Heel Pain

What is Plantar Fasciitis?  

Plantar fasciitis is a painful inflammation of the bottom of the foot between the ball of the foot and the heel.  Usually it is painful first thing after getting out of bed in the morning or after sitting for a prolonged period of time.  This is called "Post-static dyskinesia" - which means pain after being static or immobile for an extended period of time. 

Etiology:

There are several common causes for plantar fasciitis.  These include wearing high heeled shoes or boots frequently, gaining weight, or increased activity level such as walking, standing for long periods of time, or stair-climbing.   

High heeled shoes and boot use can cause this issue by the mere fact that they allow the achilles tendon and fascia to contract and shorten over time.  When you return to normal shoes or barefoot, these structures are tight and put an increased amount of stress on the heel bone (calcaneus).  The pain comes from this pulling on the bone and microtrauma where these structures attach to the bone, and the resultant inflammation and associated pain. 

Gaining weight also will cause a generalized overload to this area and result in microtrauma and inflammation.  Additionally, weight gain can place you at risk for damage to the fat pad which is normally present under the heel.  With additional weight, fat pad breakdown will be an additioal source of pain in addition to the pain of the microtrauma to the plantar fascia.

Recreational activities may play a role in plantar fasciitis even if you are not doing activities that are that different than those you did in the past.  Perhaps a slight change in your walking or running regimen has caused an increased amount of stress on this area of the body.  Sometimes a change in terrain (ie walking on the beach instead of the sidewalk) may be causative.  For people who run, running on concrete sidewalks is more traumatic to the body than runing on asphalt (the concrete is harder and has less give to it.) Additionally shoes that wear out will subsequently place additional stress on different areas of the foot and ankle. 

Symptoms:
The main symptom of plantar fasciitis is pain when you walk.  You may also feel pain when you stand and even when you are at rest.  Pain is typically seen as you first step out of bed in the morning or after you get up from sitting for a prolonged period of time.  This occurs because the fibers that had begun to heal in a contracted or shortened position are stretching and tearing.  The pain usually eases up with walking but will often present again after a period of rest or non-weight bearing. 

Examination:
Clinical exam often reveals pain beneath the calcaneus (heel bone).  Pain from side to side is a less common finding.  Generally, plain film xrays will be taken to rule out other less common causes of heel pain such as stress fractures (hairline), calcific tendonosis, fractures, or rarely bone tumors.  Some tests may be performed to examine for nerve issues that can present in the same location or in a location very close to the plantar fascia.  Additionally, MRI may be indicated in certain cases. 

Treatment:
There are two main forms of treatment when discussing plantar fasciitis.  The first form is to control the initial pain, inflammation, and symptoms.  The second form of treatment is aimed at controlling the cause and thus preventing the problem from occurring again.

Conservative measures which target this inital pain, inflammation, and symptoms include anti-inflammatory medications and cortico-steroid injections if pain is severe enough.  Various athletic-type strapping can be applied to the foot and ankle to support the arch and limit overload to the fascia.  Oftentimes, if strapping provides good relief, this will give a decent indication of how much a custom molded orthotic may help.  Additionally, physical therapy is often recommended for various stretching excercises and for application of electrical stimulation and ultrasound treatments. 

Home stretching excercises which target a tight calf muscle complex will often help out a great deal.  These should be performed 3-4 times daily  for maximum relief. 

Additionally, certain products can help with stretching such as the Prostretch pictured here.  This device is designed to provide a controlled stretch that is reproducible each time.  This specific device is often used by athletes and by physical therapy departments.
To read more about Prostretch, click here.





The second arm of treatment is aimed at controlling the cause and preventing a recurrence. 

Often times the foot needs to be supported and there are multiple prefabricated orthotics that can support the foot shape enough to eliminate this pain.  These are much more effective than just simple cushioning pads that are often found at a drug store.  Below are a few samples:
  Orthofeet BioSole-Gel Self Forming


  Powerstep Pinnacle Insoles (Orthotic) Arch Supports


If prefabricated orthotics do not provide enough relief, custom molded orthotics are often recommended.  Custom molded orthotics are specific for each individual foot shape and type.  These devices are created in a lab from a mold or a digital scan.  In contrast to prefabricated orthotics which have a limited lifespan, custom orthotics may last 15-20 years depending upon the materials they are constructed out of.  Generally a firm control layer is the foundation for these devices, and this part holds up for many years.  The top-cover(the part that is against your foot) and the associated cushioning will need to be refurbished from time to time.  For long term control and treatment, custom molded orthotics will provide the best relief.  Over time, the foot may change shape and a new orthotic will need to be fabricated. 

For long-standing or severe plantar fasciitis, a night splint may be recommended.  This is worn at night and when at rest (ie. watching TV with your leg up on a pillow).  The purpose of this splint is to prevent the fascia and calf muscles from contracting while you are at rest.  The fascia begins to heal every time you rest and this helps to allow it to heal in a more stretched out position. 

Active Ankle Dorsal Night Splint


Additionally, a CAM walker (Controlled Ankle Motion), also known as a walking boot, may be recommended to partially immobilize and allow the body to heal on its own.  This is usually reserved for the most resistant cases of plantar fasciitis.  If utilizing this in a weight bearing fashion does not alleviate the associated pain within 6-8 weeks, you may be instructed to utilize this device with crutches for complete non-weight bearing.
Ossur Equalizer Premium Walker - High Top Walker

A below knee cast with crutches is also a viable option to consider prior to any surgical intervention.  This treatment would keep all weight off of this part of the body for a period of 6 weeks or more in an attempt to allow the body to heal on its own. 


Surgical Intervention:
Once conservative measures have been exhausted, surgical treatment may be recommended.  Open surgical procedures are available where both the fascia is released and the spur is can be removed.  However, the spur is usually not causing the pain associated with this procedure, this is found because the body reacts to stress by building more bone. 

Other surgical intervention includes the endoscopic plantar fasciotomy in which two small incisions are made, one on each side of the heel.  A microscopic camera is then inserted and the medial 1/2 of the fascia is released with an endoscopic scalpal.  This procedure usually has very little down time and you will be walking that day after surgery.