Through non-operative treatment and lifestyle advice, up to 80% of patients with plantar fasciitis can be managed in the primary care setting. Read more about the general practitioner’s role, and a novel minimally invasive surgical technique that can bring efficient and effective relief when conservative therapy fails.
INTRODUCTION
Plantar fasciitis is the most common cause of heel pain. Also called ‘heel spur syndrome’, it is estimated to affect around 10% of people at some point in their lifetime.
It remains a frequently encountered yet poorly understood condition that can affect a diverse demographic of patients from young to elderly. Despite the complexity of plantar fasciitis, there are proven and effective modalities of treatment, as well as emerging minimally invasive surgical techniques, to treat those suffering from a recalcitrant form of this condition.
WHAT IS PLANTAR FASCIITIS?
The plantar fascia, or plantar aponeurosis, is a band of fascia that supports the medial arch of the foot. It is designed to absorb high stresses and strains on our feet when we walk, run and play sports.
However, repetitive expansion and contraction of the plantar fascia tissue over time can lead to fascia thickening, weakening and tearing.
Our body’s natural response to injury is inflammation, leading to the pain felt at the sole of the foot. Imagine a band of tissue being pulled and stretched to its limit. When inflamed, it is like having a rubber band on the brink of snapping.
If left untreated, the pain might intensify, eventually becoming a chronic unbearable pain that can lead to more serious injury.
CAUSES OF PLANTAR FASCIITIS
Plantar fasciitis is often labelled as a ‘chronic inflammation’, but this characterisation is misleading. It is currently understood that the condition is not due to an inflammatory process, but rather a chronic degeneration leading to microtears in the plantar fascia and collagen necrosis, called fasciosis. The degeneration is usually caused by repetitive strain, overload and overuse that leads to the microtears in the tissue.
This wear and tear may not manifest immediately, but can take weeks or even months of continuous microinjury to the fascia before it weakens and becomes susceptible to inflammation leading to pain.
The link with calcaneal spur formation
Calcaneal spur formation has a controversial causal association with plantar fasciitis, as a heel spur can be found in patients both with and without the condition.1
It is suggested that heel spur formation is an adaptive response to repetitive stress at the insertional site of the plantar fascia into the bone.
Factors that increase load on the plantar fascia will increase the risk of having this condition. These include:
Being overweight
Pregnancy (late pregnancy due to increase in weight)
Repetitive high-impact activity (endurance runners/dancers/sportsmen)
Age between 40-70 years
Female (due to hormonal differences as compared to men)
Poor footwear without arch support
Flatfoot (tight and flattened plantar fascial bands)
SYMPTOMS OF PLANTAR FASCIITIS
The symptom of plantar fasciitis is typically a dull, throbbing pain along the inside edge of the heel, near the arch of the foot.
The pain is worse on placing weight on the foot and is usually most pronounced in the morning when the foot is first placed on the floor, resulting in difficulty taking the first few steps of the day.
Prolonged standing can also increase symptoms of pain. Putting pressure on this part of the heel usually elicits acute tenderness.
Patients also tend to have either a tight achilles tendon or gastrocnemius, which limits ankle dorsiflexion.
As painful and complex as this condition is, plantar fasciitis does not have to be a lifelong sentence. Relief from its symptoms can often be obtained from non-surgical therapy with proper guidance from a general practitioner (GP) in up to 80% of patients, over a period of six to 12 months.
