Heel pain.

It is estimated that 10% of the population will experience heel pain in their lifetime. It is one of the most common reasons for people to attend a podiatrist or physiotherapist. In most situations, the interventions from a podiatrist, GP, physiotherapist, osteopath or chiropractor will result in the successful eradication of the pain.

To be clear, here we are talking about pain on the bottom of your heel, otherwise known as the plantar aspect. We are not talking about the back of the heel or the Achilles. The vast majority of the time, the condition you are experiencing is plantar fasciitis. The plantar fascia is a semi-flexible band that runs on the underside of the foot. It originates on the bottom of the heel and spreads out, eventually inserting under the toes. The plantar fascia has three main jobs involving supporting the arch, protecting deeper structures and helping with propulsion during gait. Please see the diagram.

Excessively flattening feet (excessive pronation), prolonged periods of standing or walking, and carrying extra weight can be some of the causes of plantar fasciitis. Certain sports and activities can predispose people to the condition as well. When the condition commences, the region becomes inflamed, hence the term ‘…itis’. When you see the term ‘itis’ at the end of a condition in medicine, it relates to inflammation. Typically, this is treated with rest, icing, orthotics, shoe advice, stretching and strengthening exercises, and in most cases, this will do the job, and the pain subsides. It is the chronic, recalcitrant or non-responding cases that typically will be referred to Dr Damien Lafferty.

Plantar fasciosis.

If the condition persists and does not settle, particularly after months, the condition changes, and the region is no longer inflamed. The region becomes degenerated, scarred and stagnant. This region has a relatively poor blood supply, and if the body cannot heal the region, the area develops into a firm, degenerated area. The condition now becomes plantar fasciosis. Note that the term “…itis” is no longer present, and the term ‘…osis’ is seen. The condition may have the same symptoms, yet it now has a different physical make-up. Since the condition has changed, the initial interventions, such as ice, etc., will no longer be effective.  Typically, patients are referred to Dr Laffery for plantar fasciitis, where it is actually plantar fasciosis. The origin of the plantar fascia becomes enlarged, often with small regions of degeneration and even tiny intrasubstance tears. This is not to be confused with rupture.

As the condition is now different from plantar fasciitis, the treatment interventions are different. To confirm the diagnosis of plantar fasciosis, an ultrasound scan will be carried out. This can be carried out in our office in Greenwich. We have an ultrasonographer on the premises, and radiologists will report on the scan to confirm the extent of the fasciosis.

Typically, the interventions Dr Laferty will be carrying out revolve around ultrasound-guided injections. The aim is to eradicate the pain and allow for the full return of activities without surgery. It must be mentioned that in rare conditions, surgery is an option and will be discussed at the end. Luckily, the ultrasound-guided injections are typically successful.

Ultrasound-guided injections.

There are two types of injections carried out. The first injection is known as high-volume hydrodissection and carried out with an ultrasound to ensure the fluid is entering the correct location. The fluid injected is saline, local anaesthetic and dilute corticosteroid. This injection is to help free up the scar tissue and provide some pain relief. The mainstay of the intervention is the regenerative injections. There are two primary forms, one being known as prolotherapy, which is a mixture of local anaesthetic and diluted glucose. A more potent regenerative method is that of platelet-rich plasma or PRP.

Platelet-rich plasma- PRP

These interventions are also carried out in our rooms. It will often be carried out in conjunction with Dr Joseph Grace, who has many years of experience both in the research and the implementation of this therapeutic intervention.

The process involves taking a small amount of your blood, again under ultrasound guidance to allow for expert and pain-free blood drawing. This blood is spun in a centrifuge that will enable the constituents of the blood to settle out. The platelet-rich plasma and often platelet-rich fibrin are then drawn into a syringe. Under ultrasound guidance, the PRP is injected into the degenerated plantar fascia. To help with comfort, a local anaesthetic can be administered before the injection, plus nitrous oxide or laughing gas is available before the injection. Improvement is achieved with the first injection; however, a further injection is commonly required to produce 100% relief.

Baxter’s nerve entrapment.

It has been estimated that 20% of recalcitrant, chronic heel pain can be attributed to an entrapment of a nerve called Baxter’s nerve. At the inside of the back of the foot, the tibial nerve appears and spreads into two nerves on the bottom of the foot: the medial and lateral plantar nerves. There is a branch of one of these nerves known as Baxter’s nerve that runs close to the lateral fascia under a muscle belly, again right next to the painful location of the plantar fascia. This is often the reason it is mistaken for plantar fasciitis. Sadly, most health professionals are unaware that this nerve exists, let alone its ability to mimic plantar fascia pain. Dr Lafferty will conduct an initial consultation to investigate this matter. Luckily, this condition responds very well to high-volume hydrodissection that Dr Laferty can carry out in his rooms under ultrasound guidance.

Is surgery ever required for heel pain?

Yes, in a tiny percentage of cases that do not respond to any of the above locations, and every non-surgical intervention has been attempted. Dr Lafferty has the training and expertise to carry this out. Typically, he will carry out a minimally invasive release/lengthening of the plantar fascia. This involves a small incision on the non-weight-bearing location of the arch, and the plantar fascia is released, allowing the tension off the band and eventual healing.

What about a heel spur?

In the past, the focus was on the presence of a heel spur. The spur is often not present, yet if it is, it occurs following chronic planar fascia, where the cord has been pulling away from the bone, leading to bone being laid down and hence a spur formation. Luckily, it has been shown that the symptoms originate from the fascia coming off the bone and not the actual bone. It typically does not need to be removed unless it is huge.