Watch this video of Dr Philip Carolan, Sports & Exercise Medicine Physician discussing ‘Diagnosis and Management of Plantar Fascia Injury in Runners’ .
This video was recorded as part of Sports Surgery Clinic’s Evening for Runners in July.
Dr Philip Carolan is a Consultant Sports and Exercise Medicine Physician at Sports Surgery Clinic specialising in Plantar Fasciitis.
My talk this evening is on plantar fasciitis. My name is Dr Philip Carolan. I’m a Sports & Exercise Medicine Consultant in Sports Surgery Clinic in Santry. I’m also the Cavan team doctor, and I’m currently the Ulster senior football champions.
I have been asked this evening to talk about plantar fasciitis, which is a very common condition. It seems in many areas of life, I know this evening’s talk has to do with running injuries, but plantar fasciitis can affect the general population as well as runners.
My objectives this evening are to review the pathophysiology of plantar fasciitis, review the underlying causes – there are numerous treatment methods, and I’ll go through them and give some evidence-based facts with regard to these treatments, describe a rehabilitation program and recommend a return to play a program.
In my working week, I can see effectively about 20 odd cases of plantar fasciitis. I see patients that have been referred with initial review with an original problem or patients who’ve been sent to me that have already received modality of treatment and still have not made any headway in getting over the problem.
It is a very common condition, and I have just shown some statistics here.
|It affects 10% of runners. It also affects other athletes such as soldiers, soccer players & basketball players. In America, over 2 million patients are treated per year and have a significant interference in the athletic population and in competition. It accounts for between 11 and 15% of all foot symptoms requiring medical care|
As I said, this slide is an overview of what we might see in the clinic ourselves, between 32 to 40 new presentations a week. It is 15% of all foot presentations, and it’s the third most common running injury.
The pathophysiology of plantar fasciitis: the plantar fascia is a big thick broadband connective tissue that spans from the heel bone through the arch of the foot into the toes. It originates in the medial tubercle of the calcaneus, which is the heel bone. It inserts onto the proximal phalanges, which are the small bones at the start of the toes and inserts at the flexor sheaths. It forms both the longitudinal arch and the medial arch. It supports the arch as the weight is transferred over the foot from heel-strike to toe-off.
This is just a schematic drawing of the plantar fascia. On the left is a drawing and on the right is a cadaver specimen. You can see it’s a big thick band tissue that starts at the heel bone and fans out into the base of the toes.
The term plantar fasciitis was the original term, but I classically call it plantar fasciosis because it’s a chronic degenerative condition that is characterized histologically by cell changes fibroblastic hypertrophy, which is a fibroblast of the cells causing inflammation and disorganization of the collagen, which in turn causes you to have an inflammatory reaction and causes pain.
Simplistically it is micro-tears of the fascia from repetitive trauma, i.e. repetitive foot strike, that causes degeneration of collagen. With degeneration of collagen, we try and cause a healing response by inflammation; hence it’s called an inflammatory response but really is caused by degeneration, so I call it fasciosis rather than an ‘itis’. In medicine, ‘osis’ is degeneration, whereas ‘itis’ is inflammation.
You get cycles of tearing and healing, causing chemical mediators of inflammation to produce pain. That eventually causes myxoid degeneration and weakening of the fascia, which causes pain from scar tissue and calcification.
This is what causes the calcaneal spur – it’s interesting at times when people come into me and say to me, “I have a heel spur doctor” – that’s not actually what’s causing their pain. It is more the fascia rather than the bone because the spur is due to the recurrent calcification that occurs during the cycle of degeneration, heating and inflammation.
The causes of plantar fasciitis – there is numerous. It’s generally seen in people with high arch feet and flat feet. It is seen in people with a tight plantar fascia, with tight and weak calf muscles, if you can appreciate the plantar fascia attaches to the heel bone, which is intimately linked to the Achilles tendon and hence intimately linked to the calf muscles.
