Time to discuss a clinical topic Section

Fasciitis – I cannot even pronounce it!

This month I consider an excellent forum debate  in the March 2016 edition of Podiatry Now. I know for the patient that this is not accessible but it is worth focusing on the subject of heel pain, often attributed to fash-eee-eytis and sounds  confusing. Four podiatrists were asked 10 questions. With such an expert body, this provides a great piece of information for patients. I thought it worth summarising and putting in my own 2p.

Heel pain is represented by a wide range of symptoms as colleagues suggest. Fasciitis is key to heel pain although we are trending away from the term, even though it had a happy following. The fascial band runs from the heel to the toes and acts as a strut. A strut is a support but it is also an important method to absorb shock when the foot contacts the ground. By the time we reach 40 years of age we are susceptible to tiny tears in this band which project into the heel and arch of the foot. This inflames the heel pad which in turn becomes congested. I call it repetitive heel pad strain, but fasciosis is an alternative name. There are others but I won’t list them all.  The curious fact pointed out by the experts was that although much research exists, there are still many things we do not know about the condition. The early morning heel pain and the pain after a long day’s work, especially after rest, is classic. I took a look at our data base with 70,ooo patients and was able to review my own data and those of my colleagues. For the most part these were actually podiatric surgeons and not generalist podiatrists. We have 354,491 different contact events recorded so this gives good numbers, many connected to conservative treatment. Nationally for heel pain we record 489 cases since 2010 which broadly represents 1.3% of foot pain. So, in the big scheme  – small. My data shows 191 representing 7% of my case load who present with heel pain. It is good to know your own figures and this is why many, but not all, audit their work.

Are we any good at treating fasciitis? (Experts were asked). Well as it happens yes pretty good. All experts reported success by various methods, many without surgery. There was one niggling point though. It was clear most had not had experience with surgery or even some newer methods so one expert panel member was right, we do need more information. Academic discussion was inconsistent across this panel probably as each had their own approach and felt this worked. However, and here’s the rub, not all mentioned the period of time when action is most successful. So, the baseline is if it is treated early, success is better. Injections have a mixed view and I liked comments about the shock wave treatment. I use this at Spire and suggest 55% success to patients. If we are going more scientific the range is around 33-90% which means some better than others. Call me a cynic but when we talk about foot mechanics we need to be specific. I don’t buy into flat foot (pronation) as the key to the cause, but I do believe the nature of the band which is integral with the delicate heel fat pad, and easily damaged. This means soft structures are exposed to forces which cause deterioration. Think very broadly of a rope that looses some strands and stretches and eventually weakens. These bands actually do snap occasionally, often with a resounding thump. Steroids give a very good chance of full recovery but should not be repeated in the same location if the first fails.

What about diagnostics? Imaging is helpful. X-rays are limited unless there is a known injury. Forget the spur, it is usually irrelevant. My last spur surgery was carried out sometime in the early nineties! Don’t go there. Ultrasound currently is the favourite diagnostic and my colleague in our radiology department at Spire, Dr Ali Mehr, is a big proponent of this when managing heel pain because it shows the band and the thickness measured. Once the band is shown to be 4mm above, I can usually not only determine the correct foot which hurts but justify  treatment. MRI is okay and has a place. Blood tests are pointless and who wants a needle and Dracula to have a go when standard tests are unreliable. Of course a medical picture might suggest an inflammatory musculo-skeletal disease; that’s joints and muscles to most of us. I usually get my rheumatology colleagues to take a look here if I am concerned. If you have heel pain look for fascial pain associated with chronic repetitive heel pad pain first.

What about surgery? I realised the experts were more into conservative care and hence may have not been so clued up about surgery. I do around 20 cases a year I thought, but even I do not do as many as that. Since 2010 = 38. If I didn’t audit I would have been wildly out. This means I do not carry out surgery routinely – but it has a place. Since 2010 our national audit shows 176 surgeries performed in our field (not orthopaedics). So given this represents some 30 podiatric surgeons, I do more surgery than most maybe?

The small incision which on the side is hardly visible. The band is released then has to be stretched by exercise. Our physios at Perform help the rehab brilliantly. You can walk after surgery, but I recommend resting for 4 days. Risks – these are minimal, although I have seen someone with some numbness in the toes afterwards. I can only account for one patient not doing well after surgery so on the whole, where heel pain is 1) unresponsive to treatment 2) has been present for more than six months and meets criteria from (1) then surgery is an acceptable choice and viable option.

When you had heel pain, what did you do? Yep I too have had heel pain. I was 45 and decided to loose weight and hit the dreaded treadmill! Bad idea before I had become accustomed to exercise. The 22 year old who played rugby forgot how age creeps up. I used a heel cup called a Tuli heel cup, and a 3/4 length orthosis (cheap over the counter type) and it went. Bear in mind I started treatment at a week and experienced great success. The experts are right – go for mechanical devices aimed to help reduce foot strain. When you hit six weeks and the GPs approach…yes ibuprofen, fails, OR your stomach bloats and gives you acid reflux, so go to someone who knows how to give a steroid injection. I mean someone who does this all the time and uses the right needles, AND dare I say, knows the foot intimately. Pain killers work for around 48 hours; NO improvement, move on. Local anti-inflammatory gels, try them but you probably won’t experience much improvement.

In rare instances heel pain is part of another problem. I will deal with this another time, but heel pain triad syndrome is not so well recognised by many people who should know this. I will cover this another time. Look out for posterior tibial tendon syndrome and tarsal tunnel.

If you want to know more or read more, go to Clinician’s Portal on this website and check out my 2008 lecture. You will be amazed what the professionals do not know about heel pain. For the time being, your heel pain is most likely the common garden “fasheetus” as many patients call it. Who cares what it’s called, it just hurts! DONT LEAVE IT TO BE BECOME CHRONIC.





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