posted on 13 Jan 2015 03:49 by gatski832
There are many diagnoses within the differential of heel pain; however, plantar fasciitis is the most common cause of heel pain for which professional care is sought. Approximately 10% of the United States population experiences bouts of heel pain, which results in 1 million visits per year to medical professionals for treatment of plantar fasciitis. The annual cost of treatments for plantar fasciitis is estimated to be between $192 and $376 million dollars. The etiology of this condition is multifactorial, and the condition can occur traumatically; however, most cases are from overuse stresses.
Plantar fasciitis is the most common injury of the plantar fascia and is the most common cause of heel pain. Approximately 10% of people have plantar fasciitis at some point during their lifetime. It is commonly associated with long periods of standing and is much more prevalent in individuals with excessive inward rolling of the foot, which is seen with flat feet. Among non-athletic populations, plantar fasciitis is associated with obesity and lack of physical exercise.
Patients with plantar fasciitis typically experience pain underneath the heel and along the inner sole of the foot. In less severe cases, patients may only experience an ache or stiffness in the plantar fascia or heel that increases with rest (typically at night or first thing in the morning) following activities which place stress on the plantar fascia. These activities typically include standing, walking or running excessively (especially up hills, on uneven surfaces or in poor footwear such as thongs), jumping, hopping and general weight bearing activity. The pain associated with this condition may also warm up with activity in the initial stages of injury. As the condition progresses, patients may experience symptoms that increase during sport or activity, affecting performance. In severe cases, patients may walk with a limp or be unable to weight bear on the affected leg. Patients with this condition may also experience swelling, tenderness on firmly touching the plantar fascia (often on a specific spot on the inner aspect of the heel) and sometimes pain on performing a plantar fascia stretch.
Plantar fasciitis is usually diagnosed by a health care provider after consideration of a person’s presenting history, risk factors, and clinical examination. Tenderness to palpation along the inner aspect of the heel bone on the sole of the foot may be elicited during the physical examination. The foot may have limited dorsiflexion due to tightness of the calf muscles or the Achilles tendon. Dorsiflexion of the foot may elicit the pain due to stretching of the plantar fascia with this motion. Diagnostic imaging studies are not usually needed to diagnose plantar fasciitis. However, in certain cases a physician may decide imaging studies (such as X-rays, diagnostic ultrasound or MRI) are warranted to rule out other serious causes of foot pain. Bilateral heel pain or heel pain in the context of a systemic illness may indicate a need for a more in-depth diagnostic investigation. Lateral view x-rays of the ankle are the recommended first-line imaging modality to assess for other causes of heel pain such as stress fractures or bone spur development. Plantar fascia aponeurosis thickening at the heel greater than 5 millimeters as demonstrated by ultrasound is consistent with a diagnosis of plantar fasciitis. An incidental finding associated with this condition is a heel spur, a small bony calcification on the calcaneus (heel bone), which can be found in up to 50% of those with plantar fasciitis. In such cases, it is the underlying plantar fasciitis that produces the heel pain, and not the spur itself. The condition is responsible for the creation of the spur though the clinical significance of heel spurs in plantar fasciitis remains unclear.
Non Surgical Treatment
Over-the-counter arch supports may be useful in patients with acute plantar fasciitis and mild pes planus. The support provided by over-the-counter arch supports is highly variable and depends on the material used to make the support. In general, patients should try to find the most dense material that is soft enough to be comfortable to walk on. Over-the-counter arch supports are especially useful in the treatment of adolescents whose rapid foot growth may require a new pair of arch supports once or more per season. Custom orthotics are usually made by taking a plaster cast or an impression of the individual's foot and then constructing an insert specifically designed to control biomechanical risk factors such as pes planus, valgus heel alignment and discrepancies in leg length. For patients with plantar fasciitis, the most common prescription is for semi-rigid, three-quarters to full-length orthotics with longitudinal arch support. Two important characteristics for successful treatment of plantar fasciitis with orthotics are the need to control over-pronation and metatarsal head motion, especially of the first metatarsal head. In one study, orthotics were cited by 27 percent of patients as the best treatment. The main disadvantage of orthotics is the cost, which may range from $75 to $300 or more and which is frequently not covered by health insurance.
Plantar fasciotomy is often considered after conservative treatment has failed to resolve the issue after six months and is viewed as a last resort. Minimally invasive and endoscopic approaches to plantar fasciotomy exist but require a specialist who is familiar with certain equipment. Heel spur removal during plantar fasciotomy has not been found to improve the surgical outcome. Plantar heel pain may occur for multiple reasons and release of the lateral plantar nerve branch may be performed alongside the plantar fasciotomy in select cases. Possible complications of plantar fasciotomy include nerve injury, instability of the medial longitudinal arch of the foot, fracture of the calcaneus, prolonged recovery time, infection, rupture of the plantar fascia, and failure to improve the pain. Coblation (TOPAZ) surgery has recently been proposed as alternative surgical approaches for the treatment of recalcitrant plantar fasciitis.
Do not walk barefoot on hard ground, particularly while on holiday. Many cases of heel pain occur when a person protects their feet for 50 weeks of the year and then suddenly walks barefoot while on holiday. Their feet are not accustomed to the extra pressure, which causes heel pain. If you do a physical activity, such as running or another form of exercise that places additional strain on your feet, you should replace your sports shoes regularly. Most experts recommend that sports shoes should be replaced after you have done about 500 miles in them.