So if you have a tight calf muscle, you invariably have a tight plantar fascia. It’s also seen in tight hip flexors. There’s also the effect of activity, so it is seen with increased mileage, increased weight. Also, the type of footwear you’re wearing, i.e. big ram running shoes rather than having a nice heel and shock absorbency, and it’s also very common in HLA B27 spondyloarthropathies.
We describe in medicine there are two types of risk factors, which are intrinsic and extrinsic. Intrinsic is what the body is made up of, i.e. your anatomical, your functional, age, and inflammatory conditions. Extrinsic is what happens outside the body, so it’s your surface, footwear and the modality of motion.
So anatomical, we talk about the high arch foot or flat foot – pes planus, pes cavus, also about the way your foot strike is. Functional is regard to the muscles, be it the intrinsic small muscles of the foot, or even tight gastrocnemius or soleus muscle complex, and they can be weak as well. The age effect, we talk about collagen degeneration as we age – as we age, your collagen gets weaker, which causes weakness in connective tissue. Also, gout is a common cause of resistant plantar fasciitis.
The extrinsic causes, of course, are overload too much, too often, which causes muscle fatigue and breakdown of collagen. Running gait as we talk about heel strike, forefoot strike and of course, footwear.
So they’re the risk factors for people who develop plantar fasciitis. I talk about intrinsic and extrinsic. We try and talk about the body makeup and the structures that we run on, the surfaces we play on and our footwear.
The symptoms of plantar fasciitis are the classical presentation is heel pain first thing in the morning when you get out of bed. This may improve through the course of the day but tends to hurt again by afternoon and evening. It reoccurs upon standing after prolonged sitting, and it is worse walking barefoot and walking upstairs.
So it’s not a very difficult area to do a physical examination on because most patients describe tenderness to palpation on the anteromedial aspect of the heel. With ankle, dorsiflexion is limited by calf tightness, and you also get pain increased by great toe extension or by standing on their toes, and this is known as Windlass Test.
This schematic shows the areas that we would see most frequently affected by pain with patients who have plantar fasciitis or fasciosis. I think it highlights the central area on the posterior aspect of the heel of the posterior back of your foot, where 52% is just right on the medial attachment of the plantar fascia, and it can radiate out among the medial, central and lateral branch.
We do get patients who have pain in their forefoot – that generally acts like nodular plantar fasciitis. We get slight lumping in the plantar fascia rather than a pure inflammatory response.
The differential diagnosis that I would deal with when I see patients with heel pain are, especially patients who are doing a lot of mileage or calcaneal stress fractures, fat pad inflammation.
You can appreciate the plantar fascia acts like a sling or a strut to support the medial arch, and then under the plantar fascia, there’s a layer of fat to give cushioning and protection to the whole foot structure, and at times you can get flat fat padded inflammation or changes in the fat pad that can mimic the pain of plantar fasciitis.
Also, there’s a tendon that runs very close to the medial arch called the tibialis posterior tendon, and it can also get injured.
One of the things that can commonly mimic plantar fasciitis is medial calcaneal nerve entrapment. I will normally look into medial calcaneal nerve entrapment if I have a patient that is really struggling with the treatments we have used and still struggling with quite a severe heel pain.
Radiology, is there any value in doing X-Rays, MRI or Ultrasound? Lots of patients I would see will come in with an X-Ray report saying they have a calcaneal spur. I would normally start off with it is rarely useful, not needed in most cases, and then you get the question ‘What about the heel spur’. I think they’re probably negligible. There’s about a 13% prevalence, and they don’t cause any pain, and as I showed there only 5% of those with calcaneal heel spur complain of heel pain.
I think the use of radiology really is for three main issues: the diagnosis of a calcaneal stress fracture, especially on people who do a lot of running, and also, we get a lot of patients who’ve had chronic plantar fasciitis who present with quite a severe heel pain, and they can be very useful in diagnosing a tear in the plantar fascia.
