Plantar Fasciitis and Heel Spur Syndrome

Plantar Fasciitis [plantar (on the sole of the foot) heel pain] and heel spur syndrome results from prolonged, excessive tension in the plantar fascia and leads to inflammation and fibrosis at the attachment of the plantar fascia to the calcaneus. Then, an elongated plantar spur may develop at the attachment of the fascia.

A patient with plantar fasciitis usually presents with pain in the heel on arising in the morning or after periods of rest (poststatic dyskinesia). The pain may subside after several steps, and then slowly worsen as the day progresses. In worse cases, the pain is persistent and may awaken the patient while sleeping. Some people describe a "stone bruise," sharp, sticking sensation, numbness or tingling in the sole of the foot.

Examination reveals two groups of patients with plantar fasciitis.

The first subgroup has plantar central palpatory tenderness at the insertion of the central band of the plantar fascia into the calcaneal (heel) tuberosity. Patients have little to no tenderness medial to this area. The calcaneal tuber is often prominent, and bursa are occasionally present.

The larger group of patients has increased palpatory tenderness along the plantar medial and inferior medial wall of the calcaneus. Pain may be elicited by active or passive extension of the foot and digits. Palpatory tenderness extends along the fascial band into the medial arch.

The heel spur or calcaneal spur is an osteophytic growth anterior to the medial calcaneal tuberosity that usually extends its entire width or about 2-2.5cm. DuVries described three types of calcaneal spurs:

  1. Spurs that are large and asymptomatic because the angle of growth of the spur does not become a weight-bearing point or the inflammatory changes remain subacute.
  2. Spurs that are large and painful with weight bearing because the pitch of the calcaneus has been altered by depression of the longitudinal arch. As a result, the spur becomes a weight-bearing point causing intractable pain through myositis of the intrinsic musculature and adventitious bursa formation.
  3. Spurs that have a small amount of bony proliferation and whose outline is irregular and jagged, accompanied by an area of decreased density around the origin of the plantar fascia indicating a subacute inflammatory response.

Conservative treatment combines pharmacological, biomechanical, physical, and surgical therapies. Corticosteroids are the most potent group of medications. Any of the injectable preparations may appear to be appropriate, given through a medial or plantar approach.

NSAIDS (non-steroidal anti-inflammatory drugs) provide relief.

Physical therapy has a useful and sometimes limited role. Icing after periods of activity and stretching of the Achilles Tendon and plantar fascia appear helpful, especially when used after rest.

Night splints play a role by applying a constant passive stretch to tendons, fascia, and muscles by keeping the foot and ankle extended.

Short leg casting has proven effective. Successful orthotic therapy has been reported in podiatric literature.

O'Brien and Martin noted that orthotics were most helpful in patients with a history of heel pain lasting longer than 2.5 years. The use of heel cushions has been reported as a successful modality. Low dye strappings appear helpful.

Surgical procedures include neurolysis (excision of the lateral plantar nerve), heel spur resection, plantar fasciotomy (releasing the plantar fascia), and endoscopic plantar fasciotomy.