Plantar Fasciitis

By: Tina Shahian, PhD

Last Updated: Mar 1, 2019

Overview

If you hop out of bed in the morning only to be greeted by a stabbing pain in your heel, plantar fasciitis might be the culprit.

Plantar fasciitis is an overuse injury of a ligament called the plantar fascia. This tough band of connective tissue runs the length of your foot, linking your heel bone with your toes. Like the string of a bow, it exerts tension that pulls your foot into a slightly arched shape. This allows the foot to give a little with every step, absorbing shock that would otherwise be transmitted upward through your body.

The plantar fascia can take quite a beating, but when it’s overused, tiny tears begin to form. Over time, this can lead to pain, irritation and swelling of the ligament.

Left untreated, plantar fasciitis may turn into a persistent, long-term condition that keeps you from your normal activities. And the problems don’t stop with your foot. People with heel pain often change the way they step to relieve the discomfort. Over time, this abnormal movement can injure other parts of the foot as well as the knees, hips, and back.

If you are coping with plantar fasciitis, you’re in good company. About 2 million people are treated for this condition every year, making it one of the most common causes of foot pain.

Causes

The biggest risk factors for developing plantar fasciitis are mechanical issues of the legs and feet. These include high arches, low arches, tight calf muscles or tight Achilles tendons. Risk also increases with age, peaking between 40 and 70 years.

Many people associate plantar fasciitis with runners, and these athletes do tend to be more at risk. This is especially true of those who spend a lot of time running downhill or over uneven surfaces. Other sports that stress the heel include ballet, and aerobic dancing.

Footwear also plays a role. Wearing shoes with poor arch support and cushioning can aggravate the fascia. This is especially true for people like teachers or factory workers, who spend a lot of time standing on hard surfaces.

Finally, obesity likely increases the risk of plantar fasciitis by raising the pressure on the ligaments.

Many people with plantar fasciitis also have a heel spur - a bony overgrowth of the heel bone. In the past, this was believed to be a major contributor to the condition. However, research suggests that heel spurs are often painless, and that many people who have them never develop plantar fasciitis.

Symptoms

The first sign of plantar fasciitis is usually mild heel pain (also called a “stone bruise”) that flares up after exercise. In most cases, pain increases slowly over a period of months. However, it can also come on suddenly, especially after a period of intense activity.

Plantar fasciitis pain usually affects the underside of the heel or arch. You might describe it as stabbing, aching, burning and stiff in character. The pain is often most intense in the morning when you first get out of bed. It may also flare up when you’re standing around, climbing stairs, or getting up after a long sit. Walking or exercise may provide temporary relief, but may lead to even worse pain afterward.

Diagnosis

Heel pain has many causes, including stress fractures, tendonitis, arthritis, nerve irritation, and cysts. For this reason, it’s important to get a proper diagnosis of any pain that is bad enough to keep you from your daily activities for more than a week or two. Your primary care physician will likely refer you to a foot specialist (podiatrist) or sports physician for diagnosis and treatment.

In most cases, plantar fasciitis can be diagnosed by a simple history and physical exam. Your doctor will want to know:

• Your pain patterns. Does it change throughout the day? What makes the pain better? Worse?
• Your typical physical activity, including sports and job tasks.
• Any past injuries or foot conditions.

During the physical exam, your doctor will feel your foot to determine the location of the pain and may also check the flexibility of your calf and Achilles tendon. Sometimes imaging tests (MRI or X-rays) are ordered to rule out other conditions.

Treatment

Treatment of plantar fasciitis usually begins with conservative measures, including:

• Rest. You may need to stay off the affected foot for a week so as to promote healing.
• Medication. Your doctor may prescribe non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen to fight pain and swelling.
• Ice. Massaging the painful area with ice for 15 to 20 minutes several times a day feels great and may speed healing. Some people find it helpful to roll the foot over a frozen water bottle.
• Physical therapy. Research suggests that stretching is one of the best things you can do to treat plantar fasciitis. A physical therapist can show you how to stretch your foot and calf muscle safely at home. He or she may also prescribe strengthening exercises to stabilize the foot and lower leg and show you taping techniques for better arch support.
• Casting and splinting. Your doctor may recommend a special “boot” that holds the arch in a stretched position. In some cases, an additional device called a night splint is worn during sleep. This treatment usually lasts a few weeks.
• Shoes and orthotics. People with plantar fasciitis should wear shoes with low to medium heels, arch support, and lots of cushioning. You may also benefit from padding or a soft silicone heel cup worn inside the shoe to provide additional shock absorption. Orthotic devices can be bought over the counter or custom-fitted.

If your plantar fasciitis doesn’t improve after several months of conservative treatment, your doctor may recommend:

• Steroid injections. Steroids are strong medications that can relieve pain for days or weeks when injected near the fascia. However, they also cause weakening of the fascia and shrinking of the fat pad over the heel. For these reasons, they’re rarely used long-term.
• Extracorporeal shock wave therapy (ESWT). During this treatment, a technician uses a device to direct sound waves into the inflamed area of the foot and stimulate healing. Side effects include bruising, tingling, swelling, numbness, and increased pain.
• Surgery. Surgical treatment may be considered in rare cases when pain lasts a year or longer and other treatments don’t help. One option is an operation called a plantar fascia release, which detaches the ligament from the heel bone. This relieves stress on the fascia but also weakens the arch of the foot. Another type of operation called a gastrocnemius recession is sometimes used to lengthen the calf muscle and relieve pressure on the arch.

About 90 percent of plantar fasciitis cases heal within 10 months with conservative treatment only. Most people feel a lot better within two months. However, a complete recovery may take months to years.

People with a history of plantar fasciitis can prevent a recurrence by stretching their feet regularly, exercising wisely, and wearing supportive shoes.

Prevention

Not all cases of plantar fasciitis are preventable. However, there are a few things you can do to promote good foot health:

• Maintain a healthy weight.
• Stretch your feet and calves.
• If you’re starting a new sport, build up slowly to give your body time to adjust.
• Wear soft, supportive shoes, especially when standing on hard surfaces.
• Replace athletic shoes regularly.
• Don’t go barefoot.
• Include low-impact activities such as swimming and bicycling in your exercise program.

Sources

• Diseases and Conditions: Plantar Fasciitis (Feb 2014). Mayo Foundation for Medical Education and Research. Retrieved April 13, 2015 from http://www.mayoclinic.org/diseases-conditions/plantar-fasciitis/basics/definition/con-20025664
• Heel Pain (Plantar Fasciitis). American College of Foot and Ankle Surgeons. Retrieved April 13, 2015 from http://www.foothealthfacts.org/footankleinfo/heel-pain.htm.
• Plantar Fasciitis. American Orthopaedic Foot & Ankle Society; Orthopeadic Foot and Ankle Foundation; and the American Academy of Orthopaedic Surgeons. Retrieved April 13, 2015 from http://www.aofas.org/footcaremd/conditions/ailments-of-the-heel/Pages/Plantar-Fasciitis.aspx/
• Plantar Fasciitis (March 2014). US National Library of Medicine - National Institutes of Health. Retrieved April 13, 2015 from http://www.nlm.nih.gov/medlineplus/ency/article/007021.htm
• Plantar Fasciitis and Bone Spurs (June 2010). American Academy of Orthopaedic Surgeons. Retrieved April 13, 2015 from http://orthoinfo.aaos.org/topic.cfm?topic=a00149.