What I use MRI to confirm is an inflammatory response, enthesopathy, intrasubstance tear, or just chronic thickening of the fascia. So the inflammatory response, you will see a thickening of the plantar fascia, with some inflammatory cells on the dark layer of the plantar fascia.
Enthesopathy is where a tendon or the plantar fascia itself tugs on the bone where it’s attached, and it will cause some bony bruising or bone oedema in the heel bone, which is a sign of both bone and fascia pain are together, and this is more difficult to treat.
Intrasubstance tear, you will see that on MRI because you will have a fluid layer within the plantar fascia, and then the chronic events for the chronic people you will see a big thickened plantar fascia and possibly some bone oedema.
So regard to the helpfulness of this modality is that under the layer that line of inflammation enthesopathy, we have got an idea of what sort of exercise program you might put them on, i.e. intrinsic exercises for their foot, concentric, eccentric and posterior chain exercises.
So we break them up again in what we would feel is the best modality of treatment, i.e. Depo, which is a steroid injection, ESWT, which is shockwave therapy, ACP which has a platelet-rich plasma, and chronic that has had some treatment done already, put them in a boot.
On the bottom there, you can see I put in surgical – in my 13 years of dealing with plantar fasciitis. I haven’t sent on anyone for surgery for their plantar fascia.
This is just an MRI scan of a thickened plantar fascia just in under the heel bone, and you can see some white area in the heel bone, and that’s endoscopic changes. There’s a smaller tear in that fascia, and I would be recommending to that patient that they would have a platelet rich plasma injection.
That brings me on nicely to treatments. I get a lot of patients that come into me, and they have had some form of treatment done already, or they’ve gone to foot solutions and have had orthotics made, and they are getting no better. So I start off with a simple algorithm that I use, and I tick off the boxes that have been covered or not covered and move on from there.
So if running and a lot of physical activity are causing them to have severe heel pain, the first thing I tell them is to modify the activity that they are doing and give themselves more rest time. There’s talk about shoe inserts, orthotics taping support of shoes – I do believe with a taping and some form of shoe inserts, as I mentioned earlier, one of the causes is high arch feet and flat feet
. I am very easy with regard to orthotics, and I just recommended going out and get simple over the counter. Our supports offloads the medial arch until their heel pain settles down, and then you can make the diagnosis with regard to an altered gate or another gate to prescribe orthotics.
One of the great treatments out there for early-stage plantar fasciitis are night splints, and I would prescribe this regularly for a new patient. The stretching programs involve the arch, calf, soft tissue, massage of the calf, and ice. We use non-steroidal anti-inflammatories early on, but I wouldn’t recommend keeping people on non-steroidal anti-inflammatory medication long term.
Then we move into the intervention stuff that we regularly use in Santry, either steroid injection, shockwave therapy or platelet-rich plasma injections.
The principles after rehabilitation exercises, you need to have the overall flexibility and put less strain on the plantar fascia, so you need your Achilles to be flexible, the longitudinal arch to be flexible, and the calf. That involves working on the intrinsic foot muscles, ankle stability, and also looking at the way you run to try and reduce the number of forces that are going into your heel by causing relaxation and greater calf strength and flexibility.
I would normally talk about an Achilles stretching once to twice a day hanging over to the edge of the stairs, barefoot heel/toe/backward walking while carrying weights, towel toe-grabbing the intrinsic foot muscles – these are the mainstay of the rehabilitation exercises.
There was an interesting paper in the British Sports Medicine journal recently where they looked on loading the plantar fascia with intrinsic foot exercises, and it had some effect early on in healing, and the paper was called ‘Load Me up Scotty’, and so it’s another one of the newer research that has been done on plantar fascia pain.
