Plantar Fasciitis (PF) is the most common cause of heel pain, stemming from irritation and degenerative changes in the thick band of tissue running along the bottom of the foot. This connective tissue, the plantar fascia, supports the arch and acts as a shock absorber. When heel pain persists for six months or longer despite standard treatments, the condition is categorized as chronic or recalcitrant PF. This persistent discomfort severely limits daily activity.
Reasons Standard Approaches Fail
While the name “fasciitis” suggests inflammation, chronic cases are often better described as a degenerative process called plantar fasciosis. This condition is characterized by micro-tears, collagen breakdown, and scarring rather than acute swelling. Because the problem is structural degeneration, simple anti-inflammatory medications and ice therapy are often insufficient to stimulate true tissue repair.
Stretching protocols, a cornerstone of early treatment, can sometimes be counterproductive for a degenerated fascia, potentially prolonging the injury. A primary mechanical factor is limited ankle dorsiflexion, often due to a tight Achilles tendon or calf muscles, which increases strain on the plantar fascia during walking. Excessive load, such as a high Body Mass Index (BMI) or occupations requiring prolonged standing, places continuous microtrauma on the tissue, preventing healing.
Conditions That Mimic Plantar Fasciitis
When heel pain resists therapy, the initial diagnosis may have been inaccurate, or a secondary issue may have developed. Several other conditions mimic the classic pain of PF, requiring a re-evaluation of symptoms. A Calcaneal Stress Fracture presents with heel pain that typically increases throughout the day with continued weight-bearing, unlike PF, which is classically worst with the first steps after rest.
Nerve entrapment conditions also frequently masquerade as PF. Tarsal Tunnel Syndrome involves compression of the posterior tibial nerve near the ankle, resulting in burning, tingling, or shooting pain that may radiate into the arch or toes. Baxter’s nerve entrapment causes pain felt more laterally or deep within the heel, which does not respond to fascia-specific stretching. Additionally, Fat Pad Atrophy, the thinning of the protective heel cushion, causes pain in the center of the heel that feels like walking on a stone and is aggravated by hard surfaces.
Advanced Non-Surgical Interventions
Once conservative measures fail, a physician may recommend advanced non-surgical interventions. Extracorporeal Shockwave Therapy (ESWT) is a non-invasive procedure that delivers high-energy sound waves to the painful area. This mechanical energy promotes blood flow, breaks down scar tissue, and stimulates the body’s natural regenerative processes to heal the damaged fascia.
Platelet-Rich Plasma (PRP) injections offer a regenerative approach using the patient’s own blood components. Blood is drawn and spun to concentrate platelets, which contain numerous growth factors, and then injected directly into the degenerated tissue under ultrasound guidance to jump-start the repair process. Corticosteroid injections provide rapid, short-term pain relief by reducing local inflammation, but their use is limited due to the risk of fat pad atrophy or fascia weakening. Specialized physical therapy incorporating high-load strength training is also used to build the load capacity of the fascia and supporting foot muscles.
When Surgery Becomes Necessary
Surgery is considered an option of last resort, typically reserved for individuals with persistent, severe heel pain for a minimum of six to twelve months after exhausting all non-surgical methods. The primary surgical procedure is a Plantar Fascia Release, or fasciotomy, which aims to relieve tension by partially cutting the tight fascia near its attachment to the heel bone.
This procedure can be performed using an open technique (involving a larger incision) or an endoscopic technique (utilizing a small camera and instruments through tiny incisions). The minimally invasive endoscopic approach generally offers a faster recovery time and less post-operative pain. Recovery involves a gradual return to weight-bearing, with most patients returning to normal activities within six to ten weeks. Potential complications include nerve damage or a long-term change in the foot’s arch mechanics.