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Heel Pain and Plantar Fasciitis

 

Plantar fasciitis overview Plantar fascia anatomy Causes of Plantar Fasciitis Heel pain: diagnosing plantar fasciitis Heel pain: treatments you can do at home Heel pain: what to expect at the doctor's office

 

Heel Pain Overview

There are many causes of heel pain, such as stress fracture, fascia rupture, heel bursa, nerve entrapment, bone tumor or pain radiating from the low back. By far, the most common cause for heel pain is plantar fasciitis (plan –TAR   fash – ee – I – tis). This condition is classically known for causing pain in the heel at the first step in the morning. The pain can be so severe that many will limp, or grab onto a wall, in order to make their way to the bathroom. After thirty minutes or so, the pain tends to work itself out. This is classically described as morning heel pain. Pain will also occur upon standing, after long periods of sitting. Plantar fasciitis is essentially, the tearing and inflammation and subsequent deterioration of a long ligament type structure in the bottom of the foot.

Area of heel pain circled in plantar fasciitis

 

Although this is the classic description of plantar fasciitis, it does not always present in this fashion. Some individuals will only experience pain in their heel when they run, walk or hike. Others will only experience pain in the arch after long periods of standing. Many people will complain only of pain in their heels at the end of a long workday. Classic descriptive terms for plantar fasciitis include stone bruise, sharp dagger, deep throbbing and dull ache. These all represent plantar fasciitis type pain. Another name for this condition is “heel spur syndrome” even though a heel spur is rarely the cause of pain. 

Plantar Fascia Anatomy

The plantar fascia is a long band that extends across the bottom of the foot. The fascia is much like a ligament, composed of dense, highly organized collagen fibers. It is an extremely strong connective tissue band spanning the bottom of the foot.

In the image to the right the plantar fascia is shown on the bottom of the foot. There are three parts to the plantar fascia, the medial band, the central band and the lateral band, all seen here in the plantar fascia diagram. The plantar fascia originates on the bottom of the heel bone, called the calcaneus, and extends out to the toe joints, on the bottom of the foot. More information on the structure of the plantar fascia.

Anatomy of the plantar fascia showing all three bands

 

Causes of Plantar Fasciitis

Plantar fasciitis is caused by small, microscopic tears in the fascia. These tears develop as a result of repetitive stress. This means that there is excess pull and stress on the fascia which results in tiny tears. It only takes a small change in activity or change in shoes to cause microscopic tears in the plantar fascia. A change in activity could be running more on hills or starting the soccer season. But, it commonly occurs when walking in a pair of poor quality shoes, such as flimsy sandals or an old pair of gardening shoes. It's common to develop heel pain after traveling and wearing an unsupportive pair of shoes when walking around the airport. Even working at a new job on your feet or standing all day on a hard floor, in a new type of shoe can easily contribute to the development of microscopic tearing in the plantar fascia. Plantar fasciitis is not something that develops after working on your feet for years. In fact, someone working at a desk job for 25 years who switches to a job on their feet is much more likely to develop the problem.  There are multiple factors that contribute to it's development. The factors that increase risk are shown below.
Close up image of tearing and inflammation in plantar fasciitis

 
Risk Factors

The risk factors which can increase the chances for developing plantar fasciitis include:

  • age: plantar fasciitis can affect persons of all ages, but ages 40-60 are the most common.
  • occupation: jobs which involve spending long periods of time standing and walking increase risk.
  • sports: running, dancing
  • surface: the harder the surface you work on or play sports on, the greater the risk
  • weight: being overweight increases the risk of development
  • faulty foot mechanics: extreme foot types, such as flatfeet, high arch feet or overpronation

 

Heel Spurs

A spur can develop as a result the traction force from the fascia, but the heel spur is rarely the cause of pain. In the X-rays shown here, heel spurs are seen on the bottom of the heel bones. The heel spur on the X-ray on the left is quite large, but this individual has never experienced any heel pain. The existence of a heel spur on the bottom of the foot does not necessarily mean the individual will experience heel pain. Many individuals with heel pain and plantar fasciitis, will not have a heel spur. The heel spur does not cause the heel pain. Heel spur oulined on X-ray

 


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Foot Mechanics

 

Most individuals who develop plantar fasciitis have faulty foot mechanics or some type of abnormal motion in their feet. The most common abnormal motion is overpronation. Pronation is the motion of the heel rotating out, the arch collapsing and the forefoot rotating outward. The rotation at the back of the foot contributes to arch collapse and stress on the plantar fascia. Mouse over the image on the right to see how pronation and the resultant foot collapse contributes to overstress of the plantar fascia.

