Practice and Services

Tips for general practitioners

Plantar fascitis (Policeman’s Heel)

Plantar fascitiis is a common condition affecting mainly those around middle age. It is characterized by pain under the heel and is often of insidious onset. It is aggravated by excessive walking or standing. Hence the term “Policemans Heel” referring to the officers who had to walk long distances while on patrol.
Paradoxically, many patients will complain of having symptoms on waking up in the morning and putting their feet down with the pain going away after walking a few steps.

Diagnosis of Plantar Fascitis is made on clinical grounds but XRs may sometimes be obtained to exclude occult fractures of the calcaneum in active individuals.

Heel spurs are occasionally seen on XRs. These are commonly thought by laymen to be the cause of their pain. In fact the spur has nothing to do with Plantar fascitis and is present in 20% of patients who have no symptoms at all. Instead chronic tears or inflammation of the origin of the plantar fascia is thought to be the cause of the pain.

Figure 1
XR showing a typical “heel spur”

Figure 1

Treatment

90% of patients get better with conservative treatment. Treatment modalities include activity modification, shoe alteration, heel inserts, ultrasound and stretching exercises. Steroid injections can be given for recalcitrant cases.

Steroid Injections for plantar fascitiis

Steroid injections are often effective for treating cases of plantar fascitis which don’t respond to more simple treatment. Care must taken to avoid injecting into the heel pad or the tendo Achilles. This can result in atrophy of the pad or rupture of the tendo achhilles.

Technique

Equipment

• Use a 10 mL syringe and a 21-Gauge needle. A 23-Gauge needle is also acceptable.
• Lignocaine can be used safely in dosages of less than 2 mg/kg bodyweight. Generally, 50 mg (5 mL of a one percent preparation) provides adequate analgesia within safe limits.
• Triamcinolone or other steroid preparations are equally acceptable.
• Aseptic techniques should be strictly adhered to.

Important landmarks

Landmarks to note are the Heel Pad , the junctin between normal skin and the skin of the heel pad and the tendo Achilles.

Figure 2
Identify the Heel pad and the junction between the normal skin and the skin of the heel pad

Figure 2

Figure 3
Palpate for the most tender spot at the junction of the heel pad and normal skin. This should be well away from the tendo Achilles.

Figure 3

Figure 4
The Steroid and Local Anaesthetic should be injected into the most tender spot palpated. Care should be taken to avoid injecting into the heel pad as this can cause heel pad atrophy.

Figure 4

Post op advice for patients

• Effects of the lignocaine usually wear off in a few hours. However, the steroid should slowly take effect over the next few weeks.
• Avoid strenuous activity for the following 24 hours.
• If symptoms worsen within the next 2 days, seek medical attention at the clinic. This may be due to a “steroid flare”, which can be managed with cold compresses, NSAIDs and adequate rest.

Contraindications

• Skin abrasions or infections.
• Known allergy to local anesthetics.