Introduction
The London Foot and Ankle Centre has a dedicated Heel Pain Clinic for the rapid assessment and effective treatment for plantar fasciitis or heel pain.
One in ten people will experience heel pain and for many, the problem will have a very significant impact upon their lives.
Our Heel Pain Clinic at LFAC has been established to provide a comprehensive service, offering the full range of advanced treatment options for people with long term, intractable heel pain.
At our dedicated Heel Pain Clinic, you can normally have your assessment, x-rays, opinion and first treatment all during your first visit.
Plantar Fasciitis - Heel Pain Symptoms
About heel pain
There are two main types of heel pain, occurring in different places. A small number of people will have pain in both areas of the heel.
The ‘grumbling’ Achilles – non-insertional Achilles tendinopathy
The ‘grumbling’ Achilles is known medically as non-insertional Achilles tendinopathy. Although a rupture of the Achilles is well known, it is actually more common to have what is known as a grumbling Achilles. The pain is felt at the back of the heel above where the Achilles tendon joins the bone. It feels stiff and swollen, particularly in the morning and can prevent the sufferer from taking part in sport. Sometimes the pain is lower down where the tendon joins the bone. This Insertional Achilles tendinopathy is less common.
Policeman’s heel – plantar fasciitis
Policeman’s heel treatment (known medically as plantar fasciitis) is needed when pain occurs due to problems with the tendon called the fascia. The fascia is a strong band of tissue stretching from your heel to your toe bones. It supports the arch of your foot and acts as a shock absorber in the foot. Pain is felt at the bottom of the heel where it connects with the ground in each step. Pain and stiffness often leaves patients “hobbling” for the first few minutes in the morning. The pain can be severe, especially after standing for a long time.
Plantar fasciitis is very common indeed that policeman’s heel treatment is one of the main reasons for seeing a foot specialist.
Causes of Plantar Fasciitis - Heel Pain
The causes of both types of heel pain are not fully understood, but are linked to wear and tear of the tendons and an incomplete healing process. The wear and tear, whether as a result of sport or a gradual, cumulative effect, causes the tendon to thicken. It becomes painful and inflexible. The cause of wear and tear varies from one individual, but may be due to:
- Doing too much, particularly sport which has a high impact on the heel, such as long distance running
- Doing too little and becoming overweight due to sedentary lifestyle and therefore putting the heel under excess pressure
- Having very tight calf muscles. This is a problem some people are simply born with. The effect of having very tight muscles is like walking permanently on tip toes, putting the Achilles tendon and the arch of the foot under increased strain.
When these problems lead to severe heel pain, you may require specialised heel foot pain treatment to restore mobility and reduce the levels of pain felt in the heel.
Diagnosis for Plantar Fasciitis - Heel Pain
How do we assess the best treatment for each patient?
“The initial assessment must be very accurate to ensure the treatment selected will be effective. We listen carefully to the patient – if they describe their heel pain as feeling like hot coal and their calf is extremely tight, we cannot expect shockwave therapy or injections to work. It would be like a boy Scout throwing a small bucket of water on a large fire.”
Matthew Solan, Consultant Orthopaedic Surgeon, the London Foot and Ankle Centre
Our consultant orthopaedic foot and ankle surgeons will carry out a full examination of your foot to decide the best course of action for the heel foot pain treatment. This is combined with an ultrasound scan, undertaken and assessed on the same day as your initial visit to the clinic. If for example the examination shows the calf is extremely tight, we will recommend surgical calf stretching as part of the treatment for plantar fasciitis because injections or shockwave therapy will not work.
We use specialist ultrasound called a Doppler scan which provides a very detailed image of blood flow in the affected area. For some patients, the scan shows a process known medically as neovascularity. The surgeon can see there are too many small vessels feeding the tendon, perpetuating the swelling and pain. Small nerves follow the vessels. If this is the case, injections are helpful.
Treatment For Plantar Fasciitis
How is heel pain treated?
The first line of treatment for heel pain should always be calf stretching exercises. You should be seen by a physiotherapist who will demonstrate exactly how to do calf stretching exercises correctly. Footwear modifications can also be very helpful – simple heel cushions relieve pressure from the painful part of your heel. We recommend that you try first line treatment for two to three months before moving on to further treatment. Eight to nine out of ten patients with heel pain find the pain eases with stretching exercises.
At the Heel Pain Clinic, we see many patients who are still in significant pain despite trying conservative heel pain treatment. For this group of patients we offer:
- Extracorporeal shockwave therapy
- A course of injections
- Surgical calf stretching
Shockwave therapy for heel pain
If shockwave therapy is indicated as the best treatment for plantar fasciitis, you will have your first session during your initial visit to the Heel Pain Clinic.
Each session takes approximately 3–5 minutes. You will lie on your front while the shockwave is applied with a machine rather like a small pneumatic press.
Patients experience some discomfort during the procedure and there may be a little redness on the skin after treatment. Exceptionally, the heel pain becomes slightly worse after treatment for plantar fasciitis before getting better. A total of three sessions are needed, with no more than one to two weeks between each session.
