Hello everybody. Welcome back to my VLOG, which this week is going to cover
Plantar Fasciitis. I can hear you all saying, what on earth is Plantar Fasciitis?
But I can assure you, if you've had it, you'll know. And maybe you have it and
don't know the name of it but you are in pain and wondering. So hopefully I can
put everything to rest here today. So what is it? It's persistent pain, focused on
the underside of the foot, particularly in the heel. It actually gets to the
point where you can almost do no walking at all, and therefore interferes
dramatically with day to day life. It affects the plantar fascia, which is a
band of tissue and ligament which stretches all the way from the toes to
the back of the heel. So it goes along the whole under side of the foot. It
supports the arch of the foot, so it's a very important ligament. The pain that
you get with plantar fasciitis is caused by chronic, so long-term, degeneration
and repair, that then makes the fascia tight and causes pain. So who gets it?
Well lots of people get it! Ther's a 10% lifetime chance that you'll get it
and it causes 80% of all heel pain! So as a GP, if we're dealing with heel pain, the chances that it's plantar fasciitis
is really high. It's most common in people aged 40 to 60, but that doesn't mean you
can't get it outside of those ages. And we do see it in young people. Young people
that are standing all the time, running or just on their feet; up and down with their job.
So athletes, soldiers, shop workers for example do tend to suffer younger
than that 40 to 60 age range. So what are the causes? Well, having a high arch or
even flat feet, so the two opposites can be a cause. Excessive pronation, so some
people, when they walk or when they run, actually roll their feet inwards and
that can put you at risk of plantar fasciitis because it's doing damage all the
time which is then being repaired. So it's really important that you have good
shoes and if you're a runner, go to a shop where they look at your your gait
on a treadmill and then get some shoes that stop pronation.
Walking, standing or being on your feet for long periods of time can
be a cause. Being overweight can be a cause. I mean poorly fitted shoes could
also cause it. And having a tight Achilles tendon, which is the tendon which
runs at the back of your heel and into your calf muscle. Or having tight calf
muscles can also cause it. So it's really important that if you do exercise or
run, that you really stretch out before you exercise and warm down afterwards to
make sure that you're not exacerbating that tightness in the achilles or in
your calf. So what are the symptoms? well initially the onset pain in the
underside of the heel, which can be quite insidious, just coming on slowly day by day,
but gradually getting worse. Having intense pain in the first few minutes
when you get up in the morning, in the underside of that heel area, that
gets better once you start moving around and walking, is a really common sign. But
then the pain actually getting worse as the day goes on and you're on your feet
and walking or running. So how do we diagnose it? Well its a clinical diagnosis
that can be done quite simply in your GP. And initially we take a really good
history from you, to find out what you've been doing and we'll assess your risks
to see what your risk factors were for plantar fasciitis. We will examine you,
and we'd have a prod around under the foot (palpation) and quite often you'll be
tender in a certain area under the foot. And I'm going to put a link to a picture
where the most common site of pain is for plantar fasciitis. But it isn't
limited to that one spot, it can be over quite a vast area along the sole of the
foot. We would look at the the way that you walk (your gait) and that can quite often
be abnormal as you try and prevent the pain. So that can be an abnormal gait
or you can be limping. You might have what we call limited ankle dorsiflexion.
So that's when you pull your foot up and your ankle then moves so that your foot
can actually come up towards your body. That can actually be limited in plantar
fasciitis and you might have something called a 'positive windlass test'. And this is
where we would extend your big toe upwards towards your nose and that
would replicate the pain on the underside of the foot. So it's quite easy for us in GP to make a diagnosis of plantar fasciitis.
We have to always have in our mind that it could be various other things. And it
could be lots of other things. So it could be a fracture of your calcaneal
bone, so your heel bon. It could be achilles tendonitis with
the pain radiating to the sole of the foot. Your fat pads, which are the pads in
the soles your feet that protect you against damage, can actually, over time, so
they can shrink. That can cause pain. You can have bursitis under the heel bone.
You can have peripheral neuropathy. So for example, people with diabetes are more at
risk of that. Its where the nerves in your feetare actually starting to burn and be
painful. The actual plantar fascia can rupture, so that's a complete tear in in the
ligament. Your nerves can be trapped, so
nerve entrapment. And very very rarely, and I can't stress how rare this is, it can be
malignancy.
So what are the treatments for plantar fasciitis? So initially we recommend self-
care, and I'll talk you through that. After that, structured physiotherapy or podiatry.
After that, corticosteroid injections. And then finally an orthopaedic surgeon
referral, if none of those things are working.
So in terms of self-care, the reason we start here is that within six months
most people undergoing a series of self-care processes will actually get better.
So the kind of things we recommend is that you avoid long walks or standing. So
it is restrictive I'm afraid. Especially if you're somebody who has a job where
you're standing or you like to go for walks. Good shoes with strong arch support are
really important and cushioned soles. Avoiding walking barefoot is really
important, you need support and protection for the sole of the foot.
