Plantar fasciitis is the most common cause of heel pain. ‘Plantar’ means the bottom of the foot, ‘fascia’ is a type of body tissue, and ‘itis’ means inflammation.
The plantar fascia is a thick fibrous band of tissue in the bottom of the foot, which runs from the heel to the base of the toes. It forms the arch of the foot and functions as our natural shock-absorbing mechanism.
When placed under too much stress, the plantar fascia stretches too far and frays, or tears, resulting in inflammation of the fascia and the surrounding tissues. The tears are soon covered with scar tissue, which is less flexible than the fascia and this only aggravates the problem.
An X-ray or ultrasound scan is sometimes needed to rule out other possible causes of heel pain.
Symptoms
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pain, tenderness and swelling in the center base of the heel, or at the front or sides of the underside of the heel.
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some people may experience pain under the arch of the foot, when weight is put on the foot or if standing on tip toes,
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numbness along the outside of the sole of the foot.
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there may also be tightness in the calf muscles.
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the pain is usually worse first thing in the morning, or after sitting for a while. The reason for this is that during rest our muscles and ligaments tend to shorten and tighten up. On weight-bearing the plantar fascia is suddenly stretched, resulting in a stabbing pain
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after a few minutes the pain eases as the foot gets warmed up, the plantar fascia becomes more flexible. However, after walking a distance or standing for extended periods the pain will return.
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the pain can often be described as a ‘stone bruise’.
To prevent the sudden sharp pain in the morning or after sitting, it is important to give the feet a little warm-up first with some simple exercises. Also, any barefoot walking should be avoided, especially first thing in the morning, as this will damage to the plantar fascia tissue.
Causes
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over-use: overtraining, running, walking or standing for long periods
- weight gain: excess weight places great pressure on the bones, nerves, muscles and ligaments in the feet. Even late stage pregnancy can cause foot problems.
- age: as we get older ligaments become rigid and more brittle, and muscles lose mass and strength
- lack of flexibility in calf muscles and Achilles tendons
- unsupportive footwear: shoes with no support eg ballet flats and thongs
- walking barefoot: especially on hard surfaces like concrete or tiles
- sudden injury
- low arch/flat feet or over-pronation
The main cause of heel pain is overstretching of the plantar fascia ligament under the foot.
Normally excessive pronation (lowering of the foot’s arch) elongates the foot and places a traction force on the plantar fascia (See above). Over time this results in inflammation of the muscle and the surrounding tissues, causing pain in the heel and the arch.
Often, the chronic traction of the plantar fascia from the heel bone (calcaneus) may lead to the development of a bony growth on the calcaneus. This is referred to as a heel spur and causes a sharp pain in the center of the heel.
Treatment options include:
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orthotic therapies to realign the feet and relieve the strain on the plantar fascia.
Orthotics are corrective foot devices. They are not the same as soft, spongy, insoles or gel heel cups. Gel and rubber insoles may cushion the feet, but they do not provide any biomechanical correction. In fact, gel can do the opposite and make an incorrect walking pattern even more unstable.
Orthotic insoles work by supporting the arches while re-aligning the ankles and lower legs. Which reduces the tension and overwork of the plantar fascia, allowing the inflamed tissue to heal.
Alternatively, you can support the plantar fascia and arch of your foot with sports tape or kinesio tape.
- Anti-inflammatories, like ibuprofen (see your pharmacist to check if this medication is suitable for you)
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Trigger-point massaging or dry needling of tight muscles in the calves and feet.
A trigger point is an irritable knot in the muscle tissue. When pressed trigger points are very tender and can cause pain in that specific spot or elsewhere in the body (referred pain). Trigger points in the calf muscles often refer pain directly to the bottom of the foot. So treatment of these can be successful for plantar fasciitis.
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Supportive footwear. Replacing old runners before they stop supporting and cushioning the feet. Avoiding stiletto heels and shoes with excessively low heels. Buying shoes with a low to moderate heel, good arch support, and cushioning.
The best results are often seen with custom made orthotics, used in conjunction with self-care.
Self Care
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Rest: The body is capable of healing itself and can overcome inflammation, provided you give it some rest. Avoid any running, sports, walking distances, walking up or down hills and standing for prolonged periods for at least 6 weeks.
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Ice: Two or three times a day, apply an ice pack directly onto the heel and plantar fascia for 10 to 15 minutes. This will help cool down the inflammation and provide temporary pain relief.
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Stretching: to increase the flexibility of the plantar fascia, Achilles tendon and calf muscles. Stretching in the morning, before you get out of bed, or before standing after sitting, helps reduce the tightening of the plantar fascia that occurs over night or after rest
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Massage: rolling a golf or tennis ball under the foot to massage the plantar fascia. Alternatively, roll your foot over a frozen bottle of water. This will both ice and massage the plantar fascia.
Further Treatment Options:
Cortisone-steroid injections
Cortisone is a powerful anti-inflammatory and when injected directly into the heel it should work almost immediately. However, this treatment does not address the cause of the inflammation, and may need to be repeated every 3-5 months. Also, these injections are quite painful, and most doctors will consider other, less invasive treatment options first.
Strassburg Sock and night splint
The Strassburg Sock consists of a tubular fabric with two adjustable straps which extends from the toes to the lower leg. This keeps tension on the plantar fascia ligament all night long, so no tightness occurs overnight and little or no pain is experienced in the morning. In combination with orthotic insoles and exercises, this device can be very effective indeed.
A night splint is very similar but the boot-type device can be uncomfortable to wear at night and cumbersome.
Shockwave therapy
ESWT (Extra Corporeal Shockwave Treatment). A specialist targets therapeutic shockwaves to the affected heel area. This will stimulate a healing response in the affected tissue and ligaments, resulting in reduced inflammation and pain. This treatment and may take from 3 to 4 months to be fully effective. Extra-corporeal Shock Wave Therapy is a new technology to treat chronic plantar fasciitis. It is a non-invasive treatment and recommended for people who have tried other treatment like cortisone-injections, dry needling, etc, with little or no success.
Surgery
In very rare cases plantar fascia surgery is suggested. The surgeon makes an incision into the ligament, partially cutting the plantar fascia to release it. If a heel spur is present, the surgeon will remove it. Plantar Fasciitis surgery should always be considered the last resort when all the conventional treatment methods have failed to succeed.
Endoscopic plantar fasciotomy (EPF) is a form of surgery whereby two incisions are made around the heel and the ligament is being detached from the heel bone allowing the new ligament to develop in the same place. In some cases the surgeon may decide to remove the heel spur itself, if present.
Just like any type of surgery, Plantar Fascia surgery comes with certain risks and side effects and these need to be considered carefully. Wearing an arch support after surgery is usually recommended.
Heel spur surgeries may also do some damage to veins and arteries of your foot that allow blood supply in the area. This will increase the time of recovery.