Pronation causing arch collapse which stresses the plantar fascia

 

 

Plantar Fascia Degeneration

Like any injury, these tears stimulate the body's healing response and initially, inflammation occurs. With inflammation comes pain, usually at the first step in the morning and almost always by the end of a long day. After weeks of repetitive aggravation of the torn fascia and the body's failed attempt to heal the injury, the fascia begins to wear down and unravel. This is called plantar fascia degeneration or deterioration.  The initial phase of plantar fasciitis is inflammatory, involving pain, warmth and even some swelling. The later stages of the condition are degeneartive and the condition is called plantar fasciosis.

To better understand plantar fascia degeneration, let's start with collagen, the main component of the plantar fascia. The structure of collagen, which is called a triple helix, looks like braided rope, shown in the image to the right.  As the condition progresses over weeks to months, the inflammation slowly disappears and the plantar fascia starts to gradually, on a very small microscopic level, unravel. You can think of the fascia, like a rope being constantly stressed and eventually torn and frayed. Microscopic tears lead to fraying, which leads to weaking of the fascia, which leads to more tearing, more fraying and more unraveling. 
When the fascia deteriorates, it's similar to a rope fraying


Once the inflammation diminishes and the unraveling begins, the condition progresses to plantar fasciosis. The image below represents the collagen triple helix (braided rope), slowing unraveling and then breaking apart. Remember, this happens gradually over time, on a microscopic level. This is very different than a complete tear, called a plantar fascia rupture, which happens suddenly. 

Representation of collagen unwinding to demonstrate the plantar fascia degenerating

 

When the foot is injured, the injury becomes worse with each step. A vicious cycle develops. This makes the condition very difficult to treat. As the heel pain progresses, the inflammation dissappears, the plantar fascia thickens and starts to degenerate (deteriorate). Many would like to eliminate the term plantar fasciitis and replace it with plantar fasciosis, because "itis" means inflammation. More details on the breakdown of the plantar fascia.

Some conditions that contribute to the development of plantar fasciitis or mimic the symptoms of plantar fasciitis, such as ankylosing spondylitis, Reiter's syndrome, psoriatic arthritis and rheumatoid arthritis. Hypothyroidism has been linked to chronic musculoskeletal conditions and more recently, heel pain. More discussion on hypothyroidism and plantar fasciitis.


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Plantar Fasciitis Diagnosis

Patient history is the most important tool for diagnosis of plantar fasciitis. Gradually onset of pain on the bottom of the heel, generally toward the inside of the arch, which is sharp or dull with walking and achy at rest, worse at the first step in the morning, or getting up after long periods of rest, is almost diagnostic for plantar fasciitis. On exam, the patient usually will have pain with palpation (pressure) at the inside of the heel, sometimes it will make a person jump or even bring tears to the eyes when it is very inflamed. There is occassionally pain at the back of the heel or along the inside of the arch. The inside of the heel is the origin of the plantar fascia and the area that is under the greatest amount of stress. This areas is generally the first to tear and weaken, and therefore have the most pain.

X-rays are generally (but not always) taken to rule out other conditions. Some of these conditions are stress fractures, bone tumors (usually benign) and fractures of the heel spur. These conditions are not common. The X-ray will allow the doctor to better assess the position of the foot. The X-ray will show if there is a bone spur, but remember, the spur is not the cause of pain. Ultrasound is becomming a more popular diagostic tool to evaluate the thickness of the fascial band. A thickened fascia is diagnostic of plantar fasciitis. The image to the right shows a normal plantar fascia band on ultrasound.
The plantar fascia and heel bone as shown on ultrasound

An MRI is not necessary for diagnosis of plantar fasciitis. In most cases, an MRI is only needed to rule out other conditions, but can be used to evaluate the level of inflammation or the thickness of the fascial band.


