Overview

Plantar calcaneal bursitis is a medical condition in which there is inflammation of the plantar calcaneal bursa, a spongy fluid filled sac that cushions the fascia of the heel and the calcaneus (heel bone). It is characterized by swelling and tenderness of the central plantar heel area. It is sometimes called ‘Policeman’s heel’. It sometimes was, and should not be, confused with plantar fasciitis, which is inflammation of the plantar fascia and can affect any part of the foot.

Causes

There are several factors which can predispose patients to developing this condition. These need to be assessed and corrected with direction from a physiotherapist and may include poor foot biomechanics (particularly flat feet), inappropriate footwear (e.g. excessively tight fitting shoes), muscle weakness (particularly the calf, quadriceps and gluteals), muscle tightness (particularly the calf), joint stiffness (particularly the ankle, subtalar joint or foot), bony anomalies of the heel bone, inappropriate or excessive training or activity, inadequate recovery periods from sport or activity, inadequate warm up, inadequate rehabilitation following a previous Achilles injury, change in training conditions or surfaces, inappropriate running technique, inadequate fitness, poor pelvic and core stability, poor proprioception or balance, being overweight.

Symptoms

Symptoms of bursitis usually occur after rest and relaxation. Upon activity there is usually more intense pain in the area of the bursa. The common areas to have a bursitis in the foot are in the bottom of the heel, behind the heel near the attachment of the Achilles Tendon as well as along the side of a bunion. A bursa may also form in multiple areas especially along the metatarsal heads, or “ball” of your foot. You may actually feel the sac like fluid when rubbing the area of pain.

Diagnosis

Medical examination is not necessarily required in light cases where the tenderness is minimal. In all cases where smooth improvement is not experienced, medical attention should be sought as soon as possible to exclude a (partial) rupture of the Achilles tendon or rupture of the soleus muscle. This situation is best determined by use of ultrasound scanning, as a number of injuries requiring treatment can easily be overlooked during a clinical examination (Ultrasonic image). Ultrasound scanning enables an evaluation of the extent of the change in the tendon, inflammation of the tendon (tendinitis), development of cicatricial tissue (tendinosis), calcification, inflammation of the tissue surrounding the tendon (peritendinitis), inflammation of the bursa (bursitis), as well as (partial) rupture.

Non Surgical Treatment

The underlying cause of the bursitis must be identified to prevent further reoccurrences. Failure to eliminate the cause will lead to future flare ups and a poor and slow recovery. Future occurrences can be prevented with the use of stretches and strengthening exercises which will help prevent the muscles from tightening up over the bursa, Pilates and yoga are very good for this providing the aggravating movements are avoided. Wearing joint supports such as knee pads or elbow supports may also reduce the likelihood of redeveloping bursitis.

Surgical Treatment

Surgery. Though rare, particularly challenging cases of retrocalcaneal bursitis might warrant a bursectomy, in which the troublesome bursa is removed from the back of the ankle. Surgery can be effective, but operating on this boney area can cause complications, such as trouble with skin healing at the incision site. In addition to removing the bursa, a doctor may use the surgery to treat another condition associated with the retrocalcaneal bursitis. For example, a surgeon may remove a sliver of bone from the back of the heel to alter foot mechanics and reduce future friction. Any bone spurs located where the Achilles attaches to the heel may also be removed. Regardless of the conservative treatment that is provided, it is important to wait until all pain and swelling around the back of the heel is gone before resuming activities. This may take several weeks. Once symptoms are gone, a patient may make a gradual return to his or her activity level before their bursitis symptoms began. Returning to activities that cause friction or stress on the bursa before it is healed will likely cause bursitis symptoms to flare up again.

Overview

Hammer toes is a Z-shaped deformity caused by dorsal subluxation at the metatarsophalangeal joint. Diagnosis is clinical. Treatment is modification of footwear and/or orthotics. The usual cause is misalignment of the joint surfaces due to a genetic predisposition toward aberrant foot biomechanics and tendon contractures. RA and neurologic disorders such as Charcot-Marie-Tooth disease are other causes.

Causes

Medical problems, such as stroke or diabetes that affect the nerves, may also lead to hammertoe. For example, diabetes can result in poor circulation, especially in the feet. As a result, the person may not feel that their toes are bent into unnatural positions. The likelihood of developing hammertoe increases with age and may be affected by gender (more common in women) and toe length; for example, when the second toe is longer than the big toe, hammertoe is more likely to occur. Hammertoe may also be present at birth. Genetics may factor in to developing hammertoe, particularly if the foot is flat or has a high arch, resulting in hammertoe instability.

Symptoms

Some people never have troubles with hammer toes. In fact, some people don’t even know they have them. They can become uncomfortable, especially while wearing shoes. Many people who develop symptoms with hammer toes will develop corns, blisters and pain on the top of the toe, where it rubs against the shoe or between the toes, where it rubs against the adjacent toe. You can also develop calluses on the balls of the feet, as well as cramping, aching and an overall fatigue in the foot and leg.

