Performed by – David Hinsley, Ngwe Phyo, Nick Ward

Heel pain can be caused by a variety of conditions but the commonest cause is plantar fasciitis. Other causes include insertional achilles tendinopathy, Haglund deformities and bursitis, tarsal tunnel syndrome, and insufficiency fractures of the heel bone.

Plantar Fasciitis or Policeman’s heel is a painful condition typified by pain felt on the sole of the heel, often worst on the first heel strike in the morning (start-up pain). It may also become worse as the day wears on particularly if the patient has a job that involves a lot of walking. It is often due to inflammation of the plantar fascia as it attaches to the calcaneum (heel bone). The precipitating cause is often not known, but it can be associated with other inflammatory conditions, and in some cases can be linked to an overly- tight calf muscle/ achilles tendon complex.

The plantar fascia is a thick band of fibrous tissue on the sole of the foot which lies deep to the thick skin of the sole of the foot. It connects the heel bone to the base of the toes and provides support to the longitudinal arch of the foot.

This condition usually gets better with time but this can take many years. In the meantime, there are other treatments that can be employed to reduce the level of symptoms. Orthotics are insoles that can be worn within normal footwear. Heel raises with gel centres can be useful in offloading the painful heel.

Physiotherapy aimed at improving the strength of the small muscles within the foot has also been shown to reduce pain in plantar fasciitis. Eccentric stretching exercises stretch the calf and plantar fascia and are particularly beneficial.

If these conservative measures do not help, then an injection around the insertion of the plantar fascia can be performed. This can be done in conjunction with an ultrasound of the area to confirm the diagnosis. These injections can be repeated and sometimes multiple injections are required in order to settle the pain.

If patients fail to improve with these treatments, then shockwave therapy (ESWT) is a useful adjunct. It is carried out as a clinic based procedure over 3 appointments. See NICE guidance for further information:

http://www.nice.org.uk/guidance/ipg311/informationforpublic

If the calf muscle/ achilles tendon is overly tight then a lengthening procedure can be carried out as a day surgical procedure.

In rare circumstances, a surgical release of the plantar fascia can be performed in order to reduce pain. As this procedure is not guaranteed to reduce pain, and carries a small risk of damaging the small nerves that supply the sole of the foot with sensation, it is only employed as a last resort.