plantar fasciitis

What is Plantar Fasciitis?

Plantar Fasciitis is a term used to describe pain in the heel, especially on the instep of the foot. This is not a single diagnosis, but can be one of many diagnoses.

Plantar fasciitis is not well understood. We know what is associated with it, and what treatments are effective, but we do not understand what some of the causes are.

Typically, patients describe that they are unable to put their heels to the ground on waking. They hobble for half an hour and the stiffness gradually improves. As the day passes, they feel increasing pain in the heel.

The pain may be due to tightness in the calf muscle, which is continuous with the tissue in the heel. Another cause is loss of elasticity of the tissue under the heel bone. Normally, this acts as a shock absorber, but with age can lose it’s function. This means that the weight of the body through the heel may be concentrated in a small area, and this high pressure causes pain. Another cause is constriction around small nerves that go into the heel. The pain may be due to a constriction of the main nerve that goes around the inside of the heel bone. The pain may not be related to the heel, but may arise from a nearby joint. Only through close questioning and examination can the most likely cause be found.

Commonly, patients are told that this pain is due a heel spur. Unfortunately, this is not true.

If you have heel pain, it is best to see an orthopaedic surgeon who specialises in foot and ankle surgery. You should have x-rays taken in a standing position – this may demonstrate if there is a bone or joint cause for the pain.

If you have tightness in the calf muscles, then exercises may help to resolve the pain. The video below demonstrates how to perform them.

How is Surgery Performed?

Plantar fasciitis surgery is not commonly performed. There are two reasons for this. One is that most plantar fasciitis will eventually settle if a course of physiotherapy of at least three months is rigorously followed. The other reason is that there is no operation which will reliably settle all the symptoms of plantar fasciitis.

incision for release of gastrocnemius tendon

Patients who have morning stiffness and hobble when they get out of bed, or after sitting for a period can be helped if their clinical tests show that one of the tendons in the calf is too tight. This can be settled by physiotherapy, but if it does not, then surgery can help, although surgery does carry risks.

Patients who have pins and needles in the sole of their foot with positive tests for nerve entrapment may be helped by releasing the nerve, or small branches of it causing the pain.

There are other operations, which are all less reliable than these.

Surgery is carried out under general anaesthetic, but can be carried out with local anaesthetic injections behind the knee or around the ankle. The injections are normally given while you are asleep for your comfort. They can give good pain relief for the first day after the operation. You can go home the same day in the evening.

Risks of Surgery

There is a risk of injury to a nerve that eventually  goes to the skin on the outside of the ankle. There is also a risk of bleeding, infection, poor bone healing, poor skin healing, injury to tendons, injury to nerves, recurrence, and a need for further surgery.

There is a small risk of blood clots in the legs or lungs (DVT and PE), and there are also risks from anaesthesia – the process of being put to sleep for your operation.

Risks of Anaesthesia

The injection behind your knee is given using an ultrasound machine to guide the needle. There is a less than 1% chance of injury to the nerve. General anaesthetic also carries risks. These risks are proportional to your general health. You will need to be assessed for your fitness for surgery and an Anaesthetist will be able to advise you on your individual risk.

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