Recovery usually involves a combination of lifestyle changes and treatments that ultimately aim to support and cushion the foot.2 1. Rest and activity modification
Rest alone is often a miracle healer for many patients suffering from plantar fasciitis. A simple home modification to avoid walking barefoot at home can be effective in relieving symptoms. Modifying activities to low-impact exercises such as cycling or swimming will put less stress on the foot than walking or running. 2. The right footwear and orthotic devices
The first crucial step in alleviating plantar fasciitis pain is either: Choosing the correct footwear that provides adequate arch support which acts as a cushion to the tight plantar fascia, or provides a slight heel elevation, or Using silicon heel pads to help relieve tension in the Achilles tendon
3. Stretching
Plantar fasciitis is aggravated by a tight plantar fascia and calf muscles. Hence, stretching of the calves and plantar fascia is a mainstay of treatment for plantar fasciitis. Stretching can be performed either seated or standing, but must be done with the knee extended to isolate the gastrocnemius. Stretching in bed before taking one's first step in the morning helps to relieve some of the symptoms. Regardless of the type of stretching, adherence to a daily regimen is the key to success. 4. Extracorporeal shockwave therapy (ESWT)
ESWT delivers low-frequency, high-energy acoustic waves to the plantar fascia, which induces micro-trauma leading to tissue regeneration, increased blood flow and collagen synthesis. Patients usually require several treatment sessions on a weekly basis, depending on the severity of their condition.
Studies have shown that ESWT can improve symptoms in recalcitrant plantar fasciitis by up to 60%.4 It remains a suitable option of treatment for patients who have undergone a trial of standard treatment without improvement.
5. Injections • Corticosteroid injections
The use of corticosteroid injections to treat the pain associated with plantar fasciitis is controversial – as the rationale behind their use has come into question, as we come to understand the condition as a degenerative rather than inflammatory process.
Furthermore, the therapeutic effects of corticosteroid injections only serve to provide short-term relief that has not shown to last past four weeks.3 In addition, steroid injections are known to cause fat pad atrophy and weaken the plantar fascia, leading to plantar fascia rupture resulting in flattening of the foot and chronic pain.
In summary, steroid injections may provide temporary symptomatic relief but are associated with complications that patients should be advised on prior to injection. • Platelet-rich plasma (PRP) injections PRP has grown in popularity for the treatment of plantar fasciitis. It is extracted from autologous blood and contains a high concentration of endogenous growth factors that help to stimulate the body’s healing response.
Compared to corticosteroid injections, PRP has been shown to demonstrate longer-term pain reduction. However, there is minimal literature regarding its effectiveness in the treatment of plantar fasciitis and the use of PRP as first-line treatment should be limited.
Based on current national body guidelines, the use of PRP for the treatment of plantar fasciitis is considered an off-label use and should be considered only after unsuccessful trials of shockwave therapy or if a plantar fascia tear is evident.
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THE GP’S ROLE IN CARE
The GP plays an important role in the initial assessment of a patient presenting with heel pain.
With an accurate diagnosis of plantar fasciitis, the following is a summary of non-operative treatment and advice that can be instituted in the primary care setting:
Rest feet as much as possible
Calf-stretching exercises
Use an ice pack or heat pack during acute pain attacks
Modification to non-weight bearing exercises such as swimming or cycling
Wear supportive shoes with supportive insoles
Injections
Shockwave therapy
The Last Resort: Surgical Options
Enduring the symptoms of plantar fasciitis which do not go away despite the aforementioned therapies may be frustrating and unsettling.
Surgery for plantar fasciitis is generally reserved for patients who have not seen improvement after six to 12 months of non-surgical treatment.
There is currently no consensus on or evidence for any one preferred surgical procedure for the treatment of recalcitrant plantar fasciitis.
This is mainly because the condition involves multiple aetiologies, in particular:
A tight gastrocnemius and plantar fascia,
Micro-tears and degeneration to the plantar fascia, and
Bone marrow oedema at the plantar fascia calcaneal insertion site
Plantar fasciotomy and gastrocnemius release are two traditionally performed procedures aimed at reducing plantar fascial tension. These procedures can be performed either through an open or endoscopic approach.
Despite the popularity of these procedures and their relative ease to perform, there is not any strong evidence supporting its use, with literature reporting mixed outcomes.
A NOVEL MINIMALLY INVASIVE ENDOSCOPIC TECHNIQUE
The Foot and Ankle Surgery team at the Department of Orthopaedic Surgery, Sengkang General Hospital has published a novel technique involving an endoscopic debridement, calcaneal ostectomy, plantar fascial release and radiofrequency (DORR).5
The aims of this procedure are to reverse the underlying biomechanical problem and to improve the biology to the plantar fascia, thus addressing all possible causes of the condition.
