Plantar Fasciitis

“PLANTAR FASCIITIS IS ONE OF THE LEADING CAUSES OF HEEL PAIN”

What is Plantar Fasciitis?

The plantar fascia is a ligament that is attached to the bottom (plantar) of the heel bone (calcaneus). It begins as a narrow band in the center of the heel and then widens as it extends and fans to through the bottom of the foot and arch and on into the long bones and toes. It is an extension of the Achilles tendon that is attached to the back of the heel. It lies just under the skin and fat. It is purpose is to support the arch and the muscles of the arch during gait. It acts as a “rubber band” that stretches back and forth with each step as force is put through the arch. When there is an injury to the ligament and it becomes inflamed, this is called Plantar Fasciitis (-itis = inflammation).

The ligament can also suffer larger tears or partial rupture if there is a significant injury to the area.

What is a Heel Spur?

Dr. Soomekh believes it is important to make this clear distinction.

Plantar fasciitis should not be confused with a heel spur, or heel spur syndrome. A heel spur is the formation of extra bone from the constant pull of the plantar fascia ligament on its attachment at the heel bone (calcaneus). When bone is stimulated, it grows. Extra bone can formed in any location f the body where there is overstimulation of bone. When the plantar fascia is tight, and it constantly tugs and pulls on the heel bone, the bone will react by growing extra bone in the direction of the pull of the ligament on the bottom of the heel. A spur can only form over a long period of time. A heel spur does not cause pain, unless it has fractured from an acute injury, A heel spur on the bottom of the heel should not be removed surgically unless it has fractured, failed to heal, and causes chronic pain.

Patients can have a large heel spur and no plantar fasciitis and no pain. Patients can have a very small heel spur and significant pain if they also have tearing of the ligament, plantar fasciitis.  The appearance of a heel spur only informs the doctor that the ligament has been very tight for a long period of time.

A spur on the bottom of the heel should not be confused with a spur on the back of the heel called a retrocalcaneal exostosis.

What are the Symptoms of Plantar Fasciitis?

Patients will complain of different types of pain in the bottom of the heel. The pain is usually located on the bottom, inner portion of the heel, forward about an inch from the back of the heel.  Descriptions of the pain range from a deep achy pain, to a sharp knife like pain. Most patients will complain of the most significant pain when they take their first few steps out of bed or after sitting for some time, and then walking. This pain can ease when there is more walking, and then increase again towards the end of the day. There is usually no pain at rest. Some relate a burning or numbness in the skin of the heel. Most find that being barefoot, using flat shoes and shoes without support lend to more pain. The pain usually will worsen gradually over time.

There are cases when there is significant injury and tear or rupture of the ligament. The patient will note bruising to the skin, noted swelling to the heel, inability to place weight on the heel, and acute pain.

What Causes Plantar Fasciitis?

Plantar fasciitis is usually caused by a recurring injury to the area over time. If there is an instance when the ligament is not able to stretch and be elastic during an activity (even walking) the fascia can suffer micro tears near its attachment to the heel bone. As the micro tears increase, there is an onset of inflammation and pain that will be felt in the heel. When the foot is at rest or under bed sheets, the foot is in a downward position; the ligament is in a shortened, relaxed state. As soon as sudden weight is put through the foot, the already damaged ligament is asked to stretch too quickly, and more tears are created. This is the reason for the common increased pain in the mornings. As the ligament stretches out with more walking, it will tear less. It is seen in women and men, athletes and non-athletes.

The ligament can also suffer larger tears or partial rupture if there is a significant injury to the area.  This is usually seen when there is a quick movement from a stationary state to activity, a bad step off a curb or step, or a jumping activity.

How is Plantar Fasciitis Diagnosed?

Diagnosis is achieved by the clinical examination, x-rays, and a diagnostic ultrasound of the patient. Dr. Soomekh will listen to the patient’s complaints, symptoms, and goals. The examination involves a hands-on analysis of the patient’s foot and evaluating their gait. Digital radiographs (x-rays) of the feet will be obtained in the office and reviewed with the patient. The positions of the bones and joints evaluated on the x-rays help to determine the severity of the deformity and any associated deformities.

