Where is your pain?
Check Now
Make an appointment
Before describing the condition, you may wish to read about the normal anatomy of the plantar fascia here.
The plantar fascia is a thin band on the sole that has a very important role in the foot, maintaining the shape and arch of the foot.
The suffix “itis” is used to describe inflammation of a part of the body, for example gastritis, which is inflammation of the stomach. The term plantar fasciitis therefore means inflammation of the plantar fascia.
However the term plantar fasciitis is strictly incorrect. Research has shown that there is actually little, if any inflammation. That is why NSAIDs (such as ibuprofen) do not work except for patients who are in the early stages of the disease (when there is a little inflammation present). In fact, plantar fasciitis is a degenerative condition and for that reason it is more appropriate to call it plantar fasciopathy. By degeneration we mean “wear and tear”. The body’s normal healing response is impaired resulting in pain. Instead of a thin strong band of tissue the fascia becomes thickened and has weaker properties.
Patients often come to The London Foot and Ankle Clinic having been told that they have a heel spur, which is the cause of their symptoms. This was in the past thought to be the cause of plantar fasciitis but has now been disproven. A large proportion of the population has a “heel spur” and it is now seen as an incidental finding and nothing else.
The plantar fascia (white arrow) Achilles tendon (red arrow) and continuous fibres (yellow arrow)
MRI of the hindfoot demonstrating A – normal plantar fascia and B – abnormal plantar fascia consistent with plantar fasciitis
Risk factors for plantar fasciitis include:
Pain is the most common symptom of plantar fasciitis.
The characteristics of plantar fasciitis are –
On clinical examination patients complain of pain at a specific point on the plantar aspect of the heel. Patients will often have tight calf muscles.
The history and examination will aim to rule out other pathology that can cause similar symptoms. Other conditions that can cause plantar heel pain include:
The diagnosis is based on history and clinical examination in the majority of patients with “classic” symptoms and examination findings as described above.
Radiographs are rarely requested unless there are atypical symptoms and other pathology needs to be ruled out.
An ultrasound is a quick and pain free investigation that can confirm the diagnosis.
MRI is particularly useful in making the diagnosis and ruling out other conditions such as a calcaneal stress fracture. It is requested if there are atypical symptoms and examination findings.
MRI is particularly useful in assessing:
Yes the pain can become chronic in nature and more severe however this is uncommon as the condition tends to be self limiting and the majority of people get better.
Rarely the plantar fascia can rupture (partial or complete).
To ease the pain you may alter your gait pattern and therefore walk in such a way that puts abnormal pressure on other joints. As a result you may develop ankle, knee, hip or back problems.
Non-operative management aims at relieving pain ad allowing return to normal function.
It should always be the first line of treatment. Options include:
A period of rest from sports and exercise that bring on symptoms. Avoiding high impact activities and sports. Reducing the amount of time standing and walking particularly on hard surfaces.
Wearing shoes with cushioned heels.
Gel heel pads to cushion the heel and act as an additional shock absorber.
Orthotics with an arch support to help spread the load across the whole foot.
A night splint holds the plantar fascia and calf muscles in a lengthened position overnight and facilitates stretching.
Immobilisation in a walking cast or boot for 4 weeks is sometimes indicated and may help alleviate symptoms.
The use of non-steroidal anti-inflammatory drugs (NSAIDs) can decrease discomfort from plantar fasciitis in the very early stages of the condition when some inflammation is present. However usually in most patients there is no inflammation and therefore NSAIDs tend not to work.
Calf muscle stretches and plantar fascia stretches help reduce the forces going across the plantar fascia.
Intrinsic foot muscle strengthening exercise, lower limb muscle conditioning and strengthening exercise can also help ease symptoms.
This is a self limiting condition in the majority of patients. It can take up to a year or more for symptoms to settle.
Relatively new technique although evidence is coming forwards to show that it is effective in select cases. To qualify for this treatment patients should have symptoms for greater than 6 months. Patients with symptoms of less duration may find their symptoms are worse after treatment.
Shockwaves are used to create microtears in the plantar fascia, which in turn generates an inflammatory (healing) response. Three courses of ESWT are required spaced 1-2 weeks apart. Patients should avoid taking NSAIDs during treatment. The procedure is quite painful. In the majority of patients the pain is limited to the actual duration of treatment, which is about 5 minutes. We inform you of this only to forewarn rather than dissuade you of this treatment.
The complications of this procedure include bruising, swelling, pain, numbness or tingling and very rarely plantar fascia rupture. Treatment does not guarantee relief of symptoms.