I would normally say to patients who initially come in to see me before you get out of bed in the morning, get a towel put it around your foot and stretch the plantar fascia for a number of minutes prior to getting out of the bed because as I said earlier, the plantar fascia acts like a tendon, and it shrinks at night, so when it shrinks, if you put weight into it first thing you stretch it, and that causes severe pain and inflamed or injured tendon. So if you stretch it or get it activated first thing in the morning before you put it on the ground, the pain will be less obvious.
Also, we talk about running a golf ball or a tennis ball – this image shows a tin under the heel of the foot or under the foot that helps stretch out the plantar fascia.
I suppose it’s a form of an oxymoron, in the sense that one thing we’re saying is that the plantar fascia is a strut, yet we’re saying we can stretch it – both cases are probably true. It does act as a strut to the medial arch but also shrinks to act like a tendon, and so it can stretch. As you can see, the slant board stretch the stair stretch act like eccentric exercises for the Achilles but are very beneficial in treating plantar fascia pain.
I mentioned the night splint. I’m a firm believer that the night splint is underutilized in the treatment of plantar fascia pain. It’s a splint that keeps your foot in full dorsiflexion at night, so it prevents the plantar fascia from shrinking. There are different variations out there, and I’ve shown a number of splints.
The sock third over on the right is known as a Strasburg Sock. It’s less cumbersome than the boot, and a lot of patients find it more comfortable at night, but this would be one of my mainstays of treatment initially for a new patient with plantar fasciitis.
There’s been a number of studies performed on the night splint – Batt et al and Probe et al in 96 and 99 showed that with the tension night splint and heel cup, 100% were cured and ones that failed with non-steroidal anti-inflammatory stretching and shoe changes attention night splint improved our outcome. There were mixed results, but I would always use it first off.
Orthotics is a very difficult topic to talk about on its own. I’m not a firm believer in prescribing orthotics when people don’t have a normal foot strike or biomechanics because of severe heel pain. As I said earlier, I would normally recommend that the patient would go out and buy simple, over the counter arch supports to give the arch a little bit of support as they are going through a rehab program.
There is definitely no evidence to show that getting custom orthotics improves the rate of healing of people with plantar fasciitis. There’s been a number of studies out there in 1999, and they randomly assigned patients to five different groups, and over the counter arch support, full length felt 81% noticed a good improvement. With the custom three-quarter length polypro orthotics only 68% noticed an improvement. The problem with that study was that was only three quarter length orthotics used rather than the full length over counter arch support.
I am moving on to the interventional modalities that I would use with most of the patients that have tried a lot of stuff that I’ve mentioned earlier with regard to physiotherapy and calf stretching. So, I would then discuss the types of treatment that I would use, which is extracorporeal shock wave therapy, steroid injection, or platelet-rich plasma injections.
Extracorporeal shock wave therapy is non-invasive. It involves using a gun, like the pictures here. You deliver a certain dosage of shots at 10-hertz frequency, and you increase the bar of pressure to allow patients to tolerate up to a pain scale of six to seven out of ten.
The modality is a cascade effect – you put the probe onto the degenerative plantar fascia with the energy transferred across the fascia it causes an activation of the healing cascade response, which enhances blood flow into the tissue, which causes tissue regeneration.
We would normally do shockwave three to four treatments a week apart and then get the patient back two to three weeks after that for a top-up treatment.I find shockwave a very good modality. It’s not invasive, and lots of patients do very well with it.
The next option is a corticosteroid injection, which we would do under ultrasound guidance. This is an image of the ultrasound probe and a needle being directed at the plantar fascia, and you can see the ultrasound image on the right-hand side. You can kind of see a little mountain in the middle of the image and the thickened grey part on top of that is the plantar fascia.
I’m slow at recommending a steroid injection straight off. There’s definite evidence that it provides quicker pain relief at one month, but there’s no long term advantage. There has been a number of studies that have shown that steroid injections, there is a recurrence rate of 45 to 50% at six weeks.
