By: Dr Azammuddin Alias

Plantar fasciitis is an inflammation of the plantar fascia, which is the ligament that connects your heel to your toes and helps support the arch of your foot. It is one of the most common causes of heel pain.

This condition occurs due to micro-injury and inflammation in the plantar tissue. Tissue inflammation causes pain, swelling and bruising.

The fascia / tissue on the sole of the foot consists of a fibrous band of thick tissue on the sole of the foot. It covers from the heel to the base of the toes. It also acts like rubber to create tension and maintain the shape of the foot.

Plantar fasciitis commonly causes stabbing pain that often occurs with your first steps in the morning. As you get up and move, the pain normally decreases, but it might return after long periods of standing or when you stand up after sitting.

Who is prone to suffer from plantar fasciitis?

• It is more common in runners and other athletes.
• People who are overweight / obese.
• People whose jobs require standing on hard surfaces, such as teachers, nurses and mail carriers.
• People who lead an inactive lifestyle.
• Those with high or low arches of the foot, and low flexibility of the Achilles tendon or calf muscles.

You are more likely to injure your plantar fascia in certain situations. For example:

• If you walk, run, stand a lot (continuous activity that exceeds one hour).
• If you have poor foot posture (flat or high foot shape).
• If you have stiff feet or ankle joints.
• If you have muscle weakness (especially calf muscles).
• If there is excessive use of the foot or sudden stretching of the sole of the foot. (Example: inappropriate or excessive training; athletes who increase training intensity walking or distance suddenly).
• If you have tight muscles (especially calf muscles).
• If you are overweight (this will put extra pressure on your heels).
• If you have leg length difference.
• If you have been wearing shoes with reduced cushioning or poor support to the shape of the foot. (Avoid wearing loose shoes with thin soles).

What does Plantar Fasciitis feel like?

Plantar fasciitis usually causes an achy pain in your heel or along the bottom of your foot. The pain can change depending on what you’re doing or the time of day. Some types of pain you might feel include:

• Sharp or stabbing pain when you put pressure on your heel.
• Pain when you stand up after sleeping or sitting down. The pain usually goes away after walking for a few minutes.
• A dull, constant ache.
• Sharp or stabbing pain when you use your affected foot or put pressure on your heel.
• Temporary relieve of pain when exercising or moving but the pain gets worse as soon as you stop.
• Increased pain first thing in the morning or when you stand up after sitting or sleeping.
• Pain on the bottom of your foot that gets worse over time.
• Pain that is at its worst first thing in the morning or after they've been sitting for a long time.

After a few minutes of walking, the pain often decreases because walking stretches your fascia.

How to diagnose plantar fasciitis?

Plantar fasciitis can be officially diagnosed by a podiatrist, a doctor who specialises in foot and ankle conditions.

To confirm a diagnosis, your podiatrist will do a physical examination of your foot and ask you to stand and walk around. They’ll also ask you about things like:

• Your health, past illnesses and injuries.
• Where and when the pain hurts the most.
• Your level of exercise and activity.

Oftentimes, X-rays aren’t necessary since plantar fasciitis is ligament inflammation, rather than a bone injury. But depending on your symptoms, your podiatrist may recommend one if they think you may have a plantar bone spur, stress fracture or another issue.

Are diabetic patients more prone to develop Plantar Fasciitis?

Yes, diabetic patients are more prone to develop plantar fasciitis. Diabetes can lead to various complications that affect the feet, including peripheral neuropathy and poor circulation, which can contribute to the development of foot problems like plantar fasciitis.

Additionally, diabetes often involves higher levels of inflammation and changes in the structure of collagen, which can affect the plantar fascia and increase the risk of developing this condition.

Proper foot care, maintaining good blood sugar control and wearing appropriate footwear are crucial for diabetic patients to help prevent plantar fasciitis and other foot-related complications.

Treatment / pain relief for plantar fasciitis

• Rest: It's important to keep weight off your foot until the inflammation goes down.
• Ice: This is an easy way to treat inflammation, and there are a few ways you can use it.

