Plantar Fasciitis

What is Plantar Fasciitis?

Plantar fasciitis is one of the most common conditions causing heel pain. The condition involves inflammation of the plantar fascia -- a tough, fibrous band of tissue that runs along the sole of the foot with attachments to the heel bone (calcaneus) proximally and to the base of the toes distally. The plantar fascia provides support to the arch of the foot and has an important role in normal foot mechanics during walking. Tension or stress in the plantar fascia increases when one places weight on the foot (such as with standing) and as one pushes off on the ball of the foot and toes -- motions which occur during normal walking or running.

Inflammation and pain start in the fascia either as a result of an increase in activity level (as in initiating a walking or running program), or in association with the normal aging process. With aging, the fascia loses some of its normal elasticity or resilience and can become irritated with routine daily activities. Less commonly, plantar fasciitis can develop in association with general medical conditions such as lupus or rheumatoid arthritis.

What are the symptoms of Plantar Fasciitis?

The pain associated with plantar fasciitis is typically gradual in onset and is usually located over the inner or medial aspect of the heel. Occasionally, the pain will be sudden in onset, occurring after missing a step or after jumping from a height. The pain is commonly most severe upon arising from bed in the morning, or after periods of inactivity during the day. Thus, it causes what is known as "first-step pain." The degree of discomfort can sometimes lessen with activity during the course of the day or after "warming-up", but can become worse if prolonged or vigorous activity is undertaken. The pain is also often noted to be more severe in bare feet or in shoes with minimal or no padding at the sole.

How is the diagnosis of Plantar Fasciitis made?

Plantar fasciitis is one of many conditions causing "heel pain". Some other possible causes include nerve compression either in the foot or in the back, stress fracture of the calcaneus, and loss of the fatty tissue pad under the heel. Plantar fasciitis can be distinguished from these and other conditions based on a history and examination done by a physician.

It should be noted that heel spurs are often inappropriately thought to be the sole cause of heel pain. In fact, heel spurs are common and are nothing more than the bone's response to traction or pulling-type forces from the plantar fascia and other muscles in the foot where they attach to the heel bone. They are commonly present in patients without pain, and frequently absent from those who have pain. It is the rare patient who has a truly enlarged and problematic spur requiring surgery.

What is the treatment for Plantar Fasciitis?

The treatment of plantar fasciitis is relatively simple, yet it may take 6 to 12 weeks or more for symptoms to resolve. In general, the longer symptoms have been present and the more severe the pain, the longer the condition may take to respond to treatment. Additionally, high demand athletes, such as cross-country or marathon runners may require a longer course of treatment to achieve resolution of symptoms. The key components to treatment are as follows (all may not be recommended by the physician in every patient):

Rest and activity modification: decreasing distances and duration of walking or, particularly, running; switching from jumping or running activity to activities such as swimming or cycling to reduce the stress on the foot; changing the exercise surface (e.g. from concrete to grass)

Massage: local, deep massage to the area of pain at the heel (where the fascia attaches); usually done in the morning after a warm bath or shower.

Stretching: most important; requires routine, daily stretching of the heel cord and plantar fascia to help stretch and "recondition" the tight structures

Anti-inflammatory medications: includes aspirin and other medications such as ibuprofen (Motrin, Nuprin, Advil, etc), Naprosyn, Aleve, Voltaren, Lodine, etc. (all known as "nonsteroidal anti-inflammatory drugs")

Proper shoe wear: shoes must be comfortable; this usually means no or a minimal heel and a well-cushioned sole; rigid arch supports or orthotics should be avoided (they only increase pressure on the inflamed fascia); may consider using padded inserts (ie; Spenco heel pads)

Night splints: useful in patients for whom the pain is not responding to other measures; a splint is fashioned by the therapist to essentially maintain a gentle, constant stretch across the sole of the foot at night while sleeping.

Once the pain resolves or demonstrates a response to the above measures, a gradual return to increased levels of activity should occur. It is important to continue the stretching protocol: make it a habit!

Are steroid injections helpful?

The majority of cases will resolve with the above treatment measures, provided that they are faithfully followed. In the rare, persistent case, the use of a local steroid injection may be considered. Local steroid injections are not without potential complications. Most significantly, they can cause wasting or loss of the fatty tissue pad at the bottom of the heel. This can lead to a painful condition that cannot be easily reversed or treated.

Is surgery ever indicated?

It is only in the extremely rare case that consideration of surgical intervention is necessary. Surgery consists of an incision over the inner aspect of the heel of the foot with release of the involved fascia from its attachment to the heel bone. Recovery generally takes 6 to 10 weeks before walking is comfortable. It may be several months before one can return to athletic activity.

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