Diagnosis

A hammertoe is usually diagnosed with a physical inspection of your toe. Imaging tests, such as X-rays, may be ordered if you have had a bone, muscle, or ligament injury in your toe.

Non Surgical Treatment

Conservative treatment starts with new shoes that have soft, roomy toe boxes. Shoes should be one-half inch longer than your longest toe. (Note: For many people, the second toe is longer than the big toe.) Avoid wearing tight, narrow, high-heeled shoes. You may also be able to find a shoe with a deep toe box that accommodates the hammer toe. Or, a shoe specialist (Pedorthist) may be able to stretch the toe box so that it bulges out around the toe. Sandals may help, as long as they do not pinch or rub other areas of the foot.

Surgical Treatment

Surgery is used when other types of treatment fail to relieve symptoms or for advanced cases of hammertoe. There are several types of surgeries to treat hammertoe. A small piece of bone may be removed from the joint (arthroplasty). The toe joint may be fused to straighten it (arthrodesis). Surgical hardware, such as a pin, may be used to hold the bones in place while they heal. Other types of surgery involve removing skin (wedging) or correcting muscles and tendons to balance the joint.

Prevention

Certain exercises such as moving and stretching your toe gently with your hands and picking up small or soft objects such as marbles or towels can keep your toe joints flexible, simple exercises can stretch and strengthen your muscles. Limit high-heel use, well-designed flat shoes will be more comfortable than high heels. Don’t wear shoes that are too short or too narrow, or too shallow, this is especially important for children going through periods of rapid growth, the toe area should be high enough so that it doesn’t rub against the top of your toes.

Overview

A Hammer toes is a contracture of the toes as a result of a muscle imbalance between the tendons on the top and the tendons on the bottom of the toe. They can be flexible or rigid in nature. When they are rigid, it is not possible to straighten the toe out by manipulating it. Frequently, they develop corns on the top of the toe as a result of rubbing on the shoe. They may also cause a bothersome callous on the ball of the foot. This occurs as a result of the toe pressing downward on the bone behind the toe. This area then becomes prominent and the pressure of the bone against the ground causes a callous to form.

Causes

If a foot is flat (pes planus, pronated), the flexor muscles on the bottom of the foot can overpower the others because a flatfoot is longer than a foot with a normal arch. When the foot flattens and lengthens, greater than normal tension is exerted on the flexor muscles in the toes. The toes are not strong enough to resist this tension and they may be overpowered, resulting in a contracture of the toe, or a bending down of the toe at the first toe joint (the proximal interphalangeal joint) which results in a hammertoe. If a foot has a high arch (pes cavus, supinated), the extensor muscles on the top of the foot can overpower the muscles on the bottom of the foot because the high arch weakens the flexor muscles. This allows the extensor muscles to exert greater than normal tension on the toes. The toes are not strong enough to resist this tension and they may be overpowered, resulting in a contracture of the toe, or a bending down of the toe at the first toe joint (the proximal interphalangeal joint) which results in a hammertoe.

Symptoms

Some people never have troubles with hammer toes. In fact, some people don’t even know they have them. They can become uncomfortable, especially while wearing shoes. Many people who develop symptoms with hammer toes will develop corns, blisters and pain on the top of the toe, where it rubs against the shoe or between the toes, where it rubs against the adjacent toe. You can also develop calluses on the balls of the feet, as well as cramping, aching and an overall fatigue in the foot and leg.

Diagnosis

Hammertoes are progressive, they don?t go away by themselves and usually they will get worse over time. However, not all cases are alike, some hammertoes progress more rapidly than others. Once your foot and ankle surgeon has evaluated your hammertoes, a treatment plan can be developed that is suited to your needs.

Non Surgical Treatment

Treating hammertoe involves straightening the toe, making tendons in the toes flexible again, and preventing the problem from returning. Some simple treatments include Soaking your feet every day in warm water, then stretching your toes and ankles by pointing your toes. Using over-the-counter pads, cushions or straps to decrease discomfort. Splinting the toe to keep it straight and to stretch the tendons of the foot. Exercising the toes to relax the foot tendons (a session with a physical therapist may help you get started with foot exercises). One simple exercise is to place a small towel on the floor and then pick it up using only your toes. You also can grasp at carpet with your toes or curl your toes up and down repeatedly. Wearing shoes that fit properly and give toes plenty of room to stretch out.

Surgical Treatment

Hammertoe surgery is performed when conservative measures have been exhausted and pain or deformity still persists. The surgery is performed on an outpatient basis. It typically required about one hour of time. An incision is placed over the inter-phalangeal joint. Once the bone is exposed, the end portion of the bone is removed. Your surgeon may then use pins or other fixation devices to assist in straightening the toe. These devices may be removed at a later date if necessary. Recovery for hammertoe surgery is approximately 10 to 14 days. You are able to walk immediately following the surgery in a surgical shoe. Swelling may be present but is managed as needed. Physical therapy is used to help reduce swelling in the toe or toes after surgery. Most of these toe surgeries can be performed in the office or the outpatient surgery under local anesthesia.

