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Heel Pain (Plantar Fasciitis)

Overview

The plantar fascia is a thick ligament on the bottom of your foot. If it is repeatedly overstretched, it can become inflamed and painful, a condition we call plantar fasciitis. This common condition is not serious, but it can be uncomfortable.

The plantar fascia is a strong ligament that runs the length of your foot from the heel bone to the toes. Although it is strong, it is not very elastic, so repeated movements, such as running, can overstretch it and partially tear or pull it away from the heel bone. The plantar fascia can also overstretch or tear at the arch.

Usually, the symptoms begin gradually, but after several weeks, the pain gets worse and does not diminish. Generally, there is no swelling or bruising in the area. However, you may feel tenderness when you apply deep pressure to the heel pad or the arch.

Symptoms

Plantar fasciitis causes a number of symptoms that include:

• Sharp, stabbing pain on the bottom or side of the heel or in the arch of the foot.
• Pain that is worse in the morning or after any period of inactivity. As you begin to move around, the pain level usually improves.
• Pain that gets worse after a prolonged period of standing, walking, or running.

Pain can last for several weeks or months and can range from mild to severe. Plantar fasciitis will likely go away on its own, with rest, but it may take several months or longer to resolve completely. There is treatment to help you recover faster.

Screening and Diagnosis

We usually diagnose plantar fasciitis by asking you about your symptoms and physically examining your foot. We may order an imaging study, such as an X-ray, if we suspect that your symptoms may be caused by another condition, such as a stress fracture, but this is rare.

Causes

Excessive strain on the plantar fascia causes plantar fasciitis. Over time, this strain can tear the plantar fascia. Repeated stretching and tearing causes pain and inflammation. You may feel pain where the plantar fascia attaches to the heel bone, on the side of your heel, or in the arch area of your foot.

Risk Factors

There are a number of factors that can increase the likelihood that you will develop plantar fasciitis including:

• Excess weight. Carrying extra weight increases the load on the plantar fascia and your foot as a whole.
• Specific sports activities. Activities that put significant pressure on your foot and require it to stretch repeatedly increase your risk. These activities include running, walking long distances, jumping, tennis, basketball, and aerobics. 
• Age. Middle-aged people, between 40 and 60 years old, are more likely to develop plantar fasciitis.
• Abnormal foot mechanics. Flat feet or high arches can affect the way that pressure is distributed across your foot, placing additional stress on the plantar fascia.
• Tight Achilles tendon and excessive flattening of your feet (pronation). The Achilles tendon links the calf muscle to the back of the heel. A tight calf muscle and Achilles tendon can cause your foot to flatten further, placing additional stress on the plantar fascia.
• Standing all day. Standing or walking on hard floors for a long time increases the load on your plantar fascia.
• Inadequate footwear. Excessively flat shoes that do not support your arch leave the plantar fascia unprotected. A shoe with a medium heel can heighten the arch and decrease stress on the plantar fascia.
• Sudden change in activity. Beginning an exercise program, such as high-impact aerobics, after a period of inactivity can overload the structures in your foot. Similarly, changing your running surface from grass to road can affect your plantar fascia.

Prevention

There are a number of things you can do to protect your feet and prevent injury to your plantar fascia:

• Wear supportive shoes. We recommend running shoes or "pro" walking shoes. It's a good idea to wear these when you are running or walking a long distance or when you will be on your feet for an extended period of time.
• Wear shoes with slightly higher heels. A moderate heel can shorten the arch, reduce stress on the plantar fascia, and lead to a reduction of pain.
• Do not walk barefoot, even at home.
• Lose weight. Talk to your personal physician about weight management. We have a wide range of resources, including classes that can help you eat healthily and lose weight.
• Stretch. It is important to warm up before you exercise. Stretching your calf muscles will help protect your Achilles tendon, which in turn will ensure that your feet land correctly during walking and running.

Treatment

It may take 3 to 12 months for your plantar fascia to heal completely. Treatment can help your foot heal faster. We recommend using a number of treatment approaches simultaneously, including home treatments and medical treatments. It is important that you continue treatment until you have been pain-free for at least 3 months.

The majority of people with plantar fasciitis recover within 3 to 9 months without the need for more aggressive treatment. In rare cases (less than 1%), surgical treatment may be considered.

Home Treatment

Rest

Rest your foot for 2 to 6 weeks. Stand, walk, or run less. 

Change your activities

While your foot is resting, try exercise that does not stretch your arch, like swimming or cycling.

Choose footwear that supports your foot

Shoes and devices that support your foot can help protect your plantar fascia and allow it to heal. We recommend a combination of the following footwear and devices:

• Supportive shoes. Wear shoes with good arch and heel support. A higher heel may also help. Avoid standing or walking barefoot or in unsupportive shoes like slippers or sandals.
• Arch supports. Wearing arch supports inside your shoes reduces strain on the plantar fascia. We recommend the semirigid arch supports that are available at all of our pharmacies. 

Use over-the-counter pain relievers 

• Over-the-counter (OTC) nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen or naproxen, can help manage your pain or discomfort.
• OTC NSAIDs are effective pain relievers that can be used if you have no health conditions that prevent you from taking them. Even though you do not need a prescription for OTC NSAIDs, you should be careful to consult the package so that you take the correct dose.
• Be aware that OTC NSAIDs can interact with other medicines you may be taking and cause problems for people with various medical conditions. 
• These medications can help reduce the pain while your plantar fascia is healing. If they do not seem to be helping, do not continue taking them.
• If you have a complex medical condition, are pregnant or trying to get pregnant, or have been taking OTC NSAIDs and they do not relieve your symptoms, please let us know so that we can recommend an alternative.

Ice your foot

Massage the painful area with ice for 2 to 3 minutes, several times a day. 

Stretch

Stretch your calf muscles and Achilles tendon. It's important to stretch before and after you exercise. We recommend that you  warm up a little and then stretch at the beginning of your exercise program, if possible.

Nonsurgical Medical Treatments

If the home treatment methods do not completely resolve your symptoms, we may recommend additional treatments that may include:

Cortisone injections

We may recommend a cortisone injection to reduce inflammation and accompanying pain. Cortisone is a steroid that mimics natural hormones that reduce inflammation. 

Custom orthotic insoles

• If standard inserts are not effective, we may recommend custom orthotic inserts that are made specifically for your foot. 
• We make a cast of your foot in order to create these inserts. 

Surgery

Nonsurgical treatments are effective for most people. However, if your symptoms are severe and other treatments have not worked for at least 6 to 9 months, plantar fascia release surgery may be an option.

Plantar fascia release surgery

Plantar fascia release surgery involves cutting part of the plantar fascia in order to relieve some of the tension on the ligament. 

We may perform the surgery using tiny incisions (endoscopic surgery) or a traditional open incision on the bottom of your heel. Both types of surgeries are performed in our outpatient surgery center, and you will be able to go home the same day.  

Recovering from surgery

Most people recover within 4 to 12 months. You will need to wear a walking cast for several weeks after surgery. We will also advise you to use foot orthotics after the surgery on an ongoing basis.

Risks and complications

For most people, this surgery is successful and their pain is significantly reduced. However, as with any surgery, there are a number of potential risks and complications that we will discuss with you before your surgery. These include:  

• Nerve injury
• Prolonged recovery
• Continuing or worse pain, including pain on top of the foot
• Lowered arch

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