(heel spurs, plantar fasciitis)
Key points for doctors and physiotherapists:
- It is a degenerative pathology and NOT an inflammatory pathology (NSAIDs and SAIDS rarely provide lasting relief).
- Location of pain is important for diagnosis. Palpate carefully – this is an ‘enthesopathy’. If the patient is not experiencing pain at the insertion of the plantar fascia on the medial or lateral infracalcaneal tubercle, consider an alternate diagnosis.
- Differential diagnoses: (all treated differently)
– Baxter’s – medial calcaneal branch of the posterior tibial nerve
– Abductor digiti quinti nerve entrapment
– Tarsal tunnel
– Tib post/FHL tendinopathy
– Infra calcaneal fat pad impingement
– Calcaneal stress response.
- Duration and intensity of pain defines treatment options. Ask your patient to be precise when asking these questions.
- Pain at rest, hyperalgesia or allodynia is strongly predictive of a neuropathic component. E.g. excessive or prolonged post-injection pain.
- DO NOT IMAGE – imaging does not govern treatment pathways, diagnosis or prognosis and is often negative for neural impingement or neuritis.
- Neuropathic agents – Duloxetine (= Cymbalta/Tixol, 60mg to 120mg), Pregabalin (= Lyrica, 50mg to 150mg BD). If these produce adverse reactions or are ineffective then consider alternatives such as Gabapentin, Valproate, Carbamazepine, Tricyclic antidepressants.
- Silicone heel cups (my ‘go-to’ is Tuli, green) – consider if the infracalcaneal fat pad is diminished. Advise the patient that these will not ‘fix’ the problem but will assist the recovery.
- Strassburg sock especially if Silfverskiold test is positive. Wear overnight for at least 2 weeks.
- Physiotherapy treatment – deep plantar fascia release and medial calf release (alternating with heat applications), Low-dye or heel cup taping (navicular taping may be adequate), dry needling (periosteal pecking) at the insertion of the medial or lateral plantar bands, subtalar mobilisations into eversion, talocrural mobilisations to optimize dorsi-flexion. Footwear advice.
- Orthotics – Consider in pes planus, mid foot pronation or reduced infracalcaneal fat pad. Consider adding medial and lateral calcaneal padding and varus rear and forefoot posts. Orthotics should not be expensive.
- Medical treatments
– Steroid injection (Performed under medial ankle nerve block ideally followed by one week of non-weight bearing and regular gastroc stretching – only consider if symptoms are less than 3 months duration).
– Prolotherapy – hypertonic dextrose injections performed under medial ankle block – high success rate. Four to six injections performed one month apart – $75 per injection out-of-pocket).
– Platelet rich plasma (PRP) – high success rate. Four to six injections performed one month apart – $285 per injection out-of-pocket.
– Autologous blood injections – high success rate. Four to six injections performed one month apart – $75 per injection out-of-pocket.
– Extracorporeal shockwave therapy (8 to 12 treatments, performed one week apart – high success rate. Full course of treatment $400.
- Surgical treatments (rarely required) – plantar fascia release (slow recovery, high risk of surgical complications including postoperative neuropraxia, wound breakdown) medial gastroc release (quicker recovery – not appropriate if Silfverskiold negative).
- Additional treatments (to consider in the ‘appropriate’ patient and the ‘appropriate’ GP) – Doxycycline, GTN patches. Best not to bother with these unless you are working with a Sports physician – GP’s will make your life more difficult if you suggest these.
- Prognosis is delayed in:
– Mental health history.