Treatments For Plantar Fasciitis

The treatments for plantar fasciitis are usually conservative. The following is a list of initial steps in the treatment of early plantar fasciitis.

Home Therapy

    1. Decrease the aggravating activity
      Stop running, jogging or walking for exercise. Try biking or swimming. Avoid hills and minimize walking up and down stairs. Try not to carry any heavy items. More about decreasing activity. Ideas for athletes.

    2. Ice water bottle roll for plantar fasciitisIce massage your arch and heel
      Fill a sports water bottle with water and when frozen, place on the floor and roll your foot over it for 15 minutes at least twice a day. This will ice massage the arch, decreasing inflammation along the plantar fascia. Another option is to ice directly on the heel with an ice pack for 15 minutes, two to three times a day. The more icing the better. Icing 10+ times a day in the initial stages of plantar fasciitis will accelerate healing.    

    3. Stretch! Stretch! Stretch!
      Stretch the plantar fascia with a stretch bandThis is one of the most important treatments. Try to stretch your calf and bottom of your foot multiple times throughout the day. Stretch your calf BEFORE you get out of bed in the morning. Take a stretch band, belt or towel and place it around the ball of your foot and pull towards you with your leg extended. Stretch for a few minutes every hour throughout the day.    
       
      Perform a plantar fascia specific stretch. To perform this stretch, place your foot on you opposite knee. Grab your heel with the opposite hand. Use the other hand to pull back at the toes, especially the big toe. You should be able to palpate the plantar fascia, which will be the tense band on the inside of the arch as shown in the images below. Hold the stretch for 10 seconds and repeat 10 times. This should be performed 3 times a day. More information on stretching. Stretching needs to be continued over a period of time, short term stretching has not been shown to be beneficial. More on this study.

      A plantar fascia specific stretch involves pulling back the toes

      Palpating the plantar fascia in the plantar fascia specific stretch

       

    4. Take anti-inflammatories/NSAIDS
      NSAIDS stands for non-steroidal anti-inflammatory medications, for example ibuprofen or naproxen. This is not a mandatory step. Many individuals will improve without taking any anti-inflammatory medication. DON’T TAKE IF YOU HAVE A STOMACH ULCER. It's important to realize that NSAIDs increase the risk of stomach ulcer, bleeding, kidney disease and heart disease. It's important to realize that anti-inflammatory medications can mask the pain. If you take anti-inflammatory medications (over the counter or prescribed by your doctor) and do not make any other changes and do not try any other treatments, you will most likely get worse. It is also important to note that most cases of plantar fasciitis only are inflammatory during the first few weeks after the development of heel pain. In many cases the condition cycles between inflammatory and non-inflammatory because of reinjury. The condition then gradually progresses to deterioration of the plantar fascia, hence the term plantar fasciosis. This can occur between 4-12 weeks, but the exact point is variable and has not been well defined. At this point, the condition won't respond to anti-inflammatory medications.

    5. Try heel lifts or heel cups
      In combination with the other therapies mentioned above, heel cups can help take the pressure of the heel and aid in shock absorption. They are typically better in the initial/inflammatory phase of plantar fasciitis. A heel lift, or a wedged heel shoe can also be beneficial. A heel lift or wedged heel shoe will take pressure off of the arch, the fascia and the calf. Try at least a ¼ inch heel lift. Any type will work, but foam seems to be the most comfortable. For individuals with very sore heels, for those who complain of their heel feeling like a “stone bruise” heel cups will provide relief. Tuli’s heel cups provide a lift and help take pressure off of the heel and arch while providing shock absorption. Heel cups generally work best in the early phases of plantar fasciitis when the heel is very inflamed and very tender. Heel cups provide symptomtic relief and should not be considered a long term solution to the problem.   