The big risk with using steroids is that it’s toxic to the plantar fascia and that it may cause tendon or plantar fascia rupture. In the olden days, this is the only treatment we had, and it was regularly used and was successful, but as I say, the statistics show that one and two have a recurrence rate at six weeks.
A newer treatment we’ve started using is platelet-rich plasma, and we use the Arthex ACP separation kit. What we do is we take blood out of your arms, spin it down in a centrifuge and then, under ultrasound guidance, inject that back in the plantar fascia.
The biggest problem with the plantar fascia platelet-rich plasma injection is it does involve a certain amount of immobilization, and we put you in a boot for two weeks, pre-injection and two weeks post-injection. I would generally use this for patients who have a tear in their plantar fascia or for patients who have chronic fasciosis and have not seen any results with any of the treatments that we offer to date.
What it is, it is simply whole blood that is centrifuged that is spun down in a machine to create an increased concentration of platelets, with or without the white blood cells. In the image at the top of the screen, you can see nice and clear gold fluid at the top, that’s the enriched plasma, and at the bottom, that’s the separation layer of the red blood cells and white blood cells.
So what’s so special about platelets? They activate various growth factors within the tissue, and that makes them special because it enhances an inflammatory response to promote healing and repair of the damaged plantar fascia.
The effects of the growth factors on tissues, there are three different factors of the immediate, it causes a second messenger stimulation, and, i.e. the macrophages stimulate the tissue to cause interleukin response to cause healing. That’s within five minutes, then early between 30 minutes and four hours, you get messenger RNA stimulation to cause protein synthesis and chemo taxes of further healing enzymes to the tissue to promote further healing. Then the late responses within 24 hours, you get fibroblast mitosis, which then encourages collagen deposits and the rate of healing after the damaged plantar fascia.
PRP is not stem cells. We get asked this all the time with stem cells, it’s not lymphocytes, and it’s not bone marrow. It is simply platelets in plasma that promote an inflammatory response to promote healing and repair. As I said, it promotes inflammation, so the reason we put you in the boot is to try and let things be absorbed and adhered around the plantar fascia, and let things rest for a period of time, so there is better uptake of the plasma.
We don’t allow patients to use anti-inflammatory medication for 72 hours after the injection because it stops the cascade inflammation reaction that does promote the healing of the plantar fascia.
It is effective in chronic plantar fasciitis and in tears of the plantar fascia. There are lots of papers being written, and they all seem to highlight that plantar fascia pain that has not succeeded with other treatments do very well with platelet-rich plasma injections.
My typical treatment protocol for a new patient – I profile and try and limit the amount of activity to control the abuse of the fascia. I normally give them two weeks of anti-inflammatory medication.
I talk about ice massage and rolling the medial arch four times a day, over the counter arch support, give them handouts on exercises to work on their calf, Achilles and their plantar fascia and follow up in two weeks just to reinforce whether to do their exercises, get an MRI to see how badly damaged the plantar fascia is, and then discuss interventional therapies.
There are unusual things that can mimic the plantar fascia as I mentioned earlier, and if patients are still suffering from pain after three to six months and have not responded to treatments, which I may say, I have at times thrown the kitchen sink at plantar fascia pain involving all three modalities of treatment.
If at that stage they haven’t responded to treatment, I would always think of other conditions that may mimic it, like a fibrous sarcoma of the tissue, a foreign body within the plantar fascia that is not evident on X-Ray or on MRI. Older diseases like Paget’s disease or TB, and also gout as I mentioned earlier, gout is one of these arthropathies that can cause plantar fascia pain to linger, despite shown a lot of treatment in it and a simple uric acid blood test and treatment of gout gets rid of the plantar fascia pain.
The one thing that I see quite regularly is when I’ve shown a lot of treatments that the plantar fascia is a nerve entrapment syndrome. In the past year, I would have seen probably six or seven nerve entrapments is of the medial calcaneal nerve and sural accessory nerve. If treatment is not going well, I would normally refer these patients for EMG studies and getting the entrapped nerve flushed with saline, and local anaesthetic generally helps relieve the pain.