Prevention

There should be at least one-half inch between the tip of your longest toe and the front of the shoe. Never buy shoes that feel tight and expect them to stretch with wearing. If you hammertoe have prominent areas on your feet such as hammertoes and bunions, avoid shoes with a lot of stitching or multiple pieces of fabric, as these stitched areas tend not to stretch to accommodate various toe deformities.

Overview

Overpronation is the exaggerated inward rolling of the foot and ankle, which can lead to a collapsed arch and flat feet. Many people overpronate and do not even realize it; one way to tell is to simply look at the foot and see how it is placed on the ground when standing in a neutral position. Another way is to wet the bottom of the foot and step on a piece of paper. If the entire imprint of the foot is shown, it means you overpronate.

Causes

There are many biomechanical issues that can contribute to excessive pronation, including weak foot intrinsic muscles, limited ankle dorsiflexion mobility and calf flexibility, weak ankle invertor muscles (e.g. posterior tibialis), weak forefoot evertor muscles (peroneus longus), poor hip strength and control, Anterior pelvic tilting, heel InversionIn a person who overpronates, the heel bone goes into an everted position meaning that it turns out away from the midline of the body. The opposite motion of eversion is inversion. Inversion is a motion that needs to be controlled to prevent the foot from excessively pronating.

Symptoms

Common conditions seen with overpronation include heel pain or plantar fasciitis, achilles tendonopathy, hallus valgus and or bunions, patellofemoral pain syndrome, Iliotibial band pain syndrome, low back pain, shin splints, stress fractures in the foot or lower leg.

Diagnosis

Look at your soles of your footwear: Your sneaker/shoes will display heavy wear marks on the outside portion of the heel and the inside portion above the arch up to the top of the big toe on the sole. The “wet-foot” test is another assessment. Dip the bottom of your foot in water and step on to a piece of paper (brown paper bag works well). Look at the shape of your foot. If you have a lot of trouble creating an arch, you likely overpronate. An evaluation from a professional could verify your foot type.

Non Surgical Treatment

Studies have shown that the most effective way to dexrease a high Q angle and lower the biomechanical stresses on the knee joint is to prevent excessive pronation with custom-maflexible orthotics. One study found that using soft corrective orthotics was more effective in reduknee pain than a traditional exercise program. A more recent study showed that Q angle asymmetries, secondary to excessive pronation affecting knee alignment, can be effectivecontrolled or corrected utilizing custom-made, flexible orthotics. Another project involving meof a running club determined that 75% of those using orthotics eliminated or greatly reduced pain in the feet, ankles, shins, knees and hips

Surgical Treatment

The MBA implant is small titanium device that is inserted surgically into a small opening between the bones in the hind-mid foot: the talus (ankle bone) and the calcaneus (heel bone). The implant was developed to help restore the arch by acting as a mechanical block that prevents the foot from rolling-in (pronation). In the medical literature, the success rate for relief of pain is about 65-70%. Unfortunately, about 40% of people require surgical removal of the implant due to pain.

Overview

As children reach their growth spurt in early puberty, the heel is one of the first body parts to grow to full size. Because children’s bones are growing so fast, the muscles or tendons can’t keep up and often become tight. The tight heel tendons can put a lot of stress on the heel, especially if a child is involved in athletics or other weight-bearing activity. Over time, too much pressure on the heel can injure it and result in Sever’s disease, also called calcaneal apophysitis.

Causes

The exact cause of Severs disease is not completely understood. It is thought to be associated with an overuse type injury, in which repetitive stress from the Achilles tendon causes a portion of the growth plate to pull away from the heel. In medical terms, this is described as cyclic, micro-avulsion type fractures to the calcaneal apophyses.

Symptoms

Symptoms include complaints of pain or tenderness in the heel (or heels), discomfort when heel is squeezed, limping, and more severe pain after walking, running or playing sports. Sever?s disease is directly related to overuse of the bone and tendons in the heel. This can come from playing sports or anything that involves lots of heel movements and hard shoes such as cleats. It can be associated with starting a new sport, or the start of a new season. It occurs more commonly in children who pronate (feet roll inward), and involves both heels in more than half of patients.

Diagnosis

Low-grade inflammation of the calcaneal apophysis cannot be seen on x-ray. Therefore, although x-rays are often done to rule out bony injuries in children with Sever’s disease these x-rays are usually normal. Advanced Sever’s disease can be seen on x-ray but usually the problem is treated before it reaches this point. Other diagnostic tests, such as bone scans or MRI’s, are not usually required in typical cases of Sever’s disease. These, or other tests, may be required to rule out other conditions, such as stress fractures of the calcaneus or other bony abnormalities that can mimic Severs disease.