We use the latest shockwave therapy machine, called the Swiss Dolar Clast. This is more effective than older machines which focused energy on a limited area, or ‘pin-head’. The new technology works by emitting the energy like the ripples from throwing a stone into water.
How does shockwave therapy for heel pain work?
It is understood that shockwave therapy works in two ways:
- Shockwaves cause micro damage to tissue in the affected area and in so doing, stimulate healing. Nature gets a second chance.
- The policeman’s heel treatment has a directeffect on the nerve endings which make them less sensitive and therefore less likely to transmit pain.
The benefit of shockwave therapy for heel pain is often not felt until after the third session. This type of treatment for plantar fasciitis works well for 80 per cent of patients. The effect of the treatment is usually permanent and there is no need to return for further sessions at a later date.
NICE (National Institute for Health and Clinical Excellence) recently evaluated shockwave therapy for heel pain in August 2009. The recommendation was that the treatment is effective and should be offered, providing centres audit their results and inform patients of possible side-effects. You can read the guidelines on the NICE website.
What evidence is there that shockwave therapy for heel pain works?
LFAC Consultant Orthopaedic Surgeon Mr Matthew Solan and Consultant Radiologist Dr Andrew Carne are among a small number of UK specialists to be trained by ATRAD. This is an international Association for Radial Pain Therapy, which is at the forefront of training, researching and developing technology in this field.
Mr Solan and Dr Carne adhere to NICE guidance and also are registered with ASSERT, a data collection study for Shockwave treatment. They have both published research on their work and results.
Surgical calf stretching
“If you imagine the lower leg like a rasher of bacon, the calf muscle has a rind. You can only stretch the bacon itself so far because the rind remains tight and limits flexibility. If we carefully cut the rind the rasher can be stretched further. In real life the gap in the “rind” fills with scar tissue – but the rind is then longer. Surgical calf stretching is a way of stretching the tight calf muscle in a very controlled way and allow release of strain from the affected heel area.”
Matthew Solan, Consultant Orthopaedic Surgeon, the London Foot and Ankle Centre
Surgical calf stretching, known medically as Gastrocnemius Release is an established procedure, further developed by Consultant Orthopaedic Surgeon Matthew Solan for the treatment of heel pain. It is carried out as a day procedure and is minimally invasive, using a very small incision behind the knee.
Injections for heel pain
Injections are particularly helpful for people with neovascularity, when the Doppler scan shows there is a large number of small veins feeding a swollen tendon and perpetuating the pain. A course of three injections is normally given, with several weeks between each injection. Injections are undertaken with ultrasound guidance to ensure the injection reaches the target area.
Concerned about your foot and ankle health? Get peace of mind today – contact the London Foot and Ankle Centre today to arrange a consultation with our expert team.
Frequently Asked Questions (FAQ) About Plantar Fasciitis
At the London Foot and Ankle Centre we offer expert diagnosis and treatment for stubborn cases of plantar fasciitis. To make an appointment contact:
- [email protected]
- 0207 078 3800
Plantar fasciitis is a common condition that causes pain in the heel and bottom of the foot. It occurs when the plantar fascia, a thick band of tissue that runs across the bottom of your foot and connects your heel bone to your toes, becomes inflamed.
The most common symptom of plantar fasciitis is sharp, stabbing pain in the bottom of the foot near the heel. This pain is usually worse in the morning with the first few steps out of bed or after periods of inactivity. The pain can also increase after long periods of standing or after exercise.
Plantar fasciitis is caused by strain and stress on the plantar fascia ligament. This can result from:
- Overuse, such as from excessive running or standing.
- High-impact activities.
- Poor footwear with inadequate support.
- Being overweight.
- Having high arches or flat feet.
- Tight Achilles tendons or calf muscles.
Several factors can increase the risk of developing plantar fasciitis, including:
- Age: Plantar fasciitis is most common in individuals between 40 and 60 years old.
- Certain types of exercise: Activities that place a lot of stress on the heel and attached tissue, such as running, ballet, and dance aerobics.
- Foot mechanics: Having flat feet, a high arch, or an abnormal walking pattern can affect the way weight is distributed when you’re standing and put added stress on the plantar fascia.
- Obesity: Excess weight can put extra stress on the plantar fascia.
- Occupation: Jobs that keep you on your feet for long periods, such as factory workers, teachers, and waitstaff.
A doctor will diagnose plantar fasciitis based on your medical history and a physical examination. They will check for areas of tenderness in your foot and evaluate your foot arch and heel. Imaging tests like X-rays or MRIs are usually not necessary but may be used to rule out other problems. Ultrasound scans can be used to confirm the diagnosis.
Treatment for plantar fasciitis typically includes:
- Rest: Reducing or avoiding activities that worsen the pain.
- Weight loss: even being a little bit too heavy makes recovery harder.
- Ice: Applying ice to the affected area to reduce inflammation and pain.
- Stretching: Exercises to stretch the plantar fascia and Achilles tendon.
- Orthotics: Custom or over-the-counter shoe inserts to support the arch and heel.
- Pain relievers: Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen or naproxen, rarely reduce pain.
