Heel Pain & Plantar Fasciitis
diagnosis and treatment information

The image to the right demonstrates a foot in a pronated position. Some pronation during walking is normal, but over-pronation can over stress the arch and hence the plantar fascia. Individuals who overpronate are at risk of developing plantar fasciitis and other types of foot problems. When over pronation is combined with a soft, flexible and unsupportive shoe, the plantar fascia becomes strained and is at risk for small tears. These small microscopic tears cause small levels of inflammation, the plantar fascia weakens and then is at risk for further tearing. The cycle repeats itself as long as the fascia is strained. It is very common for plantar fasciitis to develop after starting a new job or a new activity. Although restarting a regular running routine may not seem like overuse, with abnormal motion and unsupportive shoe gear, the plantar fascia is over stressed. A day spent in the garden in a old, worn out pair of tennis shoes, a long walk on an uneven trail, a day spent running around the airport in work shoes, carrying luggage or a new job that requires standing on a concrete surface in soft shoes can all strain the plantar fascia and cause plantar fasciitis to develop.

A heel spur may show on X-ray, but the existence of a heel spur does not necessarily mean the individual will experience heel pain. It's possible to have plantar fasciitis and heel pain and no heel spur. It's possible to have a heel spur and no heel pain. The spur is a result of the traction force from the plantar fascia on the heel bone. The bottom line is that the heel spur is rarely the cause of pain. The pain is the result of tearing and inflammation of the plantar fascia.

Without treatment, the plantar fascia can deteriorate, thicken and become a more chronic problem, more on plantar fasciosis.

Initial Treatments For Plantar Fasciitis

• Eliminate the Aggravating Activity
  Most likely there was not one particular injury or traumatic event that led to the heel pain. But, there was probably some change in your activity or your shoes or your job in the past week or two that has contributed to the development. Attempt to identify the problem and eliminate it.
  
  
• Stop running, jogging or walking for exercise
  Take two weeks and reduce high impact activities to give your foot and arch a rest. Cycling and swimming are excellent low-impact activities.
  
  

• Ice massage your arch and heel
  During the first few weeks the heel can be very inflamed. Icing will help decrease the inflammation. Fill a sports water bottle with water and when frozen, place on the floor and roll your foot over it. Do this for 15 minutes two to three times a day. Another option is to ice directly on the heel with an ice pack for 15 minutes, two to three times a day.

• Arch and calf stretching
  Stretching is one of the key therapies for plantar fasciitis. Stretch your calf and the bottom of your foot multiple times throughout the day. Stretch BEFORE you get out of bed in the morning. One way to stretch is to place a stretch band, belt or towel around the ball of your foot and pull towards you with your leg extended. A plantar fascia specific stretch is shown in the image below. Place your foot on your opposite knee as shown. Grad the toes and pull back. You should be able to feel the plantar fascia. Stretch for one minute before putting your feet down in the morning. Then, stretch for a few minutes every hour throughout the day. More information and diagrams on stretching for plantar fasciitis.

• Take anti-inflammatories medications
  Your doctor may recommend anti-inflammatory medication, such as ibuprofen. Anti-inflammatory medications can be beneficial during the initial inflammatory stage of plantar fasciitis and can help to reduce pain. But, they must be used in conjunction with other treatments, otherwise the pain will simply be masked and after discontinuation of the medication, the pain will return. DON’T TAKE IF YOU HAVE A STOMACH ULCER.

• Use heel lifts or heel cups
  A heel lift in the shoe or a wedged heel shoe is an important treatment because lifting the heel takes stress off the arch. Heel cups will aid in shock absorption and comfort, but mostly symptomtic relief and should not be considered a long term solution to the problem. More on heel cups.

• Use a night splint
  A night splint keeps the plantar fascia stretched out at night, while you sleep. This allows the plantar fascia to heal in an elongated position and helps prevent further tearing. The main problem with night splints is comfort. Some of the rigid night splints can be bulky and difficult to sleep in and some find the soft night splints restrictive. But, even wearing the night splint for a few hours each evening can make a substantial difference. Night splints have been shown to be very effective treatments. More on night splints.

The plantar fascia in a normal stance position

• Place orthotics/inserts in your shoes.
  Orthotics (semi-rigid inserts) are not soft insoles added to the shoe for cushion. Orthotics are designed to control abnormal pronation. Abnormal pronation places excess strain on the plantar fascia and controlling this motion is an important part of treatment. Although some individuals will require custom made orthotics, many people will respond to prefabricated (prefabs) semi-rigid inserts.

It's important that the insert has some rigidity. The orthotic or insert needs to hold the weight of the body - quite a task if you consider how much force is going through the foot when walking. A soft, flexible insole will simply collapse under the foot and do little more than cushion the foot. A more rigid insert will help to support the foot, decrease stress and strain on the plantar fascia and assist in healing. More on orthotics.

