Heel pain is one of the most common ailments experienced in the foot. It can be very debilitating, and in its severe state can be crippling. Heel pain is for the most part caused by chronic injury to a band of tissue on the bottom of the arch called the plantar fascia (plantar fasciitis). Contrary to popular belief, it is very uncommon for a bone spur in the heel to be the actual source of pain, although they are commonly found with plantar fasciitis. This spur is positioned parallel with the ground off the heel bone, and can extend in the direction of the toes maybe a half of an inch when severe. The spur itself simply extends the bottom platform of the heel bone, as it is not directly stepped on. Unless the spur fractures off the heel bone (which is uncommon), or unless there is a rare formation of a spur that points down to the ground from the heel bone (as seen in uncommon conditions like rheumatoid arthritis), the spur will be pain-free and does not contribute significantly to heel pain. So, what does cause this ailment? Well, the plantar fascia is a tight band of rubbery stretchable tissue that supports the bottom of the foot to a certain degree. It gets injured in one of three ways. The most common injury is seen when people with flat or flexible feet consistently strain the fascia as they walk or stand, leading eventually to microscopic tearing of the tissue. Every minute standing or walking will gradually worsen the injury. The second injury pattern is seen in people with high arched feet. This pattern is much less common. The foot needs to flatten a little to absorb shock generated by walking. High arched feet do not flatten enough to absorb the shock, and this shock eventually causes damage to the fascia. The third injury pattern is even more less common, and involves a direct trauma to the heel itself, such as stepping on a pointed rock or straining the foot on a narrow ladder rung. The fascia can even outright tear in half in certain injuries.
This brings us to the focus of this article. Is surgery really necessary for treatment? The short answer is typically surgery is not needed. As a foot surgeon, I operate on many kinds of foot injuries and deformities. However, it is rare that I have to operate for heel pain (and I treat a lot of heel pain). The key to understanding how to treat heel pain is understanding what is occurring and why it occurs. Simply stated, the pain is due to swelling of tissue in the heel and arch (which usually is not felt as a lump when touching the heel), where the microscopic tearing in the plantar fascia creates a reaction in the body that brings in fluid and cells for the purpose of healing the damage. This swelling irritates surrounding tissue, including nerves, and pain is felt with pressure on it. If left alone, healing would probably take place just fine. Unfortunately, we must walk and stand in our daily activities, and by the time the we actually begin to feel enough pain from this process, the damage to the fascial tissue is more advanced. This process repeats itself daily, and long-term changes in the strength of the plantar fascia can ensue. Now, one may ask why, if the condition is related to foot structure usually and this is the same from a young age, does a person not have this pain most of their life? Well, not everyone with flat or high arched feet will get plantar fasciitis. They simply have a greater chance than someone with a normal arch, and usually some minor unnoticed injury, twist, or turn starts the process, which may take years to gradually evolve. This process is the ‘why’ in what and why is heel pain occurring. In essence, treatment needs to address both of these factors in order to fully relieve heel pain. Non-surgical treatment usually consists of at the very least reducing the inflammation, which will reduce the pain. This can include any combination of numerous techniques, including stretching or a stretching night splint to make the fascia more relaxed, icing, anti-inflammatory medication, and/or steroid (cortisone-like) injections to reduce the inflammation process, physical therapy to push the tissue from a chronic injury state into a healed state, or immobilizing the foot in a walking boot or cast to fully relieve the pressure and allow the fascia to mend itself. The second part of non-surgical treatment involves support of the foot structure that has allowed the plantar fascia to become injured in the first place. This involves the long term use of prescription orthotic inserts to support a flattened foot, or to absorb shock in the high arched foot. This is certainly much easier than having surgery to reconstruct the foot structure to a more ‘normal’ position. Over-the-counter inserts can be considered, but are usually inefficient and ineffective in the long run and provide limited initial help. They also must be replaced regularly as they wear out, and many popular brands are simply designed for increased comfort and not so much for actual medical-grade arch support despite their marketing. Without addressing the foot structure, most patients are doomed to experience plantar fasciitis again despite an initial cure.
How does surgery fit into this picture? Well, as I stated, most people don’t need it. Non-surgical therapy can take several months to work, although most patients are pain-free within a month or two. Surgery is not something to simply leap into, as recovery is not as quick as one might think. I am often seeing patients who had only had a couple of the non-surgical treatment options listed above, continued to have pain for many years after giving up on treatment, and then present to me requesting I immediately operate on them. I simply explain that relief is not instantaneous, sometimes (though not usually) requires a large combination of many treatment options at the same time, and nearly always leads to full and long-lasting relief. Surgery is a fine treatment option, but it can on occasion have complications that may be worse than the original condition, and the fasciitis can potentially return anyway if the foot structure is not addressed after the surgery. Surgery for heel pain usually falls into two categories. The first category is the most commonly used technique, and involves making an incision along the side or bottom of the heel and removing a wedge of fascia. Only part of the fascia is removed, because if it is cut across the entire width the foot will become unstable. This wedge will fill in with scar tissue, effectively lengthening the fascia and reducing the tight traction forced on it by a flat foot. The heel spur, if present, is also traditionally removed at this time, although this seems to be a residual procedure from a time in which it was commonly believed the spur had something to do with the pain. Complications from this procedure can include a transferring of inflammation to the remaining uncut portion of the fascia, opening of the incision, or nerve damage to small but noticeable nerves in the area. If too much heel spur is removed, a heel bone stress fracture can also gradually occur. The second surgical category involves changing the tissue on the inside of the fascia by creating an acute microscopic injury in an effort to stimulate a rapid healing response in the tissue. Long term plantar fasciitis becomes chronically inflamed (as opposed to acutely inflamed when first injured), and converting it back to an acute inflammation may help promote a quick healing time. This surgical category can use radiofrequency waves from a probe inserted directly into the tissue, local high energy ultrasound-based shockwaves generated externally, or even newer techniques involving chemicals directly linked to the healing process applied into or on the fascia. Results have been variable, although generally successful, and may need repeat procedures for long term success. Orthotics and structural support still need to be used in the long term. Complications are less, but may include failure of the surgery to help in the long run. Recovery for both categories still requires protective weight bearing for a period of time after the surgery, and post-surgical pain is always possible within a month after surgery for most procedures.
In summary, while surgery has been successfully used for many years to treat heel pain, it is rare for this surgeon to have to resort to the operating room to cure plantar fasciitis. Non-surgical treatment is not instantaneously effective, but is long-lasting and nearly always successful. Some patients do require surgery to ultimately fix their condition, but it is never necessary to resort to surgery as the initial treatment, and uncommonly necessary to resort to surgery at all.