Severe recalcitrant heel pain, resulting from repetitive trauma to the plantar fascia, is a commonly observed phenomenon. Although this condition is frequently referred to as ‘heel spurs’ and plantar fasciitis (acute inflammatory stage) and plantar fasciosis (chronic degeneration) are currently accepted as the more accurate terms. Symptoms most often occur during the first few steps in the morning but may also be effected during intense activity or with prolonged standing. The source of pain symptoms, which are usually perceived as a gradual onset of burning, is located at the origin of the plantar fascia at the calcaneous (heel bone). Risk factors such as low or high arches or over-pronation of the foot, gastrocnemius equines (tight calf muscle), systemic disease, or obesity may exacerbate pain.
The plantar fascia, or aponeurosis, is a multi-layered fibrous structure consisting three discreet sections: medial, central, and lateral. The plantar fascia fans out distally from the mid-portion of the heel and connects to the five digits of the foot. The function of the plantar fascia is to provide support to the arch of the foot and stability to the joint in the largest toe, where most weight bearing occurs during the heel rise phase of walking. The cause of the pain mechanism in recalcitrant plantar fasciitis is not yet clear, but is believed to be associated with a degenerative response linked to chronic overuse. On magnetic resonance imaging (MRI), acute plantar fasciitis exhibits microtears in the fascia and concomitant signs of acute inflammation such as marked thickening of the insertion of the plantar fascia, edema at the fascia-muscle and fascia-fat interfaces, and inflammation of the adjacent subcutaneous fat. Over time, unresolved recalcitrant plantar fasciitis shows relatively less edema in the fascia and histological evidence of localized fibrosis and/or degeneration, including fibrovascular hyperplasia and fibroblastic proliferation, with no evidence of classic inflammation. Several authors have suggested that this condition is more accurately described as ‘plantar fasciosis’. The physical characteristics of plantar fasciosis are similar to those observed with refractory tendinosis, which is recognized as a non-inflammatory, degenerative condition distinct from tendonitis. The current school of thought is that tendinosis, and similarly plantar fasciosis, may be a result of a ‘failed healing’ process, thus a principal objective in treatment is to initiate a localized angiogenic response (increased blood supply) to aid in healing.
Bob Anderson, MD, President of the Orthopedic Foot & Ankle Society has been quoted as stating that 15 million treatments for plantar fasciitis-fasciosis were performed in 2007.
Conservative treatment options for plantar fasciosis include:
rest, stretching, strengthening, ice water soaks, and massage, progressing to non-steroidal anti-inflammatories, steroid injections with continued recalcitrance. Orthotics, heel cups, night splints, and plantar strapping (taping) are other conservative options frequently recommended by treating physicians. Patient outcomes and response to conservative measures is usually positive with the Weil Foot & Ankle Institute reporting 80% success after six weeks of the basic treatments.
With non-responsive cases, approximately 15% of all presenting cases, cast immobilization and surgical care may be necessary. Extracorporeal shockwave (ESWT) treatment has recently been advocated for the recalcitrant cases.
A study performed by Dr. Lowell Weil, Jr. has shown ESWT to be effective in 70-85 percent in the recalcitrant cases of plantar fasciitis-fasciosis with no complications.
Surgical Plantar fasciotomy or fascia release, either partial or complete is commonly the surgical procedure of choice for treating plantar fasciosis with a reported success of 80-85%.(Dr. Wendy Benton-Weil) However, this surgery has a risk of complications and is thought to alter the biomechanics of the foot, which may be linked to post-operative lateral column pain and medium-term disability. Other complications including nerve damage have also been reported with endoscopic plantar fasciotomy. Plantar, micro-fasciotomy (Radiofrequency Topaz Coblation) of the plantar fascia has also shown a success rate equal to plantar fasciotomy, in a two arm, randomized blinded study. (Dr. Lowell Scott Weil, Sr.)
Lowell Scott Weil, Sr., DPM, FACFAS
Chairman & CEO
Weil Foot & Ankle InstituteDes Plaines, IL