• Lose Weight
  This is probably the worst thing someone could hear. Weight loss is difficult enough without excruciating foot pain keeping you immobile. Unfortunately, those with excess weight on their bodies put excess weight through their feet. This increases the strain on the plantar fascia and slows the healing process and increases the chance for recurrence. Losing five or ten pounds can make a difference. More information on weight loss and heel pain.
  
  
• Wear Supportive Shoes
  Thin, flimsy, soft shoes will not only contribute to the development of plantar fasciitis, they will prevent healing of the plantar fascia. Think of the ligament on the bottom of the arch as an injured area of the body that needs to be braced. The area of the shoe supporting the arch should be rigid and help prevent excess strain and stress on the plantar fascia. Check all of your shoes to make sure they are not too flexible. To test this, grab your shoe by the heel and place the toe box on the floor and press down. If the shoe collapses, it is much flexible and is not supportive.

In a supportive shoe with a rigid sole, the shoe will only bend at the toe area. This rigidity helps to support the plantar fascia and minimize midfoot collapse. This decreases the chance of tearing the plantar fascia and helps prevent further re-injury of the fascia. The shoe doesn't need to be a hiking boot or even an athletic shoe, the test above can be done with any shoe. More on choosing shoes. Choosing a running shoe.

• Plantar Fascia Taping
  The goal in taping your foot is to reduce excess strain on the plantar fascia. Taping tends to be more effective when performed by your doctor or physical therapist, but it can be done at home as well. Using tape adherent and 1 inch sports tape, wrap a strap around the foot, starting at the 5th toe joint (5th MPJ), coursing around the heel and then up to the big toe joint (1st MPJ). After three straps are added in this fashion, 3 straps with 2 inch sports tape are used starting on the outside of the foot and wrapping towards the arch. Step by step instructions for plantar fasciitis taping.

Doctor Recommended Therapies

There are many therapies that may be recommended by your doctor.

• Steroid Injections
  A steroid (cortisone) injection is designed to reduce inflammation at the highest point of pain. The steroid is injected right into the area of the most inflammation, at the heel. A steroid injection does not heal the fascia and it does not dissolve heel spurs. Steroid injections work the best in the initial, inflammatory phases of plantar fasciitis and when they are used in conjunction with all the conservative therapies.
  
• Custom made orthotics
  Custom made orthotics are devices which are molded specifically to your feet and designed to control abnormal motion, generally pronation. A mold of your foot is taken by wrapping plaster around your feet or placing your foot in a foam box. The most common type of foot needing a custom made orthotic is a flatfoot.
  
  
• Physical therapy
  Most physical therapists are well trained in treatment of plantar fasciitis because it is so common. Physical therapy may involve ice baths, contrast soaks, specific stretching and strengthening exercises, ultrasound and iontophoresis.
  
  
• Hard casts and Cast Boots
  A cast and crutches or a walking cast boot may be used in some cases of plantar fasciitis. Generally, this step is only used in cases which have not responded to other treatments. The idea is to take all the pressure off of the heel and allow the plantar fascia to heal. This can take 4-6 weeks.
  
  
• Acupuncture
  There are no evidence based studies showing the effectiveness of acupuncture in the treatment of plantar fasciitis. There have been reports of benefits with this treatment, but this is mostly anecdotal. If you do choose to pursue this type of therapy, consider that you are not truly addressing the two main problems, inflammation (initially) and abnormal motion (pronation).
  
  
• Shockwave therapy
  Extracorporeal shockwave therapy (ESWT) is not a new treatment, but has become a popular treatment for plantar fasciitis over the past decade. Shockwaves are sound waves that create vibrations and the vibrations cause controlled injury to the tissue around the heel. The body responds by increasing it’s healing ability at that area and stimulating the repair process. The FDA approved ESWT for the treatment for plantar fasciitis in the year 2000, but it is still a controversial treatment. More information on ESWT.
  
  
• Coblation Therapy
  Coblation Therapy is a bipolar radiofrequency-based technology that stimulates the release of growth factors and formation of new blood vessels to jump start the body's own healing response. Coblation therapy is used for later stages of plantar fasciitis, termed plantar fasciosis.
  
  
• Endoscopic Plantar Fasciotomy (EPF)
  EPF is a minimally invasive surgical treatment for plantar fasciitis. A small camera is inserted into the heel through small incisions and allows the surgeon to visualize the plantar fascia. Surgical tools are inserted through the portal to release the plantar fascia.
  
  
• Open Heel Surgery
  Open heel surgery is usually the last resort as over 90% of patients will improve without surgery. Typically 6-12 months of conservative care is attempted before surgery is considered. This type of surgery usually involves a walking cast, a cast boot or sometimes crutches for 4-6 weeks.
  
  No surgery is free of complications. Complications from either the EPF of the open heel surgery include nerve problems, infection, slow healing, pain on the outside of the foot, tendon rupture, recurrence and foot instability. Although these problems are relatively rare, they should be taken into consideration when undergoing the procedure.