Non Surgical Treatment

Activity Modification: to decrease the pain, limiting sporting activities is essential. Cutting back on the duration, intensity, and frequency can significantly improve symptoms. Heel cord stretching is important if heel cord tightness is present. Heel cushions/cups or soft orthotics decreases the impact on the calcaneus by distributing and cushioning the weight bearing of the heel. Use of NSAIDS. Ibuprofen (Nuprin, Motrin) or naproxen (Aleve) can decrease pain and secondary swelling. Ice. Placing cold or ice packs onto the painful heel can alleviate pain. Short-leg cast. For recalcitrant symptoms a short-leg cast is occasionally used to force rest the heel.

Overview

The function of the heel in walking is to absorb the shock of your foot striking the ground as it is put down and to start springing you forward on the next step. It contains a strong bone (the calcaneum). Under the bone are a large number of small pockets of fat in strong elastic linings, which absorb much of the shock (fat pads). The heel is attached to the front of the foot by a number of strong ligaments which run between the front part of the calcaneum and various other parts of the foot. The strongest ligament is the plantar fascia, which attaches the heel to the toes and helps to balance the various parts of the foot as you walk. It therefore takes a lot of stress as you walk. In some people the plantar fascia becomes painful and inflamed. This usually happens where it is attached to the heel bone, although sometimes it happens in the mid-part of the foot. This condition is called plantar fasciitis and causes Heel Pain.

Causes

Plantar Fasciitis is the most common form of heel pain. The tears and inflammation that develop along the plantar fascia ligament result in dull aching pain or a burning sensation along the bottom of the foot. Pain becomes particularly noticeable after periods of rest, such as during the first few steps after getting out of bed in the morning, or after getting up after a prolonged period of sitting. Another common form of heel pain is the development of a heel spur. A heel spur, as mentioned above, is the formation of a bony hook extending from the heel. Typically, these growths develop near the area where the plantar fascia connects to the heel bone. The repetitive pressure on the plantar fascia that results from stretching excessively away from the heel bone causes a response from our body that delivers calcium to the area. The heel pain that ensues develops from the nerves and sensitive tissue that become irritated when the bone fragment digs into the bottom of the heel. Pain may decrease after walking as the tissue in the heel gets used to the fragment and adjusts around it. However, pain will be particularly problematic following periods of rest. Strained muscle tissue may cause heel pain in several areas. A tight plantar fascia causes additional tension, particularly while exercising, placing runners and other athletes at risk if the ligament is not properly warmed up prior to exercise. Additionally, a tight Achilles tendon along the back of the foot can also add tension along the plantar fascia, resulting in possible damage, not to mention the damage and pain that can occur along the Achilles tendon itself (Achilles tendonitis). It is recommended that athletes properly stretch the foot as well as the calf in order to reduce tension on muscle and other tissue in the foot.

Symptoms

Pain in the heel can be caused by many things. The commonest cause is plantar fascitis. Other causes include, being overweight, constantly being on your feet, especially on a hard surface like concrete and wearing hard-soled footwear, thinning or weakness of the fat pads of the heel, injury to the bones or padding of the heel, arthritis in the ankle or heel (subtalar) joint, irritation of the nerves on the inner or outer sides of the heel, fracture of the heel bone (calcaneum).

Diagnosis

Your doctor will listen to your complaints about your heel and examine you to see what is causing the pain, and whether anything else has started it off. If the cause of your pain seems obvious, your doctor may be happy to start treatment straight away. However, some tests may be helpful in ruling out other problems. Blood tests may be done for arthritis. An Xray will show any arthritis in the ankle or subtalar joint, as well as any fracture or cyst in the calcaneum. (It will also show a spur if you have one, but as we know this is not the cause of the pain.) Occasionally a scan may be used to help spot arthritis or a stress fracture.

Non Surgical Treatment

Orthotics, by treating the cause of the problem, lead to the cure bette than 90% of the time. A small number of patients have waited so long that the plantar fascia has become thickened and filled with scar tissue and are not helped by ?conventional? means. Those are the patients that have, traditionally, required surgical treatment in which the plantar fascia is cut off the heel bone. Luckily, most surgery has been replaced by a relatively new mode of treatment, ESWT or Extracorporeal Shockwave Therapy. ESWT involves the application of multiple shockwaves to the diseased tendon or ligament and has an approximately 85 to 90% success rate. Keep in mind we are talking about this success rate in patients who are ?tough cases,? that is, already had the conventional treatment. The ESWT machines look like miniature renal lithtripsors (kidney stone crushers). There are virtually no side effects to ESWT other than the price as only about 30% of insurance companies are paying for it. They realize that it is less costly and safer than surgery but also know that many more people who would avoid surgery would have no problem getting ESWT so the volume of services would go up. You don?t have to live with painful heels.

Surgical Treatment

Only a relatively few cases of heel pain require surgery. If required, surgery is usually for the removal of a spur, but also may involve release of the plantar fascia, removal of a bursa, or a removal of a neuroma or other soft-tissue growth.

