Plantar Fasciitis

What is plantar fasciitis?

Plantar fasciitis means inflammation of the plantar fascia. The plantar fascia is a strong band of tissue (like a ligament) that stretches from the heel to the middle foot bones. It supports the arch of the foot and also acts as a shock-absorber in the foot. Repetitive small injuries to the fascia with or without inflammation is thought to be the cause of plantar fasciitis. The injury is usually near to where the plantar fascia attaches to the heel bone.

What are the symptoms of plantar fasciitis?

Who gets plantar fasciitis?

Plantar fasciitis is quite common. It mainly affects people over 40 and seems to be more common in women. However, it can occur at any age. It is also common in athletes. Situations where it is more likely include the following:

• If you do lots of walking, running, standing, etc, when you are not used to it. (The condition is sometimes called 'policeman's heel' as policemen 'walking the beat' were said to be commonly affected.) Conversely, people with a sedentary lifestyle are also more prone to plantar fasciitis.
• If you have recently started exercising on a different surface. For example, running on the road instead of a track.
• Wearing shoes with poor cushioning or poor arch support.
• Sudden gains in weight or being overweight will put extra strain on the heel.
• Overuse or sudden stretching of the sole. For example: athletes who increase their running intensity or distance; poor technique starting 'off the blocks', etc.
• Tightness of the Achilles tendon (at the bottom of the calf muscles above the heel) causing reduced ability to flex the ankle.

Often there is no apparent cause, particularly in older people. A common wrong belief is that the pain is due to a bony growth or 'spur' coming from the heel bone (calcaneum). Many people have a bony spur of the heel bone but not everyone with this gets plantar fasciitis.

How is plantar fasciitis diagnosed?

Your doctor may diagnose plantar fasciitis just by talking to you and examining your feet. Rarely, tests are needed if the diagnosis is uncertain or to rule out other possible causes of heel pain. These can include X-rays of the heel or an ultrasound scan of the fascia. An ultrasound scan usually shows thickening and swelling of the fascia in plantar fasciitis.

What is the treatment for plantar fasciitis?

Usually the inflammation and pain will ease in time. Fascia tissue, like ligament tissue, heals quite slowly. It may take several months or more to go. However, the following treatments may help to speed recovery. There is no one specific treatment that appears stand out as the best. A combination of different treatments may help.

Rest the foot

This should be done as much as possible. Avoid running, excess walking or standing, and undue stretching of the sole. Gentle walking and exercises described below are fine.

Footwear

Do not walk barefoot on hard surfaces. Choose shoes with cushioned heels and a good arch support. A laced sports shoe rather than open sandals is probably best. Avoid old or worn shoes that may not give a good cushion to the heel.

Heel pads and arch supports

You can buy various pads and shoe inserts to cushion the heel and support the arch of your foot. These work best if you put them in your shoes at all times. The aim is to raise the heel by about 1 cm. If the heel is tender, cut a small hole in the heel pad at the site of the tender spot. This means that the tender part of the heel will not touch anything inside the shoe. Place the inserts/pads in both shoes, even if you only have pain in one foot.

Painkillers

Painkillers such as paracetamol will often ease the pain. Sometimes anti-inflammatory medicines such as ibuprofen are useful. These are painkillers but also reduce inflammation and may work better than ordinary painkillers. Some people find that rubbing a cream or gel that contains an anti-inflammatory medicine onto the heel is helpful.

Exercises

Regular gentle stretching of the Achilles tendon and the plantar fascia seems to ease the symptoms in some people. This is because most people with plantar fasciitis have a slight tightness of the Achilles tendon. This tends to pull at the back of the heel and have a knock-on effect of keeping the plantar fascia tight. Also, when you are asleep overnight, the plantar fascia tends to tighten up (which is why it is usually most painful first thing in the morning). The aim of the exercises is to gently loosen up the tendons and fascia above and below the heel. Your doctor may refer you to a physiotherapist for exercise guidance.

The following exercises can be used to help treat plantar fasciitis:

1. Stand about 40 cm away from a wall and put both hands on the wall at shoulder height, feet slightly apart, with one foot in front of the other. Bend the front knee but keep the back knee straight and lean in towards the wall to stretch. You should feel the calf muscle tighten. Keep this position for several seconds then relax. Do this about 10 times then switch to the other leg. Now repeat the same exercise for both legs but this time, bring the back foot forward slightly so that the back knee is also slightly bent. Lean against the wall as before, keep the position, relax and then repeat 10 times before switching to the other leg. Repeat this routine twice a day.
2. Stand on the bottom step of some stairs with your legs slightly apart and with your heels just off the end of the step. Hold the stair rails for support. Lower your heels, keeping your knees straight. Again you should feel the stretch in your calves. Keep the position for 20-60 seconds then relax. Repeat six times. Try to do this exercise twice a day.
3. Sit on the floor with your legs out in front of you. Loop a towel around the ball of one of your feet. With your knee straight, pull your toes towards your nose. Hold the position for 30 seconds and repeat three times. Repeat the same exercise for the other foot. Try to do this once a day.
4. For this exercise you need an object such as a rolling pin or a drinks can. Whilst sitting in a chair, put the object under the arch of your foot. Roll the arch of your foot over the object in different directions. Perform this exercise for a few minutes for each foot at least twice a day.

Injections

A steroid (cortisone) injection is sometimes tried if the pain remains bad despite the above measures. It may relieve the pain in some people for several weeks but does not always cure the problem. It is not always successful and may be sore to have done. Steroids work by reducing inflammation. Sometimes two or three injections are tried over a period of weeks if the first is not successful. Steroid injections do carry some risks including (rarely) rupture of the plantar fascia.

Splint treatment

Some people benefit from wearing a special splint overnight to keep the Achilles tendon and plantar fascia slightly stretched. The aim is to prevent the plantar fascia from tightening up overnight. In very difficult cases, sometimes a plaster cast or a removable walking brace is put on the lower leg. This provides rest, protection, cushioning and slight stretching of the plantar fascia and Achilles tendon.

Extracorporeal shock-wave therapy

High pressure sound waves directed at the plantar fascia may be used to stimulate healing if other treatments have failed. However, there are some uncertainties as to how effective this treatment is, mostly because of a lack of large, well-designed clinical trials to prove this. Also, there is a possibility of side effects from the treatment. These include damage to the bone, pain, damage to the Achilles tendon or a blood-filled swelling called a haematoma. You should discuss the treatment fully with your doctor if it is available.

Other treatments

Various studies and trials have been carried out looking at other possible treatments for plantar fasciitis. Such treatments include injection with botulinum toxin and treatment of the plantar fascia with radiotherapy. These treatments may not be widely available.

Surgery

This may be considered in very difficult cases. Surgery is usually only advised if the pain has not eased after 12 months despite other treatments. The operation involves separating the plantar fascia from where it connects to the bone and is called a plantar fascia release. It may also involve removal of a spur on the calcaneum if one is present. Surgery is not always successful. It can cause complications in some people so it should be considered a last resort. Complications may include infection, increased pain, injury to nearby nerves, or rupture of the plantar fascia.

Can plantar fasciitis be prevented?

There are certain things that you can do to try to prevent plantar fasciitis, especially if you have had it before. These include:

• Regularly changing trainers used for running or walking.
• Wearing shoes with good cushioning in the heels and good arch support.
• Losing weight if you are overweight.
• Regularly stretching the plantar fascia and Achilles tendon (see exercises above), especially before exercise.
• Avoid exercising on hard surfaces.