    6. Use a night splint.
      A night splint stretches out the plantar fascia while you sleep. Imagine that! Doing therapy while you sleep. When night splints work well, they reduce all of the morning pain and accelerate the healing of the plantar fascia, decreasing overall healing time. In some patients they are the key to treatment. The main problem with night splints is comfort. Many patients have difficulty sleeping in a splint. If you have trouble sleeping, then the night splint may not be right for you. But, many patients will wear a night splint in the evening for a few hours instead of sleeping in it. This is a considerable amount of stretching and can be extremely beneficial for therapy. The splint in the image to the right is an example of an anterior night splint. Insurances may cover a night splint if it is dispensed from a doctor's office.
      Anterior night splint for plantar fasciitis

      Night splints help improve plantar fasciitis by keeping the plantar fascia stretched out during the night. This allows the plantar fascia to heal in a lengthened position. To better understand how the night splints work, such as the Strassburg Sock, check out the images below. The final picture illustrates what a sock type night splint will do when the ankle is held at 90 degrees and the toes are pulled up.

      Plantar fascia relaxed at night in a plantar flexed position

      Plantar fascia tightened and contracted during sleep

      Tear in the plantar fascia in the morning causing heel pain

      Plantar fascia lengthened in a night splint to accelerate healing

      When we fall asleep, the foot relaxes which puts the Achilles tendon and the plantar fascia in a relaxed position.  The plantar fascia starts to contract to a shortened and tighened position during the night. At the first step in the morning, the tightened plantar fascia tears, causing pain at the bottom of the heel.
      The night splints hold the foot at 90 degrees during the night. The socks pull up the toes, stretching the plantar fascia.

    7. Place orthotics/inserts in your shoes
      Orthotics are not insoles. Insoles are generally soft and cushy supports which slip into the shoe and add comfort and cushion. They are great for that purpose, but will not help treat plantar fasciitis. The stress on the fascia needs to be decreased to allow the fascial band to heal. More rigid inserts and custom made orthotics will help do this. Many people will respond to prefabricated (prefabs) semi-rigid inserts. The research on the use of custom made orthotics for the treatment of plantar fasciitis has been mixed. More discussion on orthotics for plantar fasciitis.

      In the images below, the picture on the left shows the foot everted (pronated) as represented by the rotation at the heel and collapse at the midfoot. The angle of the heel and ankle can be seen by the line drawn, but also by the Achilles tendon. In the image on the right, a posted orthotic is holding the heel in position, aligning the heel and preventing arch collapse. This minimizing the stress on the plantar fascia.

      The orthotics shown in the image are Prolab orthotics, which are an off the shelf, prefabricated orthotic, which most closely matches a custom made orthotic. They are semi-rigid, designed to control motion and are available in posted (more motion control) and non-posted inserts. These can be obtained at many podiatrist offices.

      Pronation picture showing rotation and collapse of heel and midfoot Pronated foot in a corrected position with the Prolab Posted Orthotic

               
      Superfeet orthotics have a shock absorbing heel and supportive midfoot bed and help to decrease the stress on the fascia with each step. These prefabricated orthotics are also designed to control motion, but are a little more forgiving. The Superfeet green sport orthotics are shown below in the center and can be ordered online. Arch Molds have a deep heel cup, aggressive arch support and are heat moldable. Both help to control motion and decrease stress on the plantar fascia. Arch Molds Video.
           
           

      Prolab posted orthotics to control abnormal motion

      Superfeet Green Insoles control motion and provide arch support

      Anatomy of a custom made orthotic

      Prolab Posted Orthotic Superfeet Green Insoles Custom Made Inserts

      If you have severe flatfeet or chronic plantar fasciitis, it is recommended that you see a podiatrist for custom made orthotics. Custom made orthotics are shown in the image above on the right. They are scanned to an individual foot. The device is semi-rigid and generally has a soft cover.  Summary of research on orthotics for the treatment of plantar fasciitis.

    8. Lose weight. Probably the last thing you wanted to hear! Most people are thinking "How can I lose weight when I can't walk?!" Yes, you are right, it is very difficult to lose weight when you are told to decrease your activity and you are in pain. In fact, most people gain weight when they develop plantar fasciitis. Unfortunately, the increased weight gain puts even more stress through the arch and the heel, making the problem worse.  This is why it is so important to take the necessary steps to lose some weight. Even losing five or ten pounds will make a difference. More information on why weight loss is important for resolution of foot problems and how to take the steps necessary to start losing.

