Plantar fasciitis is the most common cause of heel pain. The plantar fascia is a thick, fibrous tissue located on the bottom of the foot that extends from the calcaneus (heel) to the base of the toes.
The pain develops over time as the fascia develops small tears, heals, scars then re-tears. This process occurs daily as the patient walks or runs. When the fascia is rested (at sleep) in the position of ankle plantarflexion, the fascia heals at a shorter length than usual. In the morning – the patient’s first steps cause a painful, abrupt stretching (micro-tearing) of the partially scarred/healed fascia, and the cycle starts over for another day.
Anyone can develop plantar fasciitis, but middle-aged, overweight folks who have limited flexibility are more prone. Also at risk are patients with excessively high or flat arches who take part in repetitive activities, such as long periods of standing, walking or running. Runners also can fall victim, especially if their foot hyperpronates (foot overly rolls inward during gait) or if they recently changed intensity of their running program, or if they run steep hills.
Prevention of the development of plantar fasciitis is similar to the early stages of treatment. We ask patients to spend less time standing on hard surfaces, wear shoes with good cushioning and support, and perform daily Achilles tendon stretches. Additionally, maintaining a healthy weight and gradually increasing exercise levels will be helpful.
When these preventative tips are unsuccessful, it may be time to seek a medical opinion. Your physician will examine your foot, evaluate for any biomechanical gait abnormality and may obtain an X-ray to rule out a stress fracture. A heel spur does not indicate the presence of plantar fasciitis.
Treatment starts with educating the patient as to the cause of the problem. Once the cause is better understood, the patient will be more likely to follow through with treatments. The goal of clinical treatment is to stop the cycle of tearing, re-tearing, scarring and shortening of the fascia. After halting this damaging cycle, the fascia is protected, rested and stretched until the tissue becomes more flexible and less likely to re-tear.
Usually we place the patient in a splint, which maintains the fascia in a stretched position through the night. In addition, ice massage, therapeutic Achilles tendon and fascial stretching exercises and occasionally over the counter anti-inflammatory medications are useful. If this regimen is unsuccessful, custom shoe inserts, corticosteroid injections and sometimes even a hard cast may be necessary. These treatments will eventually work to relieve symptoms in the great majority of patients.
After six to nine months of conservative treatment, occasionally a patient still will have painful symptoms and surgery will be necessary. A new alternative to surgery called extracorporeal shock wave therapy (ESWT) has been developed to treat plantar fasciitis. Studies on the effectiveness of this technique are conflicting, but ESWT may offer another nonsurgical treatment option for the future.
Dr. Wyland is an orthopedic surgeon at the Steadman Hawkins Clinic in Denver. He specializes in sports injuries of the knee, shoulder, elbow and ankle.