Buy yourself some insoles and heel pads. There's no evidence that having them
custom-made is any better than buying them in any good chemist/shoe shop/or
shoe repair shop. Use painkillers like ibuprofen. So NSAIDs, that the first
recommendation, but if you can't take NSAID's (and lots of people can't) then use
paracetamol and codeine. Lose weight, if you're overweight, because that will
help. You can use ice packs for 15 to 20 minutes when it's really bad to just
help with the pain and just give you some symptom relief. And self
physiotherapy, so special exercises designed for the plantar fascia. And I'm
going to put a link to those in the comments afterwards that so that you
have those. So structured physiotherapy or podiatry; why is this important? Well
you can get a proper assessment and they can look at all of the risk factors that
we talked about earlier. So a physiotherapy or podiatrist can do some
deep tissue manipulation and massage which often really helps. They can
actually do ultrasound treatment. So not the ultrasound when we take pictures
for example in pregnant women but an ultrasound that passes into the tissue
and helps repair it. So that's often very useful. They can teach you to offload, so
that you're not putting strain when you walk on the fascia. And they can
also take you through the self-care exercises, so that you know you're doing
them properly and they can assess the way that you're doing them. So it is
often quite an important part of the treatment plan. Then the corticosteroid
injections, and the jury's out on this one. Because there are some benefits that
there are also quite a few risks. So we do this really if nothing else is
working or sometimes we do it in the six month period to give you some relief
while you do the self-care exercises. But it is a very short-term relief.
So the injection itself is really painful, and I mean really painful. And
you then get some post injection pain that lasts for three to four days, and
that pain is much more painful than the plantar fasciitis itself. You generally
only get about a month of relief from the symptoms, some people get longer, but
quite often it is just a month. So a short-term gain for quite a lot of
pain. It can cause fat pad atrophy so you might be replacing one problem with
another. So as I said before, the fat pads under the feet which are there to
protect them can actually shrink with the steroid injection and that can
actually cause pain. And it can cause plantar fascia rupture; so a tear in that
fascia which is also very painful. So you need to consider the risk of those
things. If you are going to have it done, it's worth always having it done under
ultrasound guidance, to make sure it goes into the right place and this is best
practice. And also, if you're needing more than one of these, you can actually only
have it repeated once and it must be at least six weeks since you've had the
last one. So after that, if nothing's helping; not the self-care, the physio or
the corticosteroid injection, we can refer you to an orthopaedic surgeon. And they
have several tools at their disposal that we don't have. So they have
extracorporeal shockwave therapy, and this is non-invasive. And what happens
is they pass an acoustic shockwave through the area into the
fascia which causes micro damage, so tiny little areas of damage which then
get repaired and improves the situation in terms of the pain that you're having.
It also has a direct effect on the nerve endings and it reduces their sensitivity
to pain, so that's why it helps reduce the pain. You might need several sessions
and the important thing to know is that the evidence for this being effective is
actually quite patchy so it's not always available on the NHS. So you need
to check in your area and if it isn't you'd have to have it done privately. As
a last resort there's surgery and this is plantar fascia release and it's known to
be effective and to be helpful but obviously we're further down the line
because of the risks of surgery and it always will be a last resort. So those
are the things that the orthopaedic surgeons can offer. So as always, I've
looked at some other solutions for you to see if there's anything else that
might be added to what we do within the NHS
or within the medical arena. So custom made orthotics; a lot of people swear by
them and although there's no evidence to suggest that they're any better than the
ones you buy over-the-counter, they do fit your feet exactly. They are very
expensive but I know that I have some patients who say they're just more
comfortable to wear. Taping does help. So this can be done by
physiotherapists or a podiatrist, and this is where the strain is taken off
the plantar fascia by special tapes which keep the foot in certain positions.
And you would have seen the sportsman with their knees and elbows and
shoulders all taped up. It's the same kind of thing. It's providing
support in the right areas so that then other areas of the foot are not under
strain. So that can work as well. Night splints are sometimes suggested. So you
have your foot in a special splint overnight. There's actually no evidence
that these work. They're actually very uncomfortable to wear and they can
disturb sleep, so you're then adding to your problems by being tired and
possibly grumpy because you're in pain and you're not sleeping! There is some
evidence for Botox emerging. So Botox is injected into the plantar fascia to
relax it. And whilst I couldn't find a lot of evidence for this there are some
places doing it so I will put some information in the notes afterwards, so
that you can investigate it for yourself. There's also some evidence for
platelet rich plasma or PRP. Now we are using this in medicine for lots of
different joints, knees for example, to actually promote healing. And we take a
blood sample, your own blood, spin it in a special machine so that we then
take out the platelets in plasma. It's really rich and concentrated and we then
pop it back into the foot into the plantar fascia, where the aim is to promote
healing much faster than your body would automatically do it. So I will put some
links to that afterwards as well, because it does seem quite promising and does
work in other areas. So that's the low down on plantar fasciitis. We all have
a 10 percent lifetime risk of getting it, it is really really painful, and it
counts for about 80% of all heel pain! It can interfere with life to the point where
you could no longer carry on with normal activities and
that's why it's important that we get on top of it; because people that can't do
the things that they like to do get depressed they put on weight and
everything spirals from there. So getting on top of it quickly it's really
important, and if we do that, we know that with self-care, most people will get
better within six months. So I have put those exercises in the link afterwards
so then you can have a look at that. If you don't have a diagnosis but you do
have heel pain please pop along to your GP to get a formal diagnosis because
once you're on that pathway the end is in sight, in terms of getting it resolved
for you. But obviously if you don't know what it is then you may not be doing the
right thing. So again, as always pop along to your GP. It is a quick and easy consult
and you can get on the pathway to treatment. If I missed anything or you
have any questions do pop it in the comments afterwards, I'm always happy to
answer, and take suggestions for future VLOGs. So as always, thank you so much for
watching and I'll see you very soon