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Plantar Fasciitis is a Common Cause of Heel Pain

Plantar fasciitis, which may cause the heel to hurt, feel hot or swell, is inflammation of the plantar fascia, a thin layer of tough tissue supporting the arch of the foot. Repeated microscopic tears of the plantar fascia cause pain. Sometimes plantar fasciitis is called “heel spurs,” but this is not always accurate, since bony growths on the heel may or may not be a factor.

Diagnostic testing, such as X-rays, usually is not necessary to diagnose plantar fasciitis, although it may be useful to rule out other potential causes of heel pain. Typically with plantar fasciitis, the pain is worse when first getting out of bed, or is noticeable at the beginning of an activity and gets better as the body warms up. Prolonged standing may cause pain, as well. In more severe cases, the pain may worsen toward the end of the day.

There are a number of possible causes for plantar fasciitis and they often work in combination. Tightness of the foot and calf, improper athletic training, stress on the arch or weakness of the foot are potential causes. Shoes that don’t fit, certain play or work actions or overuse (running too fast, too far, too soon) may hurt the plantar fascia. People with low arches, flat feet or high arches are at increased risk of developing plantar fasciitis.


Treatments
Symptoms usually resolve more quickly when the time between the onset of symptoms and the beginning of treatment is as short as possible. If treatment is delayed, the complete resolution of symptoms may take 6-18 months or more. Treatment will typically begin by correcting training errors, which usually requires some degree of rest, the use of ice after activities, and an evaluation of the patient’s shoes and activities. For pain, nonsteroidal anti-inflammatory drugs (e.g. aspirin, ibuprofen, etc.) may be recommended.
Next, risk factors related to how the patient’s foot is formed and how it moves are corrected with a stretching and strengthening program. If there is still no improvement, night splints (which immobilize the ankle during sleep) and orthotics (customized shoe inserts) are considered. Cortisone injections are usually one of the treatments of last resort, but have a success rate of 70% or better. The final option, surgery has a 70-90% success rate.

In one study, 25% of plantar fasciitis patients cited rest as the treatment that worked the best. Wearing shoes with more arch support may help decrease stress on the area. Changing shoe size may also help. Athletes and active people may have to reduce the amount running or jumping they do to relieve stress on the plantar fascia.

Using an ice pack or ice bath on the area for about 15 minutes may relieve pain and inflammation after exercise and work. Massaging the foot in the area of the arch and heel before getting out of bed may help. Stretching is also important.

As reported in one study, 83% of patients in a stretching program were successfully treated for plantar fasciitis; 29% of study participants cited stretching as the most helpful treatment, compared with nonsteroidal anti-inflammatory drugs, orthotics, ice, heat, steroid injection, heel cups, walking, night splints, plantar strapping and shoe changes.


Stretching and Strengthening
To reduce pain and help prevent future episodes of discomfort, stretch the calves on a regular basis. Stand with your hands against a wall. With one foot forward and one back, press against the wall, shifting weight over the front foot, while straightening the back leg. Keep the heel of the back foot on the floor and feel the stretch in the heel, Achilles tendon and calf. Then, switch legs.
A similar stretch can be done by standing on a stair step with only the toes on the stairs. The back two-thirds of the feet hang off the step. By leaning forward to balance, the heel, Achilles tendon and calf will be stretched. A similar stretch can be performed when standing where the heel is on the floor and the front part of the foot is on a wood 2x4. Some patients place a 2x4 in an area where prolonged standing is done (such as in front of the sink while washing dishes). Rolling the foot over a tennis ball or 15-ounce can may also be helpful.

Almost 35% of patients in another study cited strengthening programs as the most helpful treatment. To strengthen muscles, do towel curls and marble pick ups. Place a towel on a smooth surface, place the foot on the towel, and pull the towel toward the body by curling up the toes. Or, put a few marbles on the floor near a cup. Keep the heel on the floor and use the toes to pick up the marbles and drop them in the cup.

Another exercise is toe taps. Keep the heel on the floor and lift all of the toes off the floor. Tap only the big toe to the floor while keeping the outside four toes in the air. Next, keep the big toe in the air and tap the other four toes to the floor.


Shoes and Splints
Wearing shoes that are too small may cause plantar fasciitis. Shoes with thicker, well-cushioned midsoles may help alleviate the problem. Running shoes should be frequently replaced as they lose their shock absorption capabilities.
Studies have shown that taping the arch, or using overt-the-counter arch supports or customized orthotics also help in some cases of plantar fasciitis. Orthotics are the most expensive option as a plaster cast is made of the individual’s feet to correct specific biomechanical factors. One study found that 27% of patients cited orthotics as the most helpful treatment of plantar fasciitis. Heel cups, on the other hand were ranked the least effective treatment in a survey of 411 patients.

Night splints, which are removable braces, allow passive stretching of the calf and plantar fascia during sleep, and minimize stress on the inflamed area. According to several studies, approximately 80% of patients improved after wearing a night splint. It may be especially useful in patients who have had symptoms for more than a year.

The above information is based on an article by the following Medical College authors that appeared in the February 1, 2001, issue of American Family Physician.