Prevention

You can try to avoid the things that cause heel pain to start avoid becoming overweight, where your job allows, minimise the shock to your feet from constant pounding on hard surfaces, reduce the shocks on your heel by choosing footwear with some padding or shock-absorbing material in the heel, if you have high-arched feet or flat feet a moulded insole in your shoe may reduce the stresses on your feet, if you have an injury to your ankle or foot, make sure you exercise afterwards to get back as much movement as possible to reduce the stresses on your foot and your heel in particular, If you start to get heel pain, doing the above things may enable the natural healing process to get underway and the pain to improve.

Overview

The Achilles tendon is the largest tendon in the human body. It can withstand forces of 1,000 pounds or more. It is also the most frequently ruptured tendon. Both professional and weekend athletes can suffer from Achilles tendinitis (informally: ?tendonitis?), a common overuse injury and inflammation of the tendon.

Causes

Achilles tendinitis can be caused by overly tight calf muscles, excessive running up hill or down hill, a sudden increase in the amount of exercise, e.g. running for a longer distance, wearing ill-fitting running shoes, such as those with soles that are too stiff, or wearing high heels regularly, or changing between high heels all day and flat shoes or low running shoes in the evening. Overuse is common in walkers, runners, dancers and other athletes who do a lot of jumping and sudden starts/stops, which exert a lot of stress on the Achilles tendon. Continuing to stress an inflamed Achilles tendon can cause rupture of the tendon – it snaps, often with a distinctive popping sound. A ruptured Achilles tendon makes it virtually impossible to walk. An Achilles tendon rupture is usually treated by surgical repair or wearing a cast.

Symptoms

The main complaint associated with Achilles tendonitis is pain behind the heel. The pain is often most prominent in an area about 2-4 centimeters above where the tendon attaches to the heel. In this location, called the watershed zone of the tendon, the blood supply to the tendon makes this area particularly susceptible. Patients with Achilles tendonitis usually experience the most significant pain after periods of inactivity. Therefore patients tend to experience pain after first walking in the morning and when getting up after sitting for long periods of time. Patients will also experience pain while participating in activities, such as when running or jumping. Achilles tendonitis pain associated with exercise is most significant when pushing off or jumping.

Diagnosis

On examination, an inflamed or partially torn Achilles tendon is tender when squeezed between the fingers. Complete tears are differentiated by sudden, severe pain and inability to walk on the extremity. A palpable defect along the course of the tendon. A positive Thompson test (while the patient lies prone on the examination table, the examiner squeezes the calf muscle; this maneuver by the examiner does not cause the normally expected plantar flexion of the foot).

Nonsurgical Treatment

Conservative management of Achilles tendinosis and paratenonitis includes the following. Physical therapy. Eccentric exercises are the cornerstone of strengthening treatment, with most patients achieving 60-90% pain relief. Orthotic therapy in Achilles tendinosis consists of the use of heel lifts. Nonsteroidal anti-inflammatory drugs (NSAIDs): Tendinosis tends to be less responsive than paratenonitis to NSAIDs. Steroid injections. Although these provide short-term relief of painful symptoms, there is concern that they can weaken the tendon, leading to rupture. Vessel sclerosis. Platelet-rich plasma injections. Nitric oxide. Shock-wave therapy. Surgery may also be used in the treatment of Achilles tendinosis and paratenonitis. In paratenonitis, fibrotic adhesions and nodules are excised, freeing up the tendon. Longitudinal tenotomies may be performed to decompress the tendon. Satisfactory results have been obtained in 75-100% of cases. In tendinosis, in addition to the above procedures, the degenerated portions of the tendon and any osteophytes are excised. Haglund?s deformity, if present, is removed. If the remaining tendon is too thin and weak, the plantaris or flexor hallucis longus tendon can be weaved through the Achilles tendon to provide more strength. The outcome is generally less favorable than it is in paratenonitis surgery.

Surgical Treatment

Surgery is considered the last resort and is often performed by an orthopedic surgeon. It is only recommended if all other treatment options have failed after at least six months. In this situation, badly damaged portions of the tendon may be removed. If the tendon has ruptured, surgery is necessary to re-attach the tendon. Rehabilitation, including stretching and strength exercises, is started soon after the surgery. In most cases, normal activities can be resumed after about 10 weeks. Return to competitive sport for some people may be delayed for about three to six months.

Prevention

You can take measures to reduce your risk of developing Achilles Tendinitis. This includes, Increasing your activity level gradually, choosing your shoes carefully, daily stretching and doing exercises to strengthen your calf muscles. As well, applying a small amount ZAX?s Original Heelspur Cream onto your Achilles tendon before and after exercise.

Overview

The plantar fascia is made up of 3 distinct parts: the medial, central, and lateral bands. The central plantar fascia is the thickest and strongest section, and this segment is also the most likely to be involved with plantar fasciitis. In normal circumstances, the plantar fascia acts like a windlass mechanism to provide tension and support through the arch. It functions as a tension bridge in the foot, providing both static support and dynamic shock absorption.

