Plantar fasciitis (heel pain): embolization for pain that will not settle

What plantar fasciitis is

The plantar fascia is a thick band of tissue running from the heel bone to the toes, supporting the arch. Overload, tight calf muscles, unsuitable footwear, weight gain or long periods on hard floors can irritate it where it attaches to the heel. The result is sharp heel pain, typically worst with the first steps after rest and after long standing, and a thickened fascia on ultrasound or MRI.

Usual treatment first

Treatment begins with calf and plantar fascia stretching, supportive shoes or heel cups and orthoses, activity changes, weight loss when needed, and anti-inflammatory medicines. If pain continues, options include steroid or other injections and shockwave therapy. Many people settle with these steps over months. Embolization is only for those whose pain remains disabling after at least three months of proper treatment.

How embolization is thought to work

In long-standing plantar fasciitis, the fascia near the heel contains abnormal small vessels and nerve fibres. Embolization uses a catheter, usually from the groin, guided to branches of the posterior tibial artery that supply the painful area, and closes them with a temporary agent such as imipenem/cilastatin or with resorbable particles. The aim is to reduce inflammation and pain at the heel ^{[1, 2]}.

How the procedure is done

The procedure takes about 45 to 90 minutes and is done as day-care.

• An ultrasound or MRI confirms the diagnosis, for example a thickened plantar fascia, and rules out other causes of heel pain such as a stress fracture or nerve entrapment.
• Under local anaesthetic, a catheter enters an artery at the groin and is guided to the arteries of the lower leg and foot under X-ray.
• Contrast dye shows a blush around the heel, and the feeding branches are closed using a microcatheter.
• The catheter is removed, and you walk out the same day, with advice on gradual return to activity.

What the studies show

Evidence is limited to small, mostly retrospective series. In a series of 12 patients with plantar fasciitis refractory to conservative treatment for at least 3 months, super-selective embolization with imipenem/cilastatin was technically successful in 11 (91.7%), with pain falling from an average of 7.4 to 2.3 out of 10 by the next day and a low adverse event rate ^[1]. In another series of 41 feet in 34 patients, embolization with resorbable agents gave a meaningful improvement (more than 20%) in the foot function score in 70%, 68.7% and 91.6% at 1, 3 and 6 months. Neither study had a control group.

Who may be considered

Embolization is a selective option.

• Plantar fasciitis confirmed by examination and imaging, with thickened fascia.
• Disabling heel pain that has not improved after at least three months of stretching, footwear changes and other proper treatment.
• Not suitable: active infection, serious contrast allergy, poor kidney function, pregnancy, severe artery disease or poor circulation in the leg, or another cause of heel pain.

Risks

Reported effects are bruising at the puncture site, short-lived soreness or numbness at the foot, and skin changes. Because the treated arteries lie in the lower leg and foot, closure of a non-target artery is a theoretical concern, and one case of a lower-leg artery blockage after embolization through a retrograde tibial (lower-leg) approach has been reported ^[3]. The team explains your individual risks and chooses the approach to reduce them.

Cost and insurance

The cost depends on the procedure, the embolic material used and the day-care facility, and is explained after consultation and a review of your scans. Because these treatments are newer, insurance cover varies between policies and is checked before the procedure, and it is never assumed. Please ask the team for the specifics of your policy.