East Lancs Foot Service guidelines
There is no clearly superior method of non-surgical treatment. We therefore recommend that first line management be simple and cheap, reserving more expensive treatments for those who fail to respond to simple measures. We recognise that this stance may change if further evidence becomes available.
Heel pain is normally treated in the primary care musculoskeletal clinic. Patients are referred to the team surgical clinic only where primary care treatment fails or there is diagnostic concern.
We recommend that:
- all patients should have a full clinical assessment by a member of a specialist multidisciplinary foot and ankle team
- diagnosis should normally be clinical and investigations should be performed only where there is a reasonable likelihood they will influence management
- inflammatory disease should be considered in every case and investigated where appropriate
- chronic pain features should be identified and managed accordingly
- all patients should receive an explanation of the condition and likely treatment which should emphasise its chronic self-limiting nature, self-help, the irrelevance of the spur and the low probability of needing surgery
- initial management should include
- attention to footwear, occupational factors and obesity
- simple analgesia
- stretching
- silicone heel seat where necessary
- patients who remain symptomatic despite compliance with the above should be re-evaluated for underlying disease. If none is found, second line treatment may include:
- a dorsiflexion night splint, especially if morning pain is a prominent symptom
- a customised orthosis in subtalar neutral, especially if the patient overpronates
- anti-inflammatory medication
- patients at any stage who have very severe symptoms, or patients who remain symptomatic after the above treatment, and who still do not have evidence of underlying disease, may be considered for
- a steroid injection into the plantar fascial origin from the medial approach
- a BKW cast or walker boot
- other "second-line" non-surgical treatment, such as shockwaves or radiofrequency diathermy, may be considered as available
- patients who remain symptomatic after the above, who have no evidence of underlying disease and who are within the normal range of weight for height, should be considered for surgery
- at surgery, the nerve to quadratus plantae is sought and decompressed. The medial half of the plantar fascial attachment is released from the calcaneum and any obviously abnormal areas are resected. We do not normally resect spurs. Post-operatively we allow weight bearing as tolerated and go for early range of motion exercises and desensitisation by massage and careful scar care.