Causes

Plantar fasciitis is usually not the result of a single event but more commonly the result of a history of repetitive micro trauma combined with a biomechanical deficiency of the foot. Arthritic changes and metabolic factors may also playa part in this injury but are unlikely in a young athletic population. The final cause of plantar fasciitis is “training errors.” In all likelihood the injury is the result of a combination of biomechanical deficiencies and training errors. Training errors are responsible for up to 60% of all athletic injuries (Ambrosius 1992). The most frequent training error seen with plantar fasciitis is a rapid increase in volume (miles or time run) or intensity (pace and/or decreased recovery). Training on improper surfaces, a highly crowned road, excessive track work in spiked shoes, plyometrics on hard runways or steep hill running, can compromise the plantar fascia past elastic limits. A final training error seen in athletics is with a rapid return to some preconceived fitness level. Remembering what one did “last season” while forgetting the necessity of preparatory work is part of the recipe for injury. Metabolic and arthritic changes are a less likely cause of plantar fasciitis among athletes. Bilateral foot pain may indicate a metabolic or systemic problem. The definitive diagnosis in this case is done by a professional with blood tests and possibly x-rays.

Symptoms

If you have Plantar Fasciitis, you will most likely feel a sharp pain under the ball of you heel and it will often give pain when standing after a period of rest. For example when you get out of bed in the mornings or after being sat down. Some patients describe this feeling as a stone bruise sensation, or a pebble in the shoe and at times the pain can be excruciating. Patients with Plantar Fasciitis can experience pain free periods whereby the think they are on the mend, only for the heel pain to come back aggressively when they appear to have done nothing wrong. If your plantar fasciitis came on very suddenly and the pain is relentless, then you may have Plantar Fascial Tears. We will be able to differentiate between these 2 conditions, sometimes with ultra sound imaging. The treatment for each of these conditions will need to be very different.

Diagnosis

Diagnosis of plantar fasciitis is based on a medical history, the nature of symptoms, and the presence of localised tenderness in the heel. X-rays may be recommended to rule out other causes for the symptoms, such as bone fracture and to check for evidence of heel spurs. Blood tests may also be recommended.

Non Surgical Treatment

In general, we start by correcting training errors. This usually requires relative rest, the use of ice after activities, and an evaluation of the patient’s shoes and activities. Next, we try correction of biomechanical factors with a stretching and strengthening program. If the patient still has no improvement, we consider night splints and orthotics. Finally, all other treatment options are considered. Non-steroidal anti-inflammatory medications are considered throughout the treatment course, although we explain to the patient that this medicine is being used primarily for pain control and not to treat the underlying problem.

Surgical Treatment

The most common surgical procedure for plantar fasciitis is plantar fascia release. It involves surgical removal of a part from the plantar fascia ligament which will relieve the inflammation and reduce the tension. Plantar fascia release is either an open surgery or endoscopic surgery (insertion of special surgical instruments through small incisions). While both methods are performed under local anesthesia the open procedure may take more time to recover. Other surgical procedures can be used as well but they are rarely an option. Complications of plantar fasciitis surgery are rare but they are not impossible. All types of plantar fasciitis surgery pose a risk of infection, nerve damage, and anesthesia related complications including systemic toxicity, and persistence or worsening of heel pain.

Prevention

You can help to prevent plantar fasciitis by maintaining a healthy weight, by warming up before participating in sports and by wearing shoes that support the arch and cushion the heel. In people who are prone to episodes of plantar fasciitis, exercises that stretch the heel cord (known as the Achilles tendon) and the plantar fascia may help to prevent plantar fasciitis from returning. Ice massage also can be used on the bottom of the foot after stressful athletic activities. It is possible that strict control of blood sugar will prevent plantar fasciitis in people with diabetes, although this has not been proven.

Overview

At the bottom of your foot there’s a thick band of connective tissue called the plantar fascia or arch tendon. It connects your heel bone (calcaneus) to the front of your foot. If the plantar fascia becomes irritated and sore from overuse, it’s known as plantar fasciitis. Plantar fasciitis sometimes can be mistaken for heel spurs, which is a different kind of injury with similar symptoms. Plantar fasciitis is a common cause of heel pain in runners, dancers, and athletes in sports that involve a lot of running or jumping. You don’t have to be active to get plantar fasciitis. It can affect anyone. People who are overweight, pregnant women, people whose jobs involve a lot of standing, and people who wear worn-out shoes all have a higher chance of getting plantar fasciitis.

Causes

This is a problem of either extreme, so people with high arches or those that have very flat feet are at risk of developing pain in this region. This is because of the relative stress the plantar fascia is put under. In people with excessive pronation, the plantar fascia is put under too much stretch, as their range flattens and strains it. People with a stiff, supinated (high-arched) foot lack the flexibility to appropriately shock absorb, so this too puts extra strain on the plantar fascia. Clinically, we see more people presenting with plantar fascia pain who have excessive pronation than those with stiff, supinated feet. But while the foot type is the biggest risk factor for plantar fasciitis, the whole leg from the pelvis down can affect how the foot hits the ground. A thorough biomechanical assessment will determine where in the kinetic chain things have gone wrong to cause the overload.

