Plantar Fasciitis
Background
The plantar fascia starts at the heel and attaches to the bases of the toes.
Chronic heel pain is one of the most common foot and ankle ailments. While heel pain can be related to Achilles tendonitis, stress fracture of the calcaneus, tibial nerve compression (aka tarsal tunnel syndrome), or other nearby pathologies, by far the most common cause of heel pain is plantar fasciitis.
The plantar fascia is a stout band of tissue that runs along the bottom side of the foot. It starts at the heel bone (calcaneus) and attaches near the “ball of the foot” at the base of the toes. The plantar fascia is critical in forming and maintaining the arch of the foot.
Despite its importance, the plantar fascia is also commonly problematic. It tends to get inflamed near its starting point on the bottom of the heel bone. This causes pain on the bottom of the heel, spreading into the arch. “-itis” means inflamed, so “plantar fasciitis” simply means inflammation of the plantar fascia.
The pain of plantar fasciitis has several characteristic qualities. First, the pain tends to be worst for the first few steps in the morning or after getting up from a seated or reclined position. Second, it tends to be more symptomatic with bare feet as compared to with cushioned shoes. Finally, as is typical of all overuse conditions, plantar fasciitis is exacerbated by activity and relieved by rest.
Plantar fasciitis occurs more commonly with and is caused in part by tightness of the Achilles tendon and calf musculature.
Nonsurgical Treatment
In the vast majority of patients, Dr. Bohl is able to achieve complete recovery from plantar fasciitis without surgical intervention. To do so, Dr. Bohl encourages a fairly rigorous treatment protocol right off the bat. This helps to prevent the condition from becoming the kind of chronic and pesky ailment that follows you for months or even years. Dr. Bohl’s protocol follows several stages:
Stage 1: Decrease the inflammation in the plantar fascia
Immobilization in an orthopaedic boot
Anti-inflammatory medications (prescription NSAIDs and topical gel)
Rest, activity modification
Ice at the end of the day
Dr. Bohl usually has patients initiate the above stage-1 interventions and then follow-up with him in four weeks. Some patients do well immediately with this protocol. For those that don’t and who are interested, the next step is injections, which can include either small amounts of steroid or platelet-rich-plasma. The goal is to get patients feeling better so that they can progress from stage 1 to stage 2 of treatment.
Stage 2: Promote healthy healing of the plantar fascia
Aggressive calf stretching at home or formally with physical therapy
Supportive shoes with good arch support at all times (no bare feet!)
MRI of showing the thickening and inflammation of plantar fasciitis.
Platelet Rich Plasma
Platelet rich plasma uses your body’s own progenitor cells to decrease inflammation and regenerate tissue.
Platelet rich plasma (PRP) injection deserves special mention as a nonsurgical option that is increasingly popular with patients. This treatment provides your own body’s progenitor cells with regenerative potential directly into the diseased tissue. Laboratory evidence shows that PRP injection decreases inflammation and leads to tissue healing in multiple areas throughout the musculoskeletal system.
This procedure is performed in the office at a routine patient visit. A small amount of blood is drawn, just like for a routine laboratory blood draw. This is spun down in a centrifuge and filtered for the cells with the most regenerative potential. These cells are provided carefully and accurately to the affected tissue using ultrasound guidance. The injection itself takes about one minute and is no more painful than any routine musculoskeletal injection.
Patients are encouraged to take it easy for the first few days following this procedure, but have no specific limitations. They can walk out of the clinic in regular shoes. Patients may feel some relief immediately, but most of the benefits accrue during the subsequent weeks and months.
Surgical Treatment
Although it is rarely necessary, surgery for plantar fasciitis is effective and can help you to return to activity.
Very rarely, patients will not be able to emerge from the stages listed above. Despite immobilization in a boot, anti-inflammatory medications, rest, ice, injections of steroid and/or platelet rich plasma, and formal physical therapy, their pain persists and their activities are limited. For these patients, surgery becomes an excellent option.
Depending on the balance of your lower extremity, your age and physical condition, any associated symptoms, and your goals and lifestyle, Dr. Bohl may recommend one of two different surgical interventions:
Plantar fascia and tarsal tunnel release. For patients with plantar fasciitis and concurrent symptoms of compression of the tibial nerve or its branches in the tarsal tunnel, Dr. Bohl recommends plantar fasciotomy and tarsal tunnel release. Through a small 3cm incision on the medial (inside) surface of the heel, Dr. Bohl will first identify the plantar fascia and protect the surrounding structures. He will then surgically lengthen the medial (painful, inflamed) portion of the plantar fascia, leaving the lateral (healthy) portion intact. He will then release the tibial nerve and its branches which run through the same area and are commonly compressed by the surrounding connective tissue.
Gastrocnemius lengthening. For patients with plantar fasciitis and an Achilles tendon contracture but no tibial nerve symptoms, Dr. Bohl may recommend gastrocnemius lengthening. The gastrocnemius is one of the two muscles that contributes to the Achilles tendon, so lengthening the gastrocnemius subtly lengthens the Achilles tendon. A tight Achilles tendon is a known contributor to plantar fasciitis, so this can provide a direct attack on one of the root causes of the disease. To preform this procedure, Dr. Bohl will make a small 3cm incision on the back of the mid-calf. He will identify the gastrocnemius muscle and lengthen one of the two layers of fascia that support it. Improvement of ankle motion will be confirmed intraoperatively prior to completion of the procedure.
In both cases, your wound will be closed with suture and you will be placed in a splint for two weeks. At two weeks, your sutures will be removed, you can begin walking in a boot. At six weeks, you can use a regular shoe and resume all activities.