Dr. Soomekh will evaluate the ligament using a state-of-the-art diagnostic ultrasound. This examination will show the thickness and swelling and any amount of damage and tearing of the ligament. It is used as an important tool to examine the degree of injury and the effectiveness of treatment.

An MRI may be ordered in cases of severe tearing or rupture of the ligament. It may also be needed for those patients with chronic plantar fasciitis.

It is important to distinguish plantar fasciitis from other problems that can cause heel pain such as Tarsal Tunnel Syndrome.

How is Plantar Fasciitis treated?

Dr. Soomekh educates that early diagnosis and treatment of plantar fasciitis are the keys to successful treatment, faster recovery and painless lifestyle.

Conservative Treatment for Plantar Fasciitis:

Conservative treatments rely on their ability decrease pain, reduce inflammation, stop the tearing of the ligament, and stretch the ligament. Dr. Soomekh will recommend a strict 2 to 4 week initial home therapy protocol. Reduction of the inflammation and pain can be achieved by treating the area with a daily regimen of ice therapy and the use of anti-inflammatory medications (NSAID’s). A period of rest will be needed in order to reduce the constant strain on the ligament while it is trying to heal. A discussion of appropriate shoes will be advised in order to support the ligament. The patient will be educated on a stretching regimen for the calf and the plantar fascia. Stretching of the ligament is very important in order to allow the ligament to be more elastic and reduce the occurrence of the micro tears. These stretching exercises will be especially important in the mornings before getting out of bed or after a period of rest. Dr. Soomekh may recommend a course of visits to a Physical Therapist.

Custom molded orthotics (insoles) are an integral part of healing and maintaining the integrity of the plantar fascia. The plantar fascia plays an important role in the support of the arch of the foot. When the fascia is damaged and irritated, it will need to be supported by a custom orthotic to reduce the forces placed on the fascia while walking and increased activity. The orthotics control the amount of motion through the arch during gait, and take on the pressures that ligament would normally incur.

If there is a large tear or rupture of the ligament, treatment will include a period of complete rest in a special boot with crutches and no weight bearing to the foot.

Cortisone (steroid) Injection Therapy for Acute Plantar Fasciitis:

Those patients that experience significant acute pain, or those that are not responding to other conservative treatments may benefit from an injection. Steroids that are used in medicine are catabolic, this means that they break down inflammation and scar tissue. When there is an acute injury with inflammation to the ligament, cortisone can be used to reduce the inflammation and break down any scar tissue within the ligament. This can reduce the pain as well as aid in more rapid recovery. Dr. Soomekh may recommend this safe and often therapeutic injection as an adjunct to conservative therapy; it is not meant to replace it. Cortisone injections may be helpful for some patients, and may not work for others. A common misconception about cortisone injections is that they can “wear off.” These injections do not “ware off.” When an injection helps the patient, it has done its job and is absorbed and metabolized by the body.  In situations when the heel pain returns after some time, it is considered a new injury to the ligament, not because the cortisone stopped working. Dr. Soomekh performs these injections under ultrasound guidance for accuracy.

Amniox Calrix Flo Injection Therapy for Plantar Fasciitis:

Stem Cell Therapy
This advanced treatment is made up of treated human amniotic membrane and umbilical cord tissue. These tissues have special properties that can regenerate tissues. The cells in this tissue are rich in healing factors like collagen, fibronectin, hyaluronic acid, and growth factors. These factors can help to decrease inflammation and regenerate new healthy tissues. The injection placed into the damaged portion of the plantar fascia, approached from the side of the heel. Dr. Soomekh performs these injections under ultrasound guidance for accuracy.  Dr. Soomekh is one on only a few specialist with experience using this advanced stem cell therapy.

Platelet Rich Plasma (PRP) Therapy for Chronic Plantar Fasciitis:

Platelet-rich-plasma (PRP) can be used as a treatment option for chronic plantar fasciitis. The introduction of a high concentration of platelets can “jump-start” the ligament to begin healing by increasing blood flow, converting the chronic injury into an acute inflammatory one leading to an influx of inflammatory healing cells to the ligament. It is a relatively non-invasive method using the patient’s own healing potential. Dr. Soomekh offers PRP therapy in the office setting. Click here for our details on PRP therapy.