Injections are rarely carried out due to poor results and low efficacy. May work for a short period in some patients but generally not very effective and carries significant risk of complications such as plantar fascia rupture and fat pad atrophy (the natural cushion of the heel wastes away).
In very few select cases an image guided local anaesthetic and steroid injection at the plantar fascia origin is performed. This is carried out under a short general anaesthetic and under x-ray control.
Steroids act by reducing inflammation. As most chronic cases of plantar fasciitis have no inflammation these injections tend not to work.
Multiple small needle punctures are made in the symptomatic area under ultrasound guidance. This causes bleeding at the site of the plantar fasciopathy, and like ESWT is thought to simulate an inflammatory healing reaction. Results are unpredictable but complications minimal.
Surgical management is reserved for patients who have failed to respond to non operative treatment. Surgery is very rarely necessary for the treatment of plantar fasciitis.
Patients should understand that the decision to undergo surgery should not be taken lightly.
Any intervention is considered in a step wise manner, with the least invasive procedure carried out first.
In patients who have failed conservative management and have tight calf muscles a proximal medial gastrocnemius release can be effective in easing symptoms in up to 80% of patients.
This operation involves making a small 2cm incision at the back of the knee and releasing the medial head of the gastrocnemius muscle. It lengthens the calf muscle and relieves the tension across the Achilles tendon and plantar fascia.
The operation is carried out under local anaesthetic and a short sedation. It is a day case procedure so you can expect to go home the same day. As the wound itself is small and the operation involves cutting fascia and not muscle most patients are able to walk out of hospital without crutches and are able to drive within 4 to 5 days. Calf stretching exercises are recommended for 2 weeks post surgery to help maintain the increased length obtained by surgery.
Expect to feel the benefit of the operation 6 to 8 weeks post surgery.
A typical wound following a proximal medal gastrocnemius release
Plantar fascia releases are rarely performed at The London Foot and Ankle clinic due to potential complications such as plantar fascia rupture, loss of foot arch and chronic pain.
It should be borne in mind that complications can result from a condition with or without surgery.
Complications can occur as with any type of surgery. Please see Complications for more detailed explanation of post surgical complications.
Note – these complications are not exhaustive and are meant as a guide
Please read the information regarding what to expect post surgery on this website.
Remember that below is a guide to recovery and that everyone heals at different rates and some people do take longer. Use this information to help you understand your condition, possible treatment and recovery. The timeframes given below are a minimum, it is important that you appreciate this when considering surgery as your healing and recovery may take longer.
Following a proximal medial gastrocnemius release –
You will have a small waterproof dressing applied to the back of the knee. It is advised not to remove this until seen at clinic by Mr Malik at the 2 week follow up.
For 2 weeks following surgery it is recommended that you keep the area dry. You may wish to get a Limbo bag which will stop the wound getting wet.
Most patients are able to walk comfortably without any aids after the operation. If both legs have been operated on then crutches maybe necessary. A physiotherapist will guide you before your discharge from hospital. Please ensure someone is able to drive you home after the operation. It is important that you commence calf stretching exercises as soon as possible after the operation. Activities can be gradually increased as pain allows.
You will be reviewed at the clinic and your dressings removed. Your wound will be checked and if completely healed you will be given advice regarding soft tissue massage and scar desensitisation. Scar desensitisation should start as soon as the wound has completely healed. You can do this by massaging cream (E45 for example) into the scar and around the wound area. You may shower and get the area wet only if the wound has completely healed and is dry.
You may be referred at this stage for physiotherapy for early rehabilitation – calf and plantar fascial stretches and intrinsic foot muscle strengthening exercises.
At this stage if your healing is progressing satisfactorily swelling and bruising should have subsided considerably. You should start noticing an improvement in pain levels.
Final clinical examination. Discharge if satisfactory.
This is probably the most common question asked of surgeons. Total operation time is different from the actual total surgical time. For example a flight involves not just the flying time, but the time checking in, going through security and boarding the plane for example.
The time given below is only a guide to the actual surgical time.
For a proximal medial gastrocnemius release
15 minutes
Most patients are able to drive within a week or two. Please see guidance below.
Please see guidance above and information here. Ultimately it is the responsibility of the patient to decide if they are safe to drive. A good way of knowing is if you can stamp your right foot heavily on the ground to mimic an emergency brake. If you have any hesitation or pain then it should suggest you are not safe to drive. Remember prolonged driving involves keeping your feet in a dependant position. This will worsen the post operative swelling.
Most patients are able to return to work within 3 to 5 days.
Excellent pain relief and return to sports by 3 to 6 months in approximately 80% of patients.
A mucoid cyst is a benign lump that occurs in the distal joints around fingers and toes.
