Heel Spur Syndrome / Plantar Fasciitis

Heel spur syndrome is a misnomer for a pain syndrome on the bottom of the heel. It is more accurate to call this problem plantar fascitis. Plantar Fascitis is one of the most common causes of heel pain. Dr. Wilkes provides treatment of plantar fascitis with complete diagnostic services, non surgical and state of the art surgical options for plantar fascitis treatment.

Anatomy:

The plantar fascia is a strong ligament on the bottom of the foot. It begins at the heel bone as one band and runs the along the entire bottom of the foot fanning out towards the toes. The plantar fascia is an actual continuation of the Achilles tendon and helps transfer the pull of the Achilles to the foot during walking.

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Problems with the Plantar Fascia:
The plantar fascia acts to support the inside arch of the foot. As one walks, the plantar fascia will stretch and contract as the weight is put through the foot. The problem occurs when the ligament is under constant stress and stretch such as with flat feet or tightness of the fascia. The ligament will begin to tear off from its origin in the heel bone. After several small tears develop inflammation of the area develops leading to the name plantar fascitis (-itis means inflammation).

What is a Heel Spur and does it matter:
A heel spur is extra bone on the bottom of the heel associated with the constant over pull of the plantar fascia on the heel. When there is a pulling on a bone attachment from a ligament or a tendon, bone will respond by growing in the direction of the pull. In the case of the plantar fascia, when the ligament is tight and on a constant stretch for many months and years a bone spur can grow in the area. The bone spur itself is not painful or problematic in most cases. It is when the plantar fascia begins to tear from the area that the symptoms occur. One can have a very large heel spur and no plantar fascitis or pain, and one can have a great deal of pain and no spur at all. The spur is simply a measure of the length of time the ligament has been short and tight.

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X-ray showing small heel bone spur.
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X-ray showing large heel bone spur.

Symptoms of Plantar Fascitis:
The pain of plantar fascitis is most commonly felt in the bottom of the heel towards the inside of the foot. Patients describe the pain as deep and achy and sharp at times. The main pain is with first steps after resting or not being on the foot for some time. With walking, the pain gets better and may even go away. The reason for pain with first steps is that the fascia gets tight overnight or with sitting and the first steps cause a severe stretch and tearing that causes pain.

There should be no burning pain or sharp nerve pain with plantar fascitis and there should be no deep aching pain. Often, plantar fascitis is confused with a pinched nerve or stress fracture of the heel.

Diagnosis:

The most important process in the treatment of plantar fascitis is the initial diagnosis. To often, the diagnosis is not correct or a guess is made and the proper treatment is not started.   Diagnosis is made with x-rays to make sure there is no fracture or tumor of the region. Ultrasound is used to check the fascia itself and make sure there is no tear and check the level of scar tissue and damage. Neurosensory testing, a non painful nerve test, can be used to make sure there is not a local nerve problem if pain is thought to be nerve related.

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Thick fascia and spur noted on ultrasound (Thick fascia in boxed region with arrow pointing to thick fascia and spur) Normal fascia (Normal fascia thickness in box with yellow arrow pointing to fascia)
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Partial fascia tear (Stretched fascia seen in box region with yellow arrow pointing to partial tear region) Complete fascia tear (fascia seen in box with overlap with yellow arrow pointing to torn ends)

Conservative Treatment:

Conservative treatments will heal the plantar fascitis 90% of the time. The initial conservative therapy will consist of a combination of ice therapy, stretching exercises to improve flexibility (especially in the mornings), anti-inflammatory medications, and physical therapy. Most patients will also need custom molded orthotics to help control the motion in the foot and the arch in order to take the strain off the plantar fascia. If the pain continues, a cortisone injection may be used to calm the severe swelling and pain. There may the need for the use of a night splint to hold the fascia stretched out at night.

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Dress shoe orthotic Athletic shoe orthotic

In cases of chronic plantar faciitis that is not responding to conservative care, a great in-office option is platelet rich plasma injection. The idea of platelet rich plasma (PRP) injection is to allow the growth factors in the blood to be used to cause an inflammation process in the injured tissue to allow an increase in the healing response of the body. The blood is drawn and spun down. Under ultrasound guidance and local anesthesia in the office, the injection of the PRP is placed in the damaged tissue. This allows an increased growth factor release in the area that sparks the healing process.

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Blood product drawn and spun down ready for extraction of the platelet rich plasma. Final plasma product ready for injection into the injured tissue.

In conservative therapies fail after several months, shock wave therapy may be suggested. Shockwave therapy is a non invasive procedure done in the office that allows for new blood to come to the region of fascia damage and help with healing of the fascia. Results have been excellent with over 70% of patients having relief with only one treatment. Shockwave therapy does take some time to work and results will be fully seen over a period of 3 months after treatment.

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Shockwave therapy machine Shockwave therapy setup

Surgical Treatment:

Surgery is reserved for chronic cases of plantar fascitis that do not improve with all types of conservative care. The surgical technique chosen will depend of the severity of the fascitis.

The first and less invasive surgical technique is called Coblation Surgery (cool ablation) using a Topaz probe. Topaz coblation surgery is a minimally invasive procedure that involves controlled burning of multiple tiny holes through the skin and through the plantar fascia in the heel. The ablation holes irritate the fascia enough to turn a chronic problem into an acute problem and increases circulation to the damaged area. Small nerve fibers are also calmed down decreasing pain. The patient’s own body then increases the natural healing properties which will begin to heal the newly injured ligament. This new acute injury to the ligament will be healed in a controlled environment with the foot immobilized in a boot for 2- 4 weeks. Return to walking and full activity is immediate after surgery and showering is allowed on day two after surgery.

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Picture showing initial holes being made through the skin in the heal with a pin. Picture showing Topaz probe placed through the hole and onto the Plantar Fascia.

If all forms of care fail including Topaz minimally invasive surgery, a fascia release surgery is used to release of the tight fascia. Dr. Wilkes uses an endoscopic (camera guided) approach for fascia release to allow rapid healing and limited downtime.

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Picture showing the Plantar Fascia through the camera of an arthroscope. Picture showing the Plantar Fascia after it has been cut. Notice the muscle belly showing through.

In cases of nerve entrapment and scar tissue, the nerve to the heel may need to be freed during surgery in order to remove a burning pain. This is done usually at the same time as the fascia release but through a small open incision.

In short, diagnosis of the proper problem is the key to proper treatment.