Suprafascial plantar endoscopy and plantar fascia release
Keyhole arthroscopic incisions are made on both the medial and lateral sides of the heel to allow the introduction of endoscopic instruments.
Unlike traditional methods of endoscopic plantar fascia release where there is no visualisation of the calcaneal spur, this new technique introduces the endoscope to the plane above the plantar fascia (Figure 1), allowing direct visualisation of the insertion of the plantar fascia onto the calcaneal bone or spur.
This allows for a window to introduce endoscopic instruments for burr resection of the spur, and for an accurate release of the medial plantar fascia with a radiofrequency cutting right-angled probe (Figure 2).
The resection of spur serves to decompress the bone oedema at the calcaneal insertion site of the plantar fascia.
Radiofrequency microtenotomy TOPAZ
TOPAZ therapy involves the use of coblation technology via a microdebrider that is introduced to the plantar fascia via the same endoscopic method.
TOPAZ leverages on radiofrequency therapy to create small micro-tears in a grid pattern to break up scar tissue and increase blood flow to the affected area.
Previous methods of open or percutaneous TOPAZ to plantar fascia have yielded good results.6 Our technique allows direct visualisation of the radiofrequency probe on the plantar fascia allowing more accurate delivery of the therapy (Figure 3).
Patient outcomes and recovery
The DORR procedure can be performed as a day surgery, and postoperative radiographs reveal a resection of the calcaneal spur (Figure 4). Postoperative care protocol includes one week of non-weight bearing after the procedure to allow for recovery.
Thereafter, patients are advised to ambulate with arch-supported shoes and return to daily activities after two weeks.
CONCLUSION
Plantar fasciitis is a common cause of heel pain, but does not have to slow one down. It can be self-relieving and is conservatively treated in the large majority of patients.
For the handful of patients with recalcitrant plantar fasciitis, surgery with minimally invasive endoscopic techniques has paved the way for efficient and effective relief.
REFERENCES
Johal KS, Milner SA. Plantar fasciitis and the calcaneal spur: fact or fiction? Foot Ankle Surg 2012;18:39-41
Victor Tan AK, Tan CC, Nicholas Yeo EM, Mandy Zhang, Kinjal VM, Roger Ho HT, Benedict Tan. Consensus statements and guidelines for the diagnosis and management of plantar fasciitis in Singapore. Ann Acad Med Singap 2024;53: 101-12
David JA, Sankarapandian V, Christopehr PR. Injected corticosteroids for treating plantar heel pain in adults. Cochrane Database Syst Rev 2017;6:CD009348.
Lou J, Wang S, Liu S. Effectiveness of extracorporeal shock wave therapy without local anesthesia in patients with recalcitrant plantar fasciitis: a meta-analysis of randomized controlled trials. Am J Phys Med Rehabil 2017;96:529-34.
Walter Soon YW, Dhiva G, Inderjeet SR, Chong KW, Wenxian P, Eric Cher WL. Endoscopic debridement, ostectomy, release and radiofrequency: A fully endosocpic technique for treating recalcitrant plantar fasciitis. Arthroscopy Techniques 2024; 103150
Kaesian Tay, Sean Ng YC, Inderjeet RS, Chong KW. Open technique is more effective than percutaneous technique for TOPAZ radiofrequency coblation for plantar fasciitis. Foot and ankle surgery 2012;18:4. 287-292
Assistant Professor Png Wenxian is a Consultant with the Department of Orthopaedic Surgery at Sengkang General Hospital. He was awarded the Health Manpower Development plan (HMDP) Scholarship from the Ministry of Health to pursue sub-specialty training in foot and ankle deformity surgery. He also completed a fellowship in minimally invasive foot and ankle surgery at Kantonsspital St.Gallen, Switzerland where he gained proficiency in advanced techniques in endoscopy and minimally invasive foot and ankle surgery.
GPs who would like more information about surgery for plantar fasciitis and heel pain can contact Asst Prof Png at [email protected].
GP Appointment Hotline: 6930 6000
GPs can visit the website or scan the QR code for more information about the department.
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