➢ To make an ice pack, wrap a towel around a plastic bag filled with crushed ice or around a package of frozen corn or peas. Put it on your heel three to four times a day for 15 to 20 minutes at a time.

➢ Or you can fill a shallow pan with water and ice and soak your heel in it for 10 to 15 minutes a few times a day. Be sure to keep your toes out of the water.

➢ Another option is to fill a bottle up with water and freeze it. Then rub it over your heel for five to 10 minutes or until your heel is numb.

• Pain relievers: Nonsteroidal anti-inflammatory drugs (NSAIDs) can make your foot feel better and help with inflammation.
• Stretching and exercise: Stretch your calves, Achilles tendon and the bottom of your foot. Do exercises that make your hips, lower leg and foot muscles stronger. This can help stabilise your ankle, ease pain and keep plantar fasciitis from coming back.
• Athletic tape: Tape can support your foot and keep you from moving it in a way that makes plantar fasciitis worse.
• Shoe inserts. Also called insoles, arch supports or orthotics, they can give you extra cushion and added support. You can get them over-the-counter (OTC) or have them custom made. Typically, your results will be just as good, and cheaper, with OTC inserts. When you choose one, firmer is better – and make sure it has good arch support.
• Proper footwear: Wear shoes with good arch support and cushioning. Avoid walking barefoot on hard surfaces.
• Night splints: Wearing a splint at night can keep the plantar fascia and Achilles tendon stretched during sleep.
• Corticosteroid injections: In some cases, corticosteroid injections may be recommended to reduce severe inflammation and pain.
• Extracorporeal Shock Wave Therapy (ESWT): This non-invasive procedure uses shock waves to stimulate healing in the plantar fascia.
• Surgery: If conservative treatments fail and symptoms persist for an extended period, surgery may be considered as a last resort.

What are the complications if foot pain is not treated?

• Ignoring foot pain can cause the pain to become chronic and affect a person's daily life.
• You can also have problems with your feet, knees, hips or back because foot pain leads to changes in the way you walk.
• It’s important to consult with a healthcare professional to determine the best treatment plan based on the severity of the condition and individual needs.

Surgical Treatment for Plantar fasciitis

Surgical intervention for plantar fasciitis is considered when conservative treatments have failed to relieve pain after six to 12 months. The main surgical procedures include:

1. Plantar Fascia Release: This is the most common surgery for plantar fasciitis. The surgeon partially cuts the plantar fascia ligament to relieve tension and reduce inflammation. This can be done through:

• Open Surgery: A small incision is made on the side of the heel to access and cut the ligament.

• Endoscopic Surgery: Small incisions are made, and a tiny camera (endoscope) and surgical instruments are used to perform the release. This method typically results in a quicker recovery.

2. Gastrocnemius Recession: This procedure involves lengthening the calf muscle (gastrocnemius) to relieve stress on the plantar fascia. It is considered if tight calf muscles are contributing to the plantar fasciitis.

Both procedures aim to reduce pain and improve foot function. Recovery involves rest, physical therapy, and gradual return to normal activities. It’s important to discuss the potential risks and benefits of surgery with a healthcare professional. Risks can include infection, nerve damage, and persistent pain.

Does a calcaneal spur cause plantar fasciitis?

A calcaneal spur, also known as a heel spur, is a bony growth that forms on the underside of the heel bone (calcaneus). It is often associated with plantar fasciitis, but it does not necessarily cause it. Here’s the relationship between the two:

1. Association: Heel spurs and plantar fasciitis frequently occur together. About 50 per cent of people with plantar fasciitis have a heel spur. However, the spur itself is not the primary cause of the pain; rather, it is the inflammation and irritation of the plantar fascia that cause discomfort.

2. Development: Heel spurs can develop as a result of long-term strain on the muscles and ligaments of the foot, particularly the plantar fascia. Repetitive stress and stretching can lead to the accumulation of calcium deposits where the plantar fascia attaches to the heel bone, forming a spur.

3. Symptoms: While heel spurs themselves are often painless, they can contribute to the symptoms of plantar fasciitis. The pain is primarily due to the inflammation of the plantar fascia, not the spur.