The patient’s blood will be drawn from their arm. The blood will then be placed in a centrifuge in order to obtain the highest concentration of platelets available. The area of the heel is anesthetized.  Dr. Soomekh will use precision ultrasound guidance to deliver the PRP by injection into the plantar fascia. The patient can return home with special instructions for a post treatment protocol. A walking boot is used to control the stress on the ligament during the healing period.  Some patients may benefit from a second or third PRP therapy depending on their progress.

Surgical Treatment for Chronic Plantar Fasciitis:

After a 3 to 6 month period of failed conservative therapies the plantar fasciitis may have evolved into a chronic state.  In chronic conditions the body’s healing factors are not trying to heal the area of concern and are busy taking care of the rest of the body. Presumably, there are less inflammatory cells around the ligament to aid in healing. In these cases, Dr. Soomekh offers more advanced treatment methods.

The following treatments aim to convert the chronic condition into an acute condition. By doing so, the body will recognize the injury as a new injury and respond accordingly with the appropriate inflammatory response.  Under this controlled setting the new injury can be treated in order to heal it in a timely manner. These techniques will stimulate the tendon, break up scar tissue, and attempt revascularization of the plantar fascia by converting the chronic injury into an acute inflammatory one leading to an influx of inflammatory healing cells to the tendon.

Minimally Invasive Procedures to Treat Chronic Plantar Fasciitis

Dr. Soomekh will always recommend and attempt conservative treatment when appropriate. However, when plantar fasciitis becomes chronically painful and other procedures and therapies have failed, surgery may be indicated.

Considering surgery can be intimidating. Foot surgery including plantar fascial surgery is not supposed to be painful during recovery. When the skin and the soft tissues are handled with care and focus, most patients experience little to no pain immediately after surgery and throughout the recovery period. Dr. Soomekh takes great care and focus to minimize the chance of postoperative pain. The goal of plantar fascial surgery is to stop the tearing of the ligament, alleviate pain, allow a return to normal shoes, and allow a return to all activities. The procedure allows for immediate walking and a return to work while wearing a special walking boot. Dr. Soomekh performs the procedure in an outpatient setting at state of the art facilities.

Topaz Coblation Therapy:

Topaz Coblation therapy is a minimally invasive option for the treatment of chronic plantar fasciitis. It is performed in an operating room. A grid of 12 to 20 tiny holes is made into the bottom of the heel in the areas of the most pain. A special probe is placed through the skin into each hole to the level of the ligament. The probe then “burns” small holes into the plantar fascia, stimulating the ligament. Since it only requires small holes compared to a larger open incision, it can heal faster and with no scarring. The patient will return home with special instructions for a post treatment protocol. A walking boot is used to control the stress on the ligament during the healing period.

Tenex Plantar Fasciotomy:

Tenex plantar fasciotomy is a minimally invasive option for the treatment of plantar fasciitis.  It is performed in an operating room, often with simple local anesthesia. A small incision is made on the side of the heel in the area of damaged and painful ligament. Under ultrasound guidance, the probe is placed under the skin and into the damaged fascia. When activated, the probe removes the damaged tissue, while not interrupting the healthy fascia. The patient will return home with special instructions for a post treatment protocol.  A walking boot is used to control the stress on the tendon during the healing period.

Endoscopic Plantar Fasciotomy:

Endoscopic plantar fasciotomy (EPF) is a minimally invasive procedure using a small surgical blade attached to a camera. A small incision is made on the inner side of the heel at the level where the plantar fascia attaches to the heel bone. The camera is guided into the area to inspect the anatomy. Using a precision surgical blade placed over the camera, the inner 1/3 portion of the ligament is cut. The plantar fascia is now released from its attachment.  Once cut, the ligament cannot tear anymore. The ligament will heal in a longer and more elastic and will stop tearing. A walking boot and crutches are used to control the stress on the ligament during the healing period. Dr. Soomekh performs the procedure in an outpatient setting at state of the art facilities.

Dr. Soomekh has perfected and reinvented these procedures and techniques and is recognized by his peers as one of the top plantar fascia specialists in Los Angeles.

For more information about Plantar Fasciitis, or to schedule an appointment, please complete our online form or call 310.651.2366.

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