A mucoid cyst in the 2nd toe arising from the DIP joint
No one really knows why mucoid cysts occur, although there is an association with arthritis of the DIP joint and rarely trauma.
Most people with a mucoid cyst have no symptoms.
Some people do complain of pain in the underlying DIP joint and this is due to arthritis in the joint. Patients that do present to a doctor typically do so because of frequent discharge from the cyst which almost invariably fills up again.
Rarely patients may complain of nail changes.
To summarise common symptoms include:
Investigations are rarely necessary to make diagnosis.
Radiographs may demonstrate osteophytes (bony spurs) in the DIP joint or evidence of arthritis.
The vast majority of people with a mucoid cyst are asymptomatic. It is a condition that can get worse.
If a mucous cyst ruptures & become infected, then a septic joint may result. This is a very rare complication however.
If there is a history of increasing pain, frequent discharge, swelling or an inability to do sports you may wish to consult with Mr Malik, an orthopaedic foot & ankle surgeon for further advice.
Non-operative management aims at relieving pain and limiting deformity progression. It is likely to be most effective in the early stages of the condition.
Made of silicon can be worn over the toe to protect from direct pressure and rubbing against footwear.
The use of stiff soled shoes that do not bend and therefore protect the DIP joint. Wearing a shoe with a wide and deep toe box to minimise pressure on the cyst.
The use of non-steroidal anti-inflammatory drugs (NSAIDs) can decrease discomfort from an arthritic DIP joint.
Will most likely result in recurrence and is not recommended.
Surgical management is reserved for patients who have failed to respond to non operative treatment.
Treatment options include:
Our favoured option is DIP joint fusion as this reliably relieves any arthritic pain in the DIP joint and has the lowest risk of recurrence.
All surgical procedures for mucoid cyst will be undertaken as a day case.
You will have a bandage applied similar to this during the operation.
Post operative bandage of the foot
Please do not remove your bandages until you are seen by your surgeon Mr Malik at the two week post operative clinic appointment. You will also be provided with a stiff soled black post operative shoe. Please ensure you wear this whenever you are weight bearing.
Post operative stiff soled shoe
For the first 48 hours you will be allowed to touch weight bear using two crutches. After 48hrs you can weight bear as tolerate. The physiotherapist will guide you after your operation and before your discharge from hospital with the use of crutches and mobilising.
For the first two weeks following your surgery please keep your foot elevated to the level of your heart for 95% of the time. It is recommended you stay at home during this period.
High elevation of the foot and ankle
Naturally most people do not have a hospital bed at home. The same effect can be achieved by lying in a bed or lengthways on a sofa, with pillows behind your back and under your foot. You cannot have your leg elevated sitting in a chair. It is strongly advised that during the first two weeks you are house bound.
To minimise risk of infection keep the foot dry and cool. Avoid humid and hot environments. Keep the foot dry and when showering wear a Limbo bag.
To minimise the risk of blood clots please move your foot and ankle at regular intervals. Please ensure you are well hydrated. If you have a risk of blood clots please notify Mr Malik who may organise for you to have blood thinning injections as a precaution.
You will be reviewed at the clinic and your dressings removed. Your wound will be checked and your toe taped or strapped.
At this stage if the swelling has subsided sufficiently you will be advised to keep your foot in an elevated horizontal position (50-75% of the time). You will require to wear the special post operative shoe for another 4 weeks. Short trips can be made outside, within limits of pain and swelling.
Driving will be permitted for short trips if the left foot has been operated on and you drive an automatic. If the right foot has been operated on it will be at least 8 weeks before any driving is advisable.
Scar desensitisation should start as soon as the wound has completely healed. You can do this by massaging cream (E45 for example) into the scar and around the wound area.
You will have radiographs taken just before you are seen in clinic. You will go over these with Mr Malik and compare the before and after images. If you have had a bony procedure, it will take a minimum of 6 weeks to heal.
At this stage if your healing is progressing satisfactorily swelling and bruising should have subsided considerably, although expect some degree of swelling for at least 3 to 4 months.
You will be able to start wearing normal footwear (swelling permitted), although stiff soled shoes are advisable. Continue to do the lesser toe exercises for another 6 weeks.
This depends on your rate of healing and how much pain and swelling you have. For the first 6 weeks we advise you to use the stiff post operative shoe. After 6 weeks it is advised that you wear a stiff soled shoe with a wide toe box while your foot continues to heal.
This really depends on you and your job. If you have a job that involves a lot of standing, walking and is manual it may be 8 to 12 weeks. If you have a sedentary job, for example in an office and you have a reasonable commute you may be able to go back to work at 2 weeks, although this would be exceptional and not the norm.
