By Dr. Conway McLean, DABFAS, FAPWHc
Joe went to his doctor after suffering for over a year. His pain was not debilitating (not yet anyway), but he simply didn’t want to do much, at least anything active, since it meant more discomfort. Joe wasn’t particularly fond of the sensations coming from the bottom of his heel, which could be aching and other times sharp. Getting out of bed in the morning was an adventure, entailing him tiptoeing around the house for a while until the pain subsided. And it was getting worse and not better.
X-rays of Joe’s foot revealed a mean-looking bone spur coming off his heel right in the area of pain, so it must be the cause, mustn’t it? He was concerned surgery might be needed to remove this bony projection. A cortisone injection gave him great relief: perhaps it dissolved the spur? But then his heel pain began sneaking back after a few months and ultimately returned to full strength.
Anyone with eyesight and a layman’s knowledge of x-rays could pick out Joe’s heel spur on a side view of his foot. These can be prodigious when looking at these views of the foot. And yet, interestingly, they rarely have any relation to pain experienced on the bottom of the heel. Many of us have these large protruding bone spurs on our heels but are typically oblivious to its presence since it does not directly cause pain.
An obvious question concerns their formation; why do these bony growths develop? Likely, the mere mention of Wolff’s Law will suffice. But seriously, those educated on the topic will recognize this important dictum regarding the response of bone tissue to stress. Our arch ligament attaches at this area of the heel and, depending on a multitude of factors, the pulling on the bone by this ligament-like structure can elicit bone growth in response.
Joe had obvious pain relief after the shot, but no medicine can dissolve bone so how did it provide benefits? Cortisone is a common example of a steroid medication, in this case a corticosteroid. These are effective at altering the inflammatory process, which develops in one’s arch ligament (the plantar fascia) in certain foot types and with certain activities. But when the cause of the inflammation is still present, such as an arch which collapses, the relief will always be temporary, and the pain will return.
Spur removal was the fashion years ago but is considered inappropriate by experts today. Previously, we didn’t appreciate the contribution to foot function by the fascia. It’s an important part of the mechanical changes occurring with each and every step. When the spur was removed, the surgeon, by necessity, had to detach the plantar fascia, which is your arch ligament.
Because the fascia was released, the operation provided some relief, but, too often, recovery was difficult and complications ensued. Unfortunately, releasing the fascia remains a frequent procedure for the treatment of plantar fasciitis. Yet, even if only a partial release is performed, this approach too often has ramifications, aka complications. Without its tethering effect, the arch moves abnormally, and joints can be stressed, ligaments pulled, tendons overworked.
Acute plantar fasciitis of recent onset can sometimes be resolved with simple measures, a change of shoe gear, more stretching exercises, or short term use of an anti-inflammatory. But for every one of these sufferers there are three in which the pain doesn’t resolve so easily. Or it returns, sometimes