses can work, while continuing with passive stretching exercises, rather than loaded stretching.
Another option is to wear night splints for a few weeks or even months in bed, which keep your foot stretched so that the early morning pain when placing the foot flat on the ground is reduced.
What are the best shoes for plantar fasciitis?
Chandrashekar recommends looking for shoes with the following characteristics:
✔️ Shoes that support your natural arches better.
✔️ Footwear that provide a sturdy base to walk or run on are usually the best.
✔️ Some patients feel that using shoes with moderate heels actually helps them.
Can shockwave therapy help?
There are some cases where the pain from plantar fasciitis may persist, despite following all of the above advice and treatments. In this situation, plantar fasciitis can be treated with Shockwave Therapy.
This involves 3 to 4 weekly sessions of applying pulsed energy waves to the area of maximal pain at the heel, for a period of a few minutes each time, depending on the patient’s tolerance levels.
It is a NICE recommended technique, which breaks down injured tissues or painful inflamed tissues and that helps stimulate better healing. With Shockwave Therapy one can expect a 70 to 80 per cent improvement in symptoms.
How about injections or surgery?
Other invasive methods include cortisone / steroid injection under ultrasound guidance, as a one-off method, or puncturing the inflamed area of attachment of the plantar fascia with a needle, in a procedure called ‘Dry Needling’. Dry Needling is mostly used just for very stubborn cases that have failed to resolve with the less invasive methods of treatment.
Overall, in patients who take the exercise routine and stretching program seriously, and who are motivated to do things by the book, one can expect complete resolution or cure of the symptoms of plantar fasciitis in all but a very few resistant cases.
In those with poor limb alignment or tight calf musculature, despite stretches, surgery may potentially be considered: not so much to the plantar fascia, but actually further up the limb, for example with calf releases, although thankfully this is rare.