Prognosis is excellent for plantar fascia pain, although patients I see who have it don’t feel the prognosis is good because they’ve had it for so long. 80% are generally better in 12 months. The literature explains that it is a self-limiting condition, and it can burn itself out, but you cannot put a timeframe on it. Most patients who get no treatment and get by through the pain cycles generally would say to me that after three and a half years that it would burn itself out.
We have treatments there to try and help patients, and anyone I see, I would start them onto a treatment plan, try and reduce the amount of time you suffer from heel pain. Surgical intervention is very rare, and I don’t think, as I said, I haven’t referred anyone for surgery over the 12 years that I’ve been involved in treating plantar fascia pain.
The take-home messages from this talk are that plantar fasciitis is very common. It’s a degenerative condition and not inflammatory. Strength is key. What I mean by that is that your calf muscles and your Achilles need to work synergistically to take the load out of the plantar fascia. Adjuncts do help. The heel raises, the soft heel gel pads, and over the counter arch support are all very beneficial in trying to help reduce the pain.
Segmental load is used to offload, so as I said, that new paper in the British Journal of Sports Medicine, ‘Load Me up Scotty’, is trying to load the plantar fascia early, so it reduces the pain. That is a new paper that may show added benefit over the next number of years. As I said earlier, I would normally use shockwave therapy or platelet-rich plasma injections, and surgery and steroid treatments are rare.
Again, I’d like to thank you for letting me give you this overview on plantar fasciitis. I can tell you I’m a sufferer of the condition myself. I had it for a number of years, and I understand and empathize with patients who have it.
As I said, I’m a Sports and Exercise Physician, and I work in Sports Surgery Clinic. This is a final slide of myself with three of the physios who work in the clinic who were all involved with the successful Cavan Ulster Champions of 2020.
Thank you very much, and I’m more than happy to take any questions from you.
At this event, Dr Philip Carolan (PC), answered questions from our live audience asked by Fiona Roche (FR)
FR: Katherine’s did an eight-kilometre walk with a small bit of light jogging in January, and the next day she couldn’t put any weight on her left foot. It took four weeks before she could walk comfortably again. MRI showed no injury. She still gets a lot of darts of pain in the base of her big toe after walking or lights running. She is asking why?
PC: Catherine, that is a very interesting question. You put a big load into your big toe on your walk and light jog, and there are two bones at the base of your big toe called sesamoid bones, and they have a great risk of getting inflamed, which is known as ethmoiditis and sometimes you can get a stress factor.
Generally, they would settle down after four to six weeks or even a bit longer, but on an MRI, you should see a sesamoiditis definitely, and you should see a stress fracture. There are two tendons that insert onto the base of the big toe as well that can get inflamed from overuse and increased force by doing too much activity too quickly, but the likelihood it sounds to me that it is probably more like a sesamoiditis which is an inflammatory condition with the sesamoid bone and your big toe. Generally, it affects the fibular, which is the one on the outside sesamoid bone, but it is quite common and generally settles down by wearing a hard sole, firm shoe for four to six weeks.
The only other thing is big toe pain can be related to Gout – unusual to come on after exercise, but it is something that you need to bear in mind if you have got someone with an unusual presentation with big toe pain is to probably get a uric acid blood test done to check for Gout.
FR: Mark says can PF come and go, or is it mainly a steady increase until it becomes chronic?
PC: The literature states that plantar fasciitis is a degenerative condition, and if someone gets it generally should burn itself out over time. I do see people who would inform me that they have had plantar fasciitis in the past, and it disappeared, and now it has come back as bad as ever.
It does become a chronic condition, and that is when patients generally require treatment. I can empathize with anyone that has PF, I had it myself for three and a half years, and at the time, I was doing a lot of research on it, and everywhere I read, the literature states it should disappear by itself and burn itself out. I just did the simple physiotherapy exercises, got no treatment, and eventually woke up one morning, and it was gone.
