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Plantar Fasciitis and Heel Spur Syndrome
Plantar Fasciitis [plantar (on the sole of the foot) heel pain] and
heel spur syndrome results from prolonged, excessive tension in the
plantar fascia and leads to inflammation and fibrosis at the
attachment of the plantar fascia to the calcaneus. Then, an
elongated plantar spur may develop at the attachment of the fascia.
A patient with plantar fasciitis usually presents with pain in the
heel on arising in the morning or after periods of rest (poststatic
dyskinesia). The pain may subside after several steps, and then
slowly worsen as the day progresses. In worse cases, the pain is
persistent and may awaken the patient while sleeping. Some people
describe a "stone bruise," sharp, sticking sensation, numbness or
tingling in the sole of the foot.
Examination reveals two groups of patients with plantar fasciitis.
The first subgroup has plantar central palpatory tenderness at the
insertion of the central band of the plantar fascia into the
calcaneal (heel) tuberosity. Patients have little to no tenderness
medial to this area. The calcaneal tuber is often prominent, and
bursa are occasionally present. The larger group of patients has
increased palpatory tenderness along the plantar medial and inferior
medial wall of the calcaneus. Pain may be elicited by active or
passive extension of the foot and digits. Palpatory tenderness
extends along the fascial band into the medial arch.
The heel spur or calcaneal spur is an osteophytic growth anterior to
the medial calcaneal tuberosity that usually extends its entire
width or about 2-2.5cm. DuVries described three types of calcaneal
spurs:
- Spurs that are large and asymptomatic because the angle of
growth of the spur does not become a weight-bearing point or the
inflammatory changes remain subacute.
- Spurs that are large and painful with weight bearing because the pitch of the calcaneus has
been altered by depression of the longitudinal arch. As a result,
the spur becomes a weight-bearing point causing intractable pain
through myositis of the intrinsic musculature and adventitious bursa
formation.
- Spurs that have a small amount of bony proliferation
and whose outline is irregular and jagged, accompanied by an area of
decreased density around the origin of the plantar fascia indicating
a subacute inflammatory response.
Conservative treatment combines pharmacological, biomechanical,
physical, and surgical therapies. Corticosteroids are the most
potent group of medications. Any of the injectable preparations may
appear to be appropriate, given through a medial or plantar
approach. NSAIDS (non-steroidal anti-inflammatory drugs) provide
relief. Physical therapy has a useful and sometimes limited role.
Icing after periods of activity and stretching of the Achilles
Tendon and plantar fascia appear helpful, especially when used after
rest. Night splints play a role by applying a constant passive
stretch to tendons, fascia, and muscles by keeping the foot and
ankle extended. Short leg casting has proven effective. Successful
orthotic therapy has been reported in podiatric literature. O'Brien
and Martin noted that orthotics were most helpful in patients with a
history of heel pain lasting longer than 2.5 years. The use of heel
cushions has been reported as a successful modality. Low dye
strappings appear helpful.
Surgical procedures include neurolysis (excision of the lateral
plantar nerve), heel spur resection, plantar fasciotomy (releasing
the plantar fascia), and endoscopic plantar fasciotomy.
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