29 Mar Heel pain is it Plantar fasciitis or fasciosis?
Heel pain can have a number of causes. Not all are plantar fasciitis (inflammation) or fasciosis (tissue changed)
A variety of structures may give rise to pain or occur simultaneously;
- Plantar fascia -tear, partial tear, thickening or tissue changes – inner heel. Usually there is marked thickening and fibrosis of the tissues without inflammation. (Lemont et al , 2003; Tountas and Fonasier, 1996).
- Central heel fat pad degeneration or inflammation
- Calcaneal bone stress – diffuse ache
- Nerve entrapment or irritation – 10-15% plantar foot pain is caused by nerve pain.
- Referred pain from the spine L5/S1.
- Trigger point pain referred from calf, quadratus plantae, and toe flexors
- Fibromatosis – benign nodules
- Systemic Inflammatory Arthritis – usually bilateral
It is not an inflammatory disorder unless inflammation is the result of a tear. In the absence of inflammation cortisone is not routinely used, and may cause rupture (Lemont et al, 2003, Acevedo and Beskin, 1998, Selman 1994)Heel spurs are not the source of symptoms (Abreu et al , 2003)
Imaging: X-Rays are not useful imagining. Ultrasound will show thickening, possible tears and hypervascularity, fibromatosis.MRI is the most comprehensive study.
Clinical Diagnosis Plantar Fasciosis: Morning pain. Pain when walking after sitting for a while. Worse with prolonged standing or walking.
What biomechanical factors are important?
- Loss of ankle dorsiflexion – bent knee or straight knee (lunge forward to test).
- Loss of plantar flexor strength – load tolerance up on toes and pain levels
- There is No association demonstrated with a/ Arch height b/ Leg length difference c/ Degree of pronation (Warren and Jones 1987, Powell 1998)
- Stretching: Non-weight bearing stretching is better than weight-bearing early in treatment. Intermittent stretching throughout the day.
- Need to assess what structures to stretch.
- Night splints can help ease morning pain; as long as there is no nerve irritation symptoms
- Orthotics do not help. A few well-controlled studies have shown this. (Lynch 1998, Martin et al 2001, Pfeffer et al, 1999). An off-the-shelf soft orthotic or silicone heel insert has been found to be more beneficial. Orthotics can weaken toe and ankle flexors which correlates with plantar foot pain.
- Low dye strapping can be equally helpful or a Tulle heel cup.
- Laser – low level therapeutic
- Dry needling trigger points and tight muscles
- Strengthen weak toe flexors, peroneus longus (first ray), tibialis posterior (20-30% support for plantar fascia)
- Calf raise with toes extended over a small towel – 12 -> 8 reps to failure
- Return to Running usually 3-6 months post injury
Nerve Entrapment or Irritation Local nerve irritation or entrapment in fascia (the container in which the nerve travels) can cause symptoms of;• Burning, sharp or shooting pain• Night pain• Can spread or move• Decreases with walking• Any altered sensation – tingling, ache, line of pain• Pain at rest or with driving is indicative• Failure to respond to local treatment
Come and be assessed by A-J with 20+ years of experience treating Foot and Ankle pain.