Symptoms

The symptoms of plantar fasciitis are pain on the bottom of the heel, pain in the arch of the foot, pain that is usually worse upon arising, pain that increases over a period of months. People with plantar fasciitis often describe the pain as worse when they get up in the morning or after they’ve been sitting for long periods of time. After a few minutes of walking the pain decreases, because walking stretches the fascia. For some people the pain subsides but returns after spending long periods of time on their feet.

Diagnosis

Plantar fasciitis is one of many conditions causing “heel pain”. Some other possible causes include nerve compression either in the foot or in the back, stress fracture of the calcaneus, and loss of the fatty tissue pad under the heel. Plantar fasciitis can be distinguished from these and other conditions based on a history and examination done by a physician. It should be noted that heel spurs are often inappropriately thought to be the sole cause of heel pain. In fact, heel spurs are common and are nothing more than the bone’s response to traction or pulling-type forces from the plantar fascia and other muscles in the foot where they attach to the heel bone. They are commonly present in patients without pain, and frequently absent from those who have pain. It is the rare patient who has a truly enlarged and problematic spur requiring surgery.

Non Surgical Treatment

There are several things you can do to self-treat your heel or arch pain. The first thing is to wear better shoes and consider adding arch supports or custom foot orthotics to your shoes. Stretching the calf muscles can also often be helpful. Try to stretch when you first get up in the morning and before you go to bed at night. Another good exercise is to “roll” your arch and heel. This is done by placing a tennis ball, golf ball, or lacrosse ball on the floor and rolling your foot on top of it. Some people get extra benefit by “rolling” on a frozen water bottle. You should also carefully evaluate your fitness program as you may be overdoing it. You may want consider backing of new or recently added exercises or increases in training until your heel pain improves. If you work at a standing job try to take more time to walk around during the day and avoid standing in one place for too long.

Surgical Treatment

Surgery is rarely needed in the treatment of plantar fasciitis. The vast majority of patients diagnosed with plantar fasciitis will recover given ample time. With some basic treatment steps, well over 90% of patients will achieve full recovery from symptoms of plantar fasciitis within one year of the onset of treatment. Simple treatments include anti-inflammatory medication, shoe inserts, and stretching exercises. In patients where a good effort with these treatments fails to provide adequate relief, some more aggressive treatments may be attempted. These include cortisone injections or extracorporeal shock wave treatments.

Stretching Exercises

Stretching exercises for your foot are important. Do the stretches shown here at least twice a day. Don’t bounce when you stretch. Plantar fascia stretch. To do the plantar fascia stretch, stand straight with your hands against a wall and your injured leg slightly behind your other leg. Keeping your heels flat on the floor, slowly bend both knees. You should feel the stretch in the lower part of your leg. Hold the stretch for 10 to 15 seconds. Repeat the stretch 6 to 8 times. Calf stretch. Stand with your hands against a wall and your injured leg behind your other leg. With your injured leg straight, your heel flat on the floor and your foot pointed straight ahead, lean slowly forward, bending the other leg. You should feel the stretch in the middle of your calf. Hold the stretch for 10 to 15 seconds. Repeat the stretch 6 to 8 times. Other exercises. You can also strengthen your leg muscles by standing on the ball of your foot at the edge of a step and raising up as high as possible on your toes. Relax between toe raises and let your heel fall a little lower than the edge of the step. It’s also helpful to strengthen the foot by grabbing a towel with your toes as if you are going to pick up the towel with your foot. Repeat this exercise several times a day.

Overview

Plantar fasciitis is the most common cause of heel pain in runners, eventually affecting 10 percent of the running community. While running, the plantar fascia works with the Achilles tendon to store and return energy. Because of its powerful attachment to the base of the toe, the plantar fascia stabilizes the inner forefoot as forces peak during pushoff. Unlike bone spurs and stress fractures of the heel, plantar fasciitis tends to produce pain during the pushoff phase while running, not during initial contact. A simple way to tell if you have plantar fasciitis versus a heel spur/stress fracture is to walk on your toes: heel spurs and heel stress fractures feel better while you walk on your toes, while plantar fasciitis typically produces more discomfort when you shift your weight onto your toes.

Causes

There are multiple potential causes and contributing factors to plantar fasciitis heel pain. The structure of a person’s foot and the way that they walk or run usually play a significant role in the development of plantar fasciitis. Those with an arch that is lower or higher than the average person are more likely to be afflicted. Overexertion and/or participating in activities that a person is not accustomed to also place a person at risk. This can include a heavy workout, a job change, or even an extended shopping trip. Additionally, inappropriate shoes are also often a factor. Exercising in shoes that are worn out or don’t have enough support and/or wearing inexpensive, flimsy or flat-soled dress or casual shoes are common culprits. In warm climates, such as here in Southern California, people who wear flip-flop sandals or even go barefoot throughout the year increase their chances of developing heel pain. Many athletes and weekend warriors develop heel or arch pain from over-exertion during running or other sports. People who work at jobs that involve long periods of standing, such as grocery checkers, cashiers, warehouse workers, postal workers, and teachers are more susceptible as well. Adults of all ages can develop plantar fasciitis. Heel pain in children is usually caused by a different type of condition.