Excellent pain relief and deformity correction. Ability to participate in sports by 6 months. Sometimes up to a year before the foot feels “normal” and fully healed.
As the name suggests this is a fracture at the base of the 5th metatarsal. Fractures at the base of the 5th metatarsal are quite a common injury.
A “Fracture”, “break”, and “crack” are often used to describe an injury to a bone. Contrary to what most people think, they all mean the same thing. A fracture is a complete or incomplete break in a bone resulting from the application of excessive force.
Displaced avulsion fracture at the base of the 5th metatarsal
There are 3 types of 5th metatarsal base fracture depending on the Zone of injury:
X-ray demonstrating the areas of injury from 5th metatarsal foot fractures
The mechanism of injury differs according to which zone the fracture has occurred in:
Foot x-ray demonstrating the zones of injury from 5th metatarsal fractures
These injuries are also known as a Dancer’s fracture. A twisting injury to the foot and ankle literally pulls (avulsion) of a small piece of bone at the base of the 5th metatarsal. While as the name suggests it occurs in dancers, anyone can get this fracture, from a trivial injury such as stepping off a kerb.
A muscle in the leg called peroneus brevis attaches via its tendon to the base of the 5th metatarsal. When the ankle is forced inwards, the pull on the muscle and its tendon is strong enough to pull a bit of bone off.
This is an acute injury. The mechanism of injury is similar to an avulsion injury. It occurs at the junction of the metaphysis and diaphysis of the metatarsal bone (where the widened part of the bone at its end begins to thin out as it becomes the shaft of the bone). This injury is associated with sports such as football and rugby.
X-ray of the foot demonstrating a Jones fracture
This can be thought of as a chronic Jones fracture. The history is typically of pain for several weeks or months. This is a stress fracture of the 5th metatarsal. It typically occurs in athletes and is often a sports injury. This part of the metatarsal has a poorer blood supply than the bone more proximal and distal to it. It is called a “vascular watershed” zone. For that reason healing occurs slower. Repetitive strain and injury from playing sports for example can weaken the bone and result in a stress fracture. A stress fracture occurs when the rate of injury is greater than the bodies rate of healing.
This fracture can also occur in people who have very high arched feet (pes cavus). People with this foot shape tend to walk on the outer aspect of their foot. This can cause lateral foot overload, resulting in a stress fracture of the 5th metatarsal.
Symptoms vary depending on the site of the fracture.
X-ray of the foot demonstrating the zones of injury in base of 5th metatarsal fractures
Radiographs (x-rays) of the foot help identify the fracture and importantly the zone of injury. This helps distinguish whether it is an avulsion (Zone 1) from a Jones fracture (Zone 2) for example. Radiographs also provide information regarding the fracture:
CT and MRI are not usually required to make the diagnosis in acute setting. They may be considered in the setting of delayed healing or non-union.
CT scan of the 5th metatarsal showing partial union (healing) of the 5th metatarsal bone (white circle)
The prognosis depends on individual patient factors and characteristics of the fracture itself.
The majority of these injuries heal with conservative management without complication. There is a small risk of non union particularly if there is significant displacement.
As with most fractures a Jones fracture will usually heal if the foot it protected from weight bearing for a long enough period of time. Approximately 66-75% of these fractures will heal with conservative management.
However, as discussed earlier the area of the bone that is fractured has a relatively poor blood supply. This means that it may take longer for the bone to heal (delayed union), or that the bone may not heal at all (non union). Due to the high risk of non union many patients decide to have surgical fixation.
The same can be said for these fractures. In addition as these fractures are related to repetitive stress at the level of the fracture site, there is always a concern that the fracture may recur. In patients with a foot and lower limb that lends itself towards lateral overload (High arched feet – Pes cavus for example) there may be a higher risk of developing non-union and repeat fractures.
General risk factors for delayed healing, or non union of fractures include:
CT of the foot demonstrating non union of a 5th metatarsal bone fracture
X-ray of a minor undisplaced 5th metatarsal fracture that can be treated without undergoing an operation
Surgical management is reserved for patients who have failed to respond to non operative treatment or when a decision has been made to pursue surgery due to the high complication rate associated with non operative management, for example non union. There is an argument that operative treatment can also enhance recovery and healing times which may be important for example in patients who wish to return to sports sooner.
A variety of surgical options exist which need to be tailored to the individual and the stage of the disease.
Very rarely is it necessary to operate on these fractures acutely. When there is significant displacement a patient may choose to undergo surgical fixation of the fracture.