    9. Wear supportive shoes. It's common for those suffering with plantar fasciitis to search for the softest, most flexible shoes because they feel they are more comfortable. Let's face it, your heel is sore and the more cushion means more comfort, right? Wrong! Although some cushion under your heel is ok, your shoes should have a supportive sole which is rigid from the heel to the ball of the foot. The shoe should only bend at the toes, not in the middle. To test this, take your shoe and grab the heel. Place the toe box on the floor and press down. If the shoe collapses, it is much too flexible and should not be worn.

      Shoes flexible versus supportive comparison views  

       

       A shoe which is too flexible will not support the foot when walking. In this image to the right, you can see how the shoe is collapsing under the weight of the body. The foot is also collapsing, at the midfoot area, and excess strain is being placed on the plantar fascia, contributing to tearing and further re-injury.  

      In a supportive shoe with a rigid sole, the shoe will only bend at the toes, which is where the foot should be bending when walking. This helps to minimize midfoot collapse and prevents excess stress through the arch and the heel, decreasing the chance of tearing the plantar fascia and helping to prevent further re-injury of the fascia. The image to the right, the boot is rigid, flexing only at the toes, supporting the arch and preventing excess stress and strain at the plantar fascia.  Supporting the fascia when walking will accelerate the healing process.

      Flexible and unsupportive shoe placing excess stress on the plantar fascia Supportive shoe supporting the plantar fascia

         
      If you developed plantar fasciitis once, you may very well develop it again down the road and a poor quality shoe (or even a poorly designed expensive shoe) can be the aggravating factor. Right now, the poorly designed shoe could be keeping you from improving. More on choosing shoes.

       

    10. Try Taping

        1. Plantar Fasciitis Taping to support the arch and fasciaThe goal in taping your foot is to take some of the stress off of the plantar fascia. Using tape adherent and 1 inch sports tape, wrap a strap around the foot, starting at the 5th toe joint (5th MPJ), back around the heel and to the big toe joint (1st MPJ). More images and instructions on taping for plantar fasciitis.    

          When attaching the tape to the big toe, make sure to press down on the big toe joint - mimic a high arch. Using 2 inch sports tape, start on the outside of the foot and wrap straps along the arch while holding down the big toe joint. You will need at least 3 straps of the 2 inch tape on the bottom and another locking strap around the foot of the 1 inch tape. Taping can be difficult to do on your own, so it may be best to see a podiatrist for this. This is only one of many taping methods.

 

What about massage? Massage can be a useful technique in the treatment regimen for plantar fasciitis, but it can also cause problems when used at the wrong time. In the early stages of plantar fasciitis, when the heel is very tender, massage is not recommended. Massage will only aggravate the area. In the later stages, after a few weeks or even months have passed, massage can help break up any scar tissue and increase blood flow to the area. Deep friction massage is commonly used by physical therapists in the later stages of plantar fasciitis.

If your pain persists after trying the therapy recommended above, make an appointment to see a podiatrist.

Check out our blog, Twenty Tips for Treating Heel Pain.


Heel Pain Treatments at the Doctor's Office

There are a number of treatments which can be done by your doctor or recommended by your doctor. Some of the treatments listed below are still under investigation regarding their efficacy. More details on heel pain treatments at the doctor's office.

  1. Steroid injections
  2. Taping
  3. Physical therapy
  4. Custom orthotics
  5. Hard casts
  6. Acupuncture
  7. Shockwave therapy (ESWT)
  8. Coblation therapy
  9. Platelet rich plasma injections
  10. Cryosurgery
  11. Botox
  12. Dry needling
  13. Endoscopic plantar fascial release
  14. Open heel surgery

More details on each of these heel pain treatments.

 

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last updated 4/22/15

Disclaimer: The advice on this website is not intended to substitute for a visit to your health care provider. We will not be held liable for any diagnosis made or treatment recommended. Consult your doctor if you feel you have a medical problem.