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Heel Pain and Plantar Fasciitis



diagnosis :: treatments ::  stretching ::  images ::  fasciosis
other causes :: taping :: shoes :: doctors office :: research :: blog post


Area of heel pain circled in plantar fasciitis

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. More discussion on morning heel pain.

Although this is the classic description of plantar fasciitis, it is not the only presentation of this condition. 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.”  

What is plantar fasciitis?

 Anatomy of the plantar fascia showing all three bandsPlantar fasciitis is the tearing and inflammation and subsequent degeneration of the fascia, a long ligament type structure in the bottom of the foot. This is a result of small microtears in the fascia. More details on tearing of the plantar fascia. A spur can develop as a result the traction force from the fascia, but the heel spur is rarely the cause of pain. The initial phases of plantar fasciitis are inflammatory, involving pain and swelling. As the condition progresses and becomes chronic, the inflammation slowly disappears and the plantar fascia starts to deterioriate, becoming a condition called plantar fasciosis. More information on plantar fasciosis.

The plantar fascia is composed of dense, highly organized collagen fibers and is an extremely strong connective tissue band spanning the bottom of the foot. In the image to the right the plantar fascia is shown. 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 to the toes. The fascia inserts into the base of the toes and the flexor tendons on the bottom of the foot. More detailed information on the structure of the plantar fascia.
  
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.

 

Infracalcaneal heel spur shown on X-ray Heel spur oulined on X-ray

 

Plantar fasciitis is not the only cause of heel pain. Other causes of heel pain include, but are not limited to neuritis, nerve entrapment, bone tumor, stress fracture, sciatica, tarsal tunnel syndrome. More information on causes of heel pain.

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Why does plantar fasciitis happen?

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 over pronation. Pronation is the motion of the heel rotating out, the arch collapsing and the forefoot rotating outward. In the diagram below and to the left, the right foot is pronated. The rotation at the rearfoot contributes to arch collapse and stress on the plantar fascia. Mouse over the image on the right to see how pronation contributes to stress on the plantar fascia.

Pronation image showing rotation of heel in and foot outward

Pronation causing arch collapse which stresses the plantar fascia

Pronated Right Foot mouse over image to see arch collapse and stress on the fascia

 

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 on a new type of surface 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.

Once the fascia is weakened, it tears more and then it becomes more inflamed, and then tears more. The constant weight of the body on the feet puts a tremendous force load through the feet. Think of how many steps you take throughout the day on your feet. Think of how many steps you take on your feet in the morning before you leave for work. Each step is on an injured foot. Detailed discussion of the tearing of the plantar fascia.    

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 term this condition plantar fasciosis instead of plantar fasciitis, because "itis" means inflammation. More details on the breakdown of the plantar fascia.

Some conditions 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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How Is Plantar Fasciitis Diagnosed?

The history is the most important tool for diagnosis of plantar fasciitis. On exam, the patient usually has pain with palpation (pressure) at the inside of the heel, and sometimes along the inside of the arch. These two points are the portions of the fascia under the greatest stress, and these areas have the most pain because they have the most inflammation (swelling at a small level).

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. Although these are usually not common, they do need to be ruled out. Also, the X-ray will allow the doctor to better assess the position of the foot. The X-rays should be taken while standing. Ultrasound is becomming a more popular diagostic tool to evaluate the thickness of the fascial band. 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:

    1. Decrease your 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. 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 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.
      Heel lift elevating the heel and taking pressure off the arch in plantar fasciitisIn combination with the other therapies mentioned above, heel cups and heel lifts can be beneficial. Heel lifts take pressure off of the arch, the fascia and the calf. Heel cups help to cushion the heel and provide shock absorption to limit the impact on a painful heel. 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. Strassburg Sock product review and research summary.


      For a rigid, plastic night splint, try the Langer Comfort Night Splint. For a softer night splint, try the Strassburg Sock or the Thermoskin Plantar FXT.

      Strasburg Sock soft night splint for plantar fasciitis

      Langer Comfort Night Spint for Achilles tendonitis and plantar fasciitis

      Thermoskin Plantar FXT Nightsplint Arch Stretch Diagram

      Strassburg Sock Comfort Night Splint Thermoskin Plantar FXT

      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, look at the images below.


      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, specifically stretching the plantar fascia.

    7. Place orthotics 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, 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.


      Prolab orthotics are the 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. The posted orthotic is shown here.

      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 here. 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

      Arch Molds heat moldable lean insole

      Prolab Posted Orthotic Superfeet Green Insoles ArchMolds Moldable Insoles

      Anatomy of a custom made orthoticIf you have severe flatfeet or chronic plantar fasciitis, it is recommended that you see a podiatrist for custom made orthotics. 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.

    1. Try Taping
      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 on taping.    

      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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This page was last updated 05/13/12

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.