- Physical therapy: A physical therapist can design a specific exercise program to strengthen the lower leg muscles and stabilize the ankle and heel.
Yes, if standard treatments are not effective, advanced options include:
- Corticosteroid injections: These can help reduce inflammation and pain.
- Extracorporeal shock wave therapy (ESWT): Uses sound waves to stimulate healing in the plantar fascia.
- Platelet-rich plasma (PRP) therapy: Injections of your own blood platelets aims to promote healing, but has little supportive evidence.
- Calf stretch Surgery: this can be effective if exercises alone don’t work.
- Heel Surgery: In rare cases, surgical intervention may be necessary to detach the plantar fascia from the heel bone.
Recovery time can vary depending on the severity of the condition and the treatment approach. Many people begin to feel relief within a few months with conservative treatment. However, it can take 6 to 12 months for symptoms to completely resolve. The majority of sufferers recover with simple treatments over this period.
Persistent cases may take longer and a small percentage may require advanced treatments or surgery.
Yes, plantar fasciitis can recur if the underlying causes are not addressed. Preventive measures such as maintaining a healthy weight, wearing supportive shoes, and doing regular stretching exercises can help reduce the risk of recurrence.
Several home remedies can help manage the symptoms of plantar fasciitis, including:
- Resting and avoiding activities that aggravate the pain.
- Applying ice to the affected area for 15-20 minutes several times a day.
- Weight loss if even only slightly heavy.
- Performing stretches for the plantar fascia and Achilles tendon.
- Using over-the-counter pain relievers.
- Wearing supportive shoes or using orthotic inserts.
Footwear plays a crucial role in managing and preventing plantar fasciitis. Shoes with good arch support, cushioning, and a slightly raised heel can help reduce stress on the plantar fascia. Avoid wearing worn-out shoes, high heels, or shoes with little support.
Stretching and strengthening exercises can be very beneficial for plantar fasciitis. Some effective exercises include:
- Calf stretches: Stand facing a wall with one foot in front of the other, keeping the back leg straight and heel on the ground, and lean forward.
- Slant board stretches: an effective solution and easy to perform.
- Plantar fascia stretches: Sit down, cross one foot over the opposite knee, and pull the toes back toward the shin.
Yes, weight loss can help reduce the stress and strain on the plantar fascia, which can alleviate pain and prevent further damage. Even if you are only a little overweight losing this excess will help. Maintaining a healthy weight through a balanced diet and regular exercise can be beneficial for overall foot health.
Plantar fasciitis can sometimes be associated with other conditions, such as flat feet, or high arches. Sufferers may have Achilles tendinitis too. It is also more common in individuals with certain systemic conditions like diabetes, arthritis, and other inflammatory diseases.
Heel spurs are bony growths that develop on the bottom of the heel bone. However, heel spurs do not always cause pain and can be present without plantar fasciitis.
Yes, plantar fasciitis can affect both feet, although it is more common for one foot to be more severely affected than the other. When both feet are affected, it can significantly impact mobility and quality of life.
Physiotherapy can play a significant role in treating plantar fasciitis. A physiotherapist can develop a tailored exercise program to stretch and strengthen the plantar fascia, Achilles tendon, and lower leg muscles. They may also use techniques like massage, ultrasound therapy, and taping to reduce pain and inflammation.
While it may not be possible to prevent plantar fasciitis entirely, several strategies can reduce the risk:
- Maintain a healthy weight to reduce stress on the feet.
- Choose footwear with good arch support, cushioning, and a proper fit.
- If increasing activity levels, do so gradually.
- Avoid high-impact activities on hard surfaces.
- Perform regular stretching exercises for the plantar fascia and Achilles tendon.
- Avoid walking barefoot on hard surfaces.
Yes, plantar fasciitis is common among athletes, particularly those involved in sports that put a lot of stress on the feet, such as running, basketball, and tennis. High-impact activities and repetitive motions can lead to overuse injuries like plantar fasciitis.
If your symptoms worsen despite home treatment, it is important to consult a healthcare professional. They may recommend more intensive treatments, such as physical therapy, corticosteroid injections, or advanced therapies like ESWT (shockwave). Ignoring worsening symptoms can lead to chronic pain and further complications.
Night splints can be helpful for some people with plantar fasciitis. These devices hold the foot in a dorsiflexed position overnight, which helps stretch the plantar fascia and Achilles tendon, potentially reducing morning pain. The evidence for their use is, however, weak.
Some alternative therapies that may help with plantar fasciitis include:
- Acupuncture: Can help relieve pain and improve healing.
- Chiropractic care: Can address misalignments that may contribute to plantar fasciitis.
- Massage therapy: Can help reduce tension in the plantar fascia and surrounding muscles.
Surgery is not a common treatment for plantar fasciitis and is typically considered only when other treatments have failed. Surgical options may include release of a tight calf muscle; or plantar fascia release, which involves cutting part of the plantar fascia to relieve tension and reduce inflammation.
The prognosis for plantar fasciitis is generally extremely good, especially with early and appropriate treatment. Most people experience significant improvement within a few months. However, some individuals may have persistent symptoms and require ongoing management.