4. Treatment: Treatment for plantar fasciitis with or without a heel spur is similar, focusing on reducing inflammation and stress on the plantar fascia. In rare cases where a heel spur is causing significant pain, surgical removal of the spur may be considered, but this is typically a last resort.

Understanding the relationship between heel spurs and plantar fasciitis can help in managing and treating the condition effectively.

Does PRP treatment work in Plantar fasciitis?

Platelet-Rich Plasma (PRP) therapy has been explored as a treatment option for plantar fasciitis, particularly in cases where conservative treatments have not provided sufficient relief.

PRP involves injecting a concentration of a patient’s own platelets into the affected area to promote healing and reduce inflammation.

How PRP Works:

1. Preparation: Blood is drawn from the patient and then processed in a centrifuge to concentrate the platelets.

2. Injection: The platelet-rich plasma is injected into the plantar fascia, typically under ultrasound guidance to ensure accurate placement.

Potential Benefits:

1. Promotes Healing: PRP contains growth factors that may accelerate tissue repair and regeneration.

2. Reduces Inflammation: The anti-inflammatory properties of PRP can help reduce pain and swelling.

3. Minimal risk: Since PRP uses the patient’s own blood, the risk of allergic reactions or adverse effects is low.

Evidence and Effectiveness:

1. Mixed results: Clinical studies on the effectiveness of PRP for plantar fasciitis have shown mixed results. Some studies report significant pain relief and improved function while others show no substantial benefit compared to placebo or other treatments.

2. Individual variation: Response to PRP can vary among individuals, and factors such as the severity of the condition and the specific PRP preparation methods can influence outcomes.

Considerations:

1. Cost: PRP therapy can be expensive and is often not covered by insurance.

2. Multiple injections: Some patients may require more than one injection to achieve desired results.

3. Expert consultation: It’s important to consult with a healthcare professional experienced in PRP therapy to determine if it is a suitable option.

While PRP shows promise, it is not universally accepted as a standard treatment for plantar fasciitis, and more research is needed to fully understand its effectiveness and optimal use.

Does stem cells injection work in Plantar fasciitis treatment?

Stem cell injections are being investigated as a potential treatment for plantar fasciitis, particularly for cases that do not respond to conventional therapies. The idea is that stem cells can promote tissue repair and regeneration, potentially providing relief from the pain and inflammation associated with plantar fasciitis.

How Stem Cell Injections Work:

1. Source of stem cells: Stem cells can be harvested from various sources, such as bone marrow, adipose (fat) tissue, or amniotic fluid.

2. Preparation and injection: The harvested stem cells are concentrated and then injected into the affected area of the plantar fascia, usually under ultrasound guidance for precise placement.

Potential Benefits:

1. Tissue regeneration: Stem cells have the ability to differentiate into various cell types and may help repair damaged tissue.

2. Reduction of inflammation: Stem cells can modulate the immune response, potentially reducing inflammation and pain.

3. Natural healing: Using the body’s own cells can promote natural healing processes.

Evidence and Effectiveness:

1. Limited but promising research: There is some early evidence suggesting that stem cell therapy can be beneficial for plantar fasciitis. Studies have shown improvements in pain and function, but the research is still in its early stages.

2. Need for more studies: More robust, large-scale clinical trials are needed to confirm the effectiveness and safety of stem cell injections for plantar fasciitis.

Considerations:

1. Cost: Stem cell therapy can be expensive and is typically not covered by insurance.

2. Regulatory and ethical issues: The use of stem cells can raise regulatory and ethical concerns, depending on the source of the cells and the methods used.

3. Expert consultation: It is crucial to consult with a healthcare provider who specialises in regenerative medicine to determine if stem cell therapy is appropriate.

Conclusion:

Stem cell injections offer a promising avenue for the treatment of plantar fasciitis, especially for those who have not found relief with traditional treatments.

However, due to the limited amount of high-quality evidence and the need for further research, it remains an emerging and experimental option.

-- BERNAMA

Dr Azammuddin Alias, who holds a Masters in Orthopaedic Surgery (UKM) and MD (UKM), is a Consultant Orthopaedic, Foot and Ankle Surgeon at KPJ Ampang Puteri Specialist Hospital.