By Dr. Conway McLean, DABFAS, FAPWHc
Joe went to his doctor after suffering for over a year. His pain wasn’t debilitating (yet anyway), but he just didn’t want to do much, at least something active, as it meant more discomfort. Joe didn’t particularly like the sensations coming from the bottom of his heel, which could be aching and sometimes sharp. Getting out of bed in the morning was an adventure, forcing him to tiptoe 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 dislodging from his heel right in the area of pain, so that must be the cause, right? He was concerned that surgery might be needed to remove this bony protrusion. A cortisone injection gave him great relief: maybe he loosened the spur? But then his heel pain started sneaking back after a few months and he was eventually back in full force.
Anyone with layman’s eyesight and x-ray knowledge could spot Joe’s heel spur on a lateral view of his foot. These can be prodigious when looking at these foot views. Yet curiously, they rarely have any relation to the pain felt in the bottom of the heel. Many of us have these large, protruding bony spurs on our heels, but are usually unaware of their presence as they don’t directly cause pain.
An obvious question concerns their training; Why do these bony growths develop? Probably, the mere mention of Wolff’s law will suffice. But seriously, those educated on the subject will recognize this important saying regarding bone tissue’s response to stress. Our arch ligament attaches to this area of the heel, and depending on a multitude of factors, the pull on the bone by this ligament-like structure can cause bone to grow in response.
Joe had clear pain relief after the injection, but no medicine can dissolve bone, so how did it provide benefits? Cortisone is a common example of a steroid drug, in this case a corticosteroid. These are effective in altering the inflammatory process, which develops in the proper 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 a collapsing arch, the relief will always be temporary and the pain will return.
Dewclaw removal was fashionable years ago, but is now considered inappropriate by experts. Previously, we did not appreciate the contribution of the fascia to foot function. It is an important part of the mechanical changes that occur with each pass. When the spur was removed, the surgeon, out of necessity, had to detach the plantar fascia, which is your arch ligament.
As the band was released, the operation provided some relief, but, all too often, recovery was difficult and complications ensued. Unfortunately, fascia release remains a common procedure for treating plantar fasciitis. However, even if only a partial release is done, this approach all too often has ramifications, i.e. complications. Without its binding effect, the bow moves erratically and joints can be stressed, ligaments pulled, tendons overloaded.
New-onset acute plantar fasciitis can sometimes be resolved with simple measures, a change of shoes, more stretching exercises, or short-term use of an anti-inflammatory. But for each of these sufferers there are three whose pain does not go away so easily. Or it comes back, sometimes