Symptoms

You’ll typically first notice early plantar fasciitis pain under your heel or in your foot arch in the morning or after resting. Your heel pain will be worse with the first steps and improves with activity as it warms up. As plantar fasciitis deteriorates, the pain will be present more often. You can determine what stage your are in using the following guidelines. No Heel Pain, Normal! Heel pain after exercise. Heel pain before and after exercise. Heel pain before, during and after exercise. Heel pain all the time. Including at rest! This symptom progression is consistent with the four stages of a typical overuse injury. Ultimately, further trauma and delayed healing will result in the formation of calcium (bone) within the plantar fascia. When this occurs adjacent to the heel bone it is known as heel spurs, which have a longer rehabilitation period.

Diagnosis

Your GP or podiatrist (a healthcare professional who specialises in foot care) may be able to diagnose the cause of your heel pain by asking about your symptoms and examining your heel and foot. You will usually only need further tests if you have additional symptoms that suggest the cause of your heel pain is not inflammation, such as numbness or a tingling sensation in your foot, this could be a sign of nerve damage in your feet and legs (peripheral neuropathy) your foot feels hot and you have a high temperature (fever) of 38C (100.4F) or above – these could be signs of a bone infection, you have stiffness and swelling in your heel, this could be a sign of arthritis. Possible further tests may include blood tests, X-rays – where small doses of radiation are used to detect problems with your bones and tissues, a magnetic resonance imaging (MRI) scan or ultrasound scan, which are more detailed scans.

Non Surgical Treatment

Many cases of plantar fasciitis can be treated with simple, conservative measures. These include ice packs, stretching exercises, anti-inflammatory medications, orthotic devices (custom molded orthotics), and physical therapy. It’s important to consult your doctor before you take any medications to treat this condition. In chronic or persistent cases, one of three techniques may be used to treat plantar fasciitis. Extracorporeal Shock Wave Treatment (ESWT). TOPAZ treatment. Platelet Rich P

lasma therapy.

Surgical Treatment

The majority of patients, about 90%, will respond to appropriate non-operative treatment measures over a period of 3-6 months. Surgery is a treatment option for patients with persistent symptoms, but is NOT recommended unless a patient has failed a minimum of 6-9 months of appropriate non-operative treatment. There are a number of reasons why surgery is not immediately entertained including. Non-operative treatment when performed appropriately has a high rate of success. Recovery from any foot surgery often takes longer than patients expect. Complications following this type of surgery can and DO occur! The surgery often does not fully address the underlying reason why the condition occurred therefore the surgery may not be completely effective. Prior to surgical intervention, it is important that the treating physician ensure that the correct diagnosis has been made. This seems self-evident, but there are other potential causes of heel pain. Surgical intervention may include extracorporeal shock wave therapy or endoscopic or open partial plantar fasciectomy.

Stretching Exercises

Exercises designed to stretch both your calf muscles and your plantar fascia (the band of tissue that runs under the sole of your foot) should help relieve pain and improve flexibility in the affected foot. A number of stretching exercises are described below. It’s usually recommended that you do the exercises on both legs, even if only one of your heels is affected by pain. This will improve your balance and stability, and help relieve heel pain. Towel stretches. Keep a long towel beside your bed. Before you get out of bed in the morning, loop the towel around your foot and use it to pull your toes towards your body, while keeping your knee straight. Repeat three times on each foot. Wall stretches. Place both hands on a wall at shoulder height, with one of your feet in front of the other. The front foot should be about 30cm (12 inches) away from the wall. With your front knee bent and your back leg straight, lean towards the wall until you feel a tightening in the calf muscles of your back leg. Then relax. Repeat this exercise 10 times before switching legs and repeating the cycle. You should practise wall stretches twice a day. Stair stretches. Stand on a step of your stairs facing upstairs, using your banister for support. Your feet should be slightly apart, with your heels hanging off the back of the step. Lower your heels until you feel a tightening in your calves. Hold this position for about 40 seconds, before raising your heels back to the starting position. Repeat this procedure six times, at least twice a day. Chair stretches. Sit on a chair, with your knees bent at right angles. Turn your feet sideways so your heels are touching and your toes are pointing in opposite directions. Lift the toes of the affected foot upwards, while keeping the heel firmly on the floor. You should feel your calf muscles and Achilles tendon (the band of tissue that connects your heel bone to your calf muscle) tighten. Hold this position for several seconds and then relax. Repeat this procedure 10 times, five to six times a day. Dynamic stretches. While seated, roll the arch of your foot (the curved bottom part of the foot between your toes and heel) over a round object, such as a rolling pin, tennis ball or drinks can. Some people find that using a chilled can from their fridge has the added benefit of helping to relieve pain. Move your foot and ankle in all directions over the object for several minutes. Repeat the exercise twice a day.