We have treatments out there to manage it, and I definitely would recommend patients get it managed because it does have a big effect on their quality of life.
FR: Darragh says, how long will the shockwave therapy session last?
PC: That is an interesting question because shockwave therapy is evolving – there is a lot of different machines out there at the minute between radial shockwave therapies.
It depends on the machine because the one we use in Santry is a Swiss Dollar Cast machine which we treat plantar fasciitis at 10 hertz of frequency which is a fast pulse treatment. Generally, it is 2500 shocks at 10-hertz frequency, which generally lasts between 8 and 10 minutes – it just depends on how fast the frequency of the shockwaves are.
When we started off doing shockwave, we had an older machine, and it was a 2 hertz of frequency, and it took 20 minutes to do it. So it depends on the machine. There is a set dosage for PF with all the machines, so you just put in the dosage, which, as I say, is 2500 with our machine at 10 hertz, and it comes down through the machine.
FR: Would you class a recent increase in weight gain as a risk factor for PF? If so, what would be a significant enough weight increase?
PC: This is a challenging question because, from my talk, you would have seen that we do mention that weight gain or carrying extra weight is a risk factor for PF. Anyone who gains some weight is putting a greater force into their heel and into their plantar fascia, which is acting as a destructive medial arch.
I don’t blame weight gain on being a true source of PF because people who are not carrying weight and have a normal BMI get PF as well – athletes get it, a lot of runners and sprinters get PF who is not carrying any weight, so I don’t like to use that as a true cause but of course, if you are putting weight on it is putting a greater load into the fascia so it can make it more painful.
FR: If an X-Ray showed a large increase in the size of a heel spur over a couple of years leading to heel pain and surgery, is surgery ever considered or is an increase in heel spur a secondary effect?
PC: From my talk, I mentioned that the heel spurs don’t cause pain – you can do X-Rays on a population, and there is a prevalence in about 15% of the population who have no pain from a heel spur. 10 % of heel spurs might give some pain – over my time as a consultant, and I never referred anyone for surgery for a heel spur.
What causes a heel spur is the repetitive degeneration of the plantar fascia, and as the fascia degenerates, you get the inflammatory response which causes calcification. It is a chronic evolution of the plantar fasciosis that causes calcification to make the spur, and if it is going on a long period of time, of course, you will get an enlargement of the spur, but I still think the pain is generated by the fascia rather than the spur.
FR: I suffered from my left foot three months ago. The metatarsal up to the shin is now started over on my right foot. The left foot is still not great, I had an X-Ray to rule out a stress fracture, and I have just been fitted with new runners. Is there anything I can do to help with this? Pain is in the top of my feet.
PC: This is a difficult one because, unfortunately, an X-Ray is not great for diagnosing or ruling out a stress fracture. The X-Ray will prove that you either have a fracture or not a fracture. Stress fractures don’t always give you the dreaded black line in an X-Ray, so I can’t say you have definitely out ruled a stress fracture, although the way you described the pain radiating up to the shin, it sounds like there is more nerve irritation and it could be more in neuroma causing the pain and the risk is always that it could be bilateral which is both sides and both feet.
I suppose if it is not settling and it is now radiating into another foot, I would recommend probably getting a scan of the foot to make sure there isn’t anything else going on.
With regard to footwear, I would say I am not great at giving the names for footwear for patients – my attitude is footwear should be comfortable and supportive, so a firm soul, comfortable runners, is what I recommend to try and help alleviate the pain.
FR: Plantar Fasciosis was explained as micro-tears and inflammation. We do also see a substantial group of people younger who have normal findings – any comment?
PC: I suppose the PF is a degenerative condition and can affect anyone. I saw someone today, a 15-year-old who had PF. There is some evidence of inflammatory change within the fascia on the scan. It is described as micro-tearing, but it is tearing within the cell particles, which generates an inflammatory response.