In patients managed non-operatively, if recovery has been complicated by painful non union particularly in the presence of significant displacement surgery is indicated.
A – Displaced non union 5th metatarsal fracture B – a 5th metatarsal fracture successfully fixed with plate and screws
Before and after radiographs of a non-union avulsion base of 5th metatarsal fracture fixed with bone graft and screw
Undisplaced and simple 2 part fractures, that are acute, can be treated using an intramedullary screw. This is often performed using an MIS technique.
An illustration of an Arthex 5th metatarsal solid screw
For patients with a comminuted (multi fragmentary), delayed presentation, established non union or displacement of the fracture, a mini open technique will be employed. This is to allow freshening up of the fracture site, insertion of bone graft (often obtained from the calcaneum), and anatomical fixation. A small anatomical plate is often used in such cases. This allows for rigid fixation and early mobilisation.
An illustration of a Arthex 5th metatarsal anatomical plate
An x-ray showing a plate fixation for a 5th metatarsal fracture
Operative management is as for Zone 2: Jones fracture. For recurrent fractures or non healing fractures in patients who have very high arched feet (pes cavus). It may be necessary to alter the biomechanics of the foot. People with this foot shape tend to walk on the outer aspect of their foot. This can cause lateral foot overload, resulting in a stress fracture and non healing of the 5th metatarsal.
In rare situations it may be necessary to undertake reconstructive surgery which would repair not only the fracture (often with bone grafting) but also changing the shape of the foot by cutting and repositioning one or more bones in the foot and/or lower leg. A common bone cutting procedure (osteotomy) would be a lateralising calcaneal osteotomy. This involves cutting the heel bone and shifting it more to the outside. This would stop the foot rolling on to the outside (lateral) border when weight bearing.
The aim of surgery is to alleviate pain and return a patient to full function.
Potential complications of non operative treatment applicable include:
These non operative complications apply to all three types of fracture, Avulsion 5th metatarsal base fracture, Acute and Chronic Jones fracture.
Potential complications of operative treatment to all three types of base of 5th metatarsal fractures include:
Please do not remove your bandages until you are seen by your surgeon Mr Malik at the two week post operative clinic appointment.
For 6 to 8 weeks you will non weight bearing using two crutches. The physiotherapist will guide you with this after your operation and before your discharge from hospital.
For the first two weeks following your surgery please keep your foot elevated to the level of your heart for 95% of the time. It is advisable during this period to remain at home.
High elevation of the foot and ankle following surgery
You will be reviewed at the clinic and your dressings removed. Your wound will be checked.
At this stage if the swelling has subsided sufficiently you will be advised to keep your foot in an elevated horizontal position (50-75% of the time). You will require to wear the special post operative shoe for another 4 weeks. Although this does not mean you can walk on the operated foot. The shoe is only there to protect your foot incase you stumble. Short trips can be made outside, within limits of pain and swelling.
Driving will be permitted for short trips if the left foot has been operated on and you drive an automatic. If the right foot has been operated on it will be at least 8 to 10 weeks before any driving is advisable.
You will have radiographs taken just before you are seen in clinic. You will go over these with Mr Malik and compare the before and after images. If you have had a bony procedure, it will take a minimum of 6 to 8 weeks to heal.
If there are signs of radiological healing at this appointment, you will be able to start weight bearing gradually in a special walker boot as comfort allows. During the 6 to 8 weeks of immobilisation your foot & ankle will get stiff and your calf and thigh muscles will waste. Hydrotherapy (exercises in the swimming pool) will help to restore ankle range of motion and general fitness. Pool running using a bouyancy belt is an excellent non impact form of exercise and will help regain muscle and bone strength.
Once you have been given permission to put partial weight through the injured foot then an exercise bike can also be used for fitness work. At this stage a referral to a physiotherapist will be made who will guide you through your rehabilitation.
This really depends on you and your job. If you have a job that involves a lot of standing, walking and is manual it may be 12 weeks at the earliest. If you have a sedentary job, for example in an office and you have a reasonable commute you may be able to go back to work at 2 weeks, although this would be exceptional and not the norm.
This really depends on how long it takes the fracture to heal. It will then be important to exercise and regain your fitness. Returning to activity too early, before the bone has fully healed runs the risk of re-injury or development of a new injury.
Excellent pain relief and return to full function. Ability to participate in sports by 6 months. Sometimes up to a year before the foot feels “normal” and fully healed.
Know More
Orthopaedic Outpatient Department 30 Devonshire Street, London, W1G 6PU
tel: +44 (0) 203 7956053
Mon - Fri (8am-8pm) Sat (9am - 5pm)
info@lfaclinic.co.uk
