Heel pain

Plantar fasciitis

What is it?

Plantar fasciitis is one of the most common causes of heel pain. The plantar fascia is a thick, strong band of connective tissue that runs from the heel bone (calcaneus) to the toes and helps support the arch of the foot. Plantar fasciitis occurs when this tissue becomes overloaded, irritated and painful, usually at its attachment to the heel.

The condition is most commonly seen in middle age but can occur at any age. It is associated with increased load on the foot and is particularly common in people who spend long periods standing or walking, runners, those who are overweight, or those with tight calf muscles.

The typical symptom is pain under or just in front of the heel, which is often worst first thing in the morning or after periods of rest. The pain may ease as you warm up, but often returns later in the day. Unlike acute injuries, plantar fasciitis usually develops gradually rather than after a single traumatic event.

Diagnosis is primarily clinical and based on your history and examination. Imaging such as X-ray or ultrasound is not routinely required unless the diagnosis is uncertain, or symptoms fail to improve.

Non-surgical options

The vast majority of patients with plantar fasciitis improve with non-operative treatment. This takes time and requires patience and consistency.

Non-surgical management includes:

• Activity modification – reducing activities that aggravate symptoms, particularly prolonged standing, walking on hard surfaces, or high-impact exercise.
• Stretching exercises – regular stretching of the plantar fascia and calf muscles is one of the most effective treatments. Tight calf muscles significantly increase strain on the plantar fascia.
• Footwear modification – supportive shoes with good cushioning and arch support are important. Walking barefoot or in unsupportive footwear should be avoided.
• Orthoses (insoles) – off-the-shelf or custom orthotics can help reduce strain on the plantar fascia by supporting the arch and cushioning the heel.
• Ice and simple analgesia – ice massage and simple pain relief such as paracetamol or anti-inflammatory medication (if appropriate) may help control symptoms.
• Night splints – these keep the ankle and foot gently stretched overnight and can be helpful in selected patients.
• Steroid injection – a corticosteroid injection may be considered in some persistent cases, but this is used cautiously due to the small risk of plantar fascia rupture or fat pad damage. Injection often only gives a temporary decrease in symptoms.

Shockwave therapy (ESWT)

Extracorporeal shockwave therapy (ESWT) is a well-established and evidence-based treatment for chronic plantar fasciitis that has failed to improve with initial conservative measures.

Shockwave therapy works by delivering controlled acoustic energy to the painful area. This is thought to stimulate healing by increasing local blood flow, promoting tissue regeneration, and reducing pain signalling.

Key points about shockwave therapy:

• It is non-invasive and does not involve injections or surgery.
• It is performed in the outpatient setting.
• Treatment typically consists of 3 to 6 sessions, spaced one week apart.
• Each session lasts approximately 5 - 10 minutes.
• No anaesthetic is required, although some discomfort during treatment is common.

Shockwave therapy has been shown to be particularly effective for chronic plantar fasciitis (symptoms lasting more than 3–6 months). Improvement is often gradual and may continue for several months after the final treatment session.

The success rates reported in the literature are good, with many patients experiencing significant pain reduction and functional improvement. It is a commonly used treatment in specialist foot and ankle practice.

Mr Machin uses DolorClast® Radial Shock Wave Machines at all his clinics. More information can be found here: https://www.ems-dolorclast.com/dolorclastr-radial-shock-waves

Surgical options

Surgery is very rarely required for plantar fasciitis and is only considered when symptoms have persisted for at least 9–12 months despite comprehensive non-operative treatment and when there is a specific anatomical problem which is thought to be causing the overload of the fascia such as a very tight calf or a high arch foot.

Surgical treatment typically involves calf lengthening or high arch foot surgery.

The aim of surgery is to reduce tension in the plantar fascia and relieve pain. Surgery is reserved for severe, resistant cases.