Plantar Fasciitis

What is Plantar Fasciitis?

The plantar fascia is a thick strong band of tissue on the bottom of the foot. It begins at the calcaneus (heel bone) and spreads out to insert onto the phalanges (toe bones).

Plantar fasciitis is a painful condition where inflammation and swelling occur at the point where the fascia attaches to the heel bone (calcaneus).

The inflammation at this site sometimes triggers excessive growth of the bone leading to the formation of a bony spur on the heel.

The swollen fascia may also cause a nerve entrapment syndrome, resulting in pins and needles or reduced sensation over the foot. For this reason, it is important that you tell your doctor about any changes in sensation or strength in your foot.

Plantar Fasciitis is also known as:

  • plantar fasciosis
  • heel spur syndrome

Symptoms

Symptoms of plantar fasciitis include:

  • A painful heel. The main symptom of plantar fasciitis is pain, especially when you walk. For example, when first getting out of bed.
  • The pain tends to subside at first, only to return later after long periods of weight-bearing
  • Pain may also be felt along the centre of the foot
  • Stiffness of the ankle. Bringing your foot towards to shin bone leads to pain.

Causes

There are many possible causes of plantar fasciitis, including:

Risk Factors

Plantar Fasciitis is more common in ladies who are older than 40 and are overweight.

  • Abnormal foot arches. If the arches of your foot are unusually high or low (eg flatfoot), you are more likely to develop plantar fasciitis than if your arches are normal.
  • Wearing high heels. Wearing high-heeled shoes for long periods of time is one possible cause. If you wear high-heeled shoes, including western-style boots, the fascia can become shorter. Pain then occurs when you stretch fascia that has shortened. This painful stretching might happen, for example, when you walk barefoot after getting out of bed in the morning.
  • Weight. If you gain weight, you might be more likely to have plantar fasciitis, especially if you walk a lot or stand in shoes with poor heel cushioning.
  • Activities. Increased walking, standing, or stair-climbing can lead to plantar fasciitis. Runners may get plantar fasciitis when they change their workout and increase their mileage or frequency of workouts. It can also happen with a change in exercise surface or terrain, or if your shoes are worn out and don’t provide enough cushion for your heels.
  • Tight Achilles tendons
  • Abnormal walking patterns. Many people who have had previous injuries in their foot, hips or knees unconcsiously develop a different way of walking to adapt to their injury. This may be very subtle, and increases their risk of developing further injuries.

Investigations

How is it diagnosed?

Plantar Fasciitis is usually diagnosed by an examination from your doctor. Occasionally, your doctor will order an X-Ray of your foot to check that subtle fractures are not the cause of your pain. No other test is usually needed.

Complications

Plantar fasciitis can lead to

  • Tightening of calf muscle
  • Flatfoot deformity – collapse of your foot arch

Treatment

How is it treated?

There are many treatment options available for plantar fasciitis, falling into three broad categories:

  • mechanical
  • medical
  • surgical

The treatment selected will vary with the severity of pain, but in general the mechanical options will be tried first. For this reason, you will usually see a physiotherapist and/or an orthotist rather than an orthopaedic surgeon.

The orthotist can prescribe pre-made or custom-built orthotics to relieve the pain and dysfunction of plantar fasciitis. This is generally considered the most effective method to treat plantar fasciitis.

A physiotherapist will usually cover the following components of treatment:

  • Assessing foot posture – a key component of treatment for plantar fasciitis is maintaining the arch of the foot. By doing this, your physiotherapist is preventing further injury and protecting your ability to walk normally.
  • Exercises
    • Calf stretching – the calf muscle (gastrocnemius and soleus) may become tight in plantar fasciitis, and this can worsen and prolong symptoms. Stretching this muscle can help. Night splints may also be useful.
    • Intrinsic foot muscle strengthening – when physiotherapists and doctors talk about the ‘intrinsic muscles’ of the foot they mean the small muscles between bones acting deep in the sole of your foot. These muscles can be strengthened with specific exercises – like picking up towels with your toes. By working these muscles, your physiotherapist aims to maintain the arch of your foot.
  • Icing
  • Taping – by taping your foot, your physiotherapist aims to maintain the length of the plantar fascia.

This management program aims to reduce inflammation, reduce shortening of the calf muscles (gastrocnemius), protect the shape of the foot and maintain the normal biomechanics of walking.

In general, these measures are successful in treating most cases of plantar fasciitis.

Medications that can help

  • oral anti-inflammatories – over-the-counter medications like ibuprofen (nurofen) help to relieve the inflammation that causes plantar fasciitis.
  • injections of cortisone

Surgery

  • Fasciotomy – releasing the fascia

Over 90% of people are relieved of their pain within a year without needing surgery. However if symptoms continue or you have symptoms of nerve entrapment your doctor may recommend surgery.

In general, surgical options are minimally invasive and effective in relieving pain. There may however be some change to the centre of pressure in the foot. This can lead to changes in gait which may result in further wear and tear later in life.

Newer Therapies

  • Extracorporeal shockwave therapy is being used as an alternative to surgery.

Seeking Advice

Physiotherapist

The physiotherapist can discuss the symptoms and likely cause of heel pain. They can also prescibe treatments like ice, exercises and stretches to help improve pain.

Family Doctor (GP)

The local family doctor can help diagnose and treat plantar fasciitis. He or she will be able to

  • tell you about your problem
  • advise you of the best treatment methods
  • if necessary, prescribe you medications
  • and refer you to other healthcare, including physiotherapists, orthotists and specialists (like orthopaedic surgeons) for further treatment

Prevention

The best way to prevent plantar fasciitis is to wear shoes that are well made and fit your feet. This is especially important when you exercise or walk a lot or stand for a long time on hard surfaces.

Get new athletic shoes before your old shoes stop supporting and cushioning your feet.

You should also:

  • Avoid repeated jarring to the heel.
  • Keep a healthy weight.
  • Do your leg and foot stretching exercises regularly.

F.A.Q. | Frequently Asked Questions

How long will does plantar fasciitis last?

You may find that the pain is sometimes worse and sometimes better over time. Plantar fasciitis can last for a long time, it may take many weeks to years for the pain to go away.

When can I return to my normal activities?

Everyone recovers from an injury at a different rate.

Return to your activities depends on how soon your foot recovers, nor by how many days or weeks it has been since your injury has occurred.

The goal is to return to your normal activities as soon as is safely possible. If you return too soon you may worsen your injury.

You may safely return to your activities when:

  • You have full range of motion in the injured foot compared with the uninjured foot.
  • You have full strength of the injured foot compared with the uninjured foot.
  • You can walk straight ahead without significant pain or limping.

References

J. L. Thomas, et al., “The Diagnosis and Treatment of Heel Pain: A Clinical Practice Guideline–Revision 2010”, The Journal of Foot & Ankle Surgery, Vol. 49, 2010. www.jfas.org.