Plantar fasciitis is the most common cause of adult heel pain. It accounts for 10% of all foot and ankle healthcare visits to lower extremity healthcare specialists

The plantar fascia is a broad based ligament that originates from the bottom of the heel bone and fans out attaching to the base of the toes. Excessive mechanical stresses on the ligament can cause injury to the ligament at the level of attachment to the heel bone.

The “itis” in plantar fascitis denotes inflammation of this ligament as it attaches to the heel bone. Pain associated with this inflammation is noted typically to the bottom aspect the heel bone. Pain is typically worse with initial rising from a sitting position such as getting out of bed in the morning or pain noted after arising from a prolonged sitting period.

The cause of plantar fasciitis has much more to do with inherited foot mechanics and abnormal stress placed on the plantar fascia. Abnormal foot pronation which can cause increase stress to the plantar fascia appears to be one of the main reasons for developing this injury. One of the major causes of plantar fascitis is related to abnormal walking mechanics occurring during the “midstance” phase of the walking cycle. During midstance the foot is going through complex motion called pronation and supination. The pronated foot is a very flexible foot position that can accommodate abnormal walking surfaces while the supinated foot is a rigid state that prepares the foot to transfer the weight bearing pressures of the body into the swing portion of the walking cycle. Between the midstance and propulsive portion of the walking cycle the foot normally moves from a pronated position into a supinated position in preparation of lifting the foot off of the ground as it enters the swing phase of the gait cycle. People who develop plantar fascitis generally stay in a pronated foot position as the heel lifts off of the ground. This pronated position increases abnormal pressures on the plantar fascial ligament which can lead to the development of plantar fascitis.

Other contributing factors including non supportive shoe gear, poor conditioning while returning too quickly to athletic activity and excessive body weight have an influence in its development.

Treatment is geared at stabilizing abnormal foot pronation with supportive shoe gear and orthotic as well as decreasing inflammation and pain at the plantar fascial attachment site. 

Stabilizing the foot biomechanically and controlling abnormal foot pronation is performed by wearing a very supportive shoe and over the counter orthotic device. It is very important during the period of treatment to avoid all barefoot, slipper or use of sandals and open backed shoes even around the house. The goal is to wear shoes at all weight bearing times including getting out of bed in the middle of the night to go t the bathroom. The analogy is that of a fracture. Successful healing of a fracture involves the use of a cast at all times generally for a 4-6 week period of time. If motion occurs at the fracture site healing is delayed. Although plantar fascitis is a soft tissue injury it is treated by removing the weight bearing stresses on the soft tissues with the shoe and the temporary orthtoic.

We generally recommend a supportive shoe like running shoe with a rigid heel counter, supportive midsole and lace up features as well as the addition of a firm arch support. There are many different arch supports that are commercially available but in general any arch support that is “firm” as compared to “soft” is preferred. The initial thought when the heel hurts is to get an arch support that is “soft” but remember the main use of the orthotic arch support is to decrease abnormal foot motion. Usually an over the counter arch support rather than a custom orthotic will be sufficient to help control abnormal foot pronation.

Decreasing the inflammation at the plantar fascia can be achieved with the use of ice, non steroidal anti inflammatories like ibuprofen and the possible use of a cortisone injection. Ice can be applied twice daily for 5-10 minutes by rolling a frozen water bottle over the painful region. Non steroidal antinflammatories like ibuprofen or Naproxen can be used for short periods of time in therapeutic doses. Typically three over the counter tablets of Advil (Ibuprofen) can be taken three to four times daily or over the counter Aleve (naproxen) two tablets twice daily. If you take these ant inflammatory medications be aware of potential adverse effects and consult your physician.

Cortisone injections can be a very helpful tool in decreasing inflammation at the plantar fascia.  One up to three cortisone injections can be instrumental in reducing the inflammation and pain in the heel region. Complications associated with cortisone include thinning of the protective fatty tissue on the bottom of the foot. Outside of discomfort associated with the cortisone injection complications is rarely seen. 

The balance between biomechanically controlling pronation stress on the plantar fascia as well as aggressive use of anti-inflammatory therapy should effectively decrease pain to the heel region. Typically 70-80% overall improvement should be noted after the first three weeks of therapy.

Activity modification is an essential part of recovery. Many patients who are being treated for plantar fasciitis lead active lifestyles that include physical weight bearing activity including walking and running. It is imperative to continue cardiovascular conditioning during your recovery period but modify it to include only low to non impact activity including biking or swimming.

If minimal pain relief is experienced after the first visit secondary therapy often includes the use of night splints, physical therapy, cast immobilization, custom foot orthotics and a possible secondary cortisone injection.

A night splint is a rigid brace that worn during the night maintains the foot at a ninety degree angle to the leg. The night splint by maintaining an extension stress on the plantar fascia during the night can help reduce the pain related to plantar fasciitis. The night splint as a single therapy has been shown to be helpful with reduction of the pain associated with plantar fascitis.

Formal physical therapy including often times including the application of electrical current, topical cortisone delivered through ultrasound and additional therapeutic tools to help reduce inflammation to the region.

Custom orthotic therapy can be utilized if conservative shoe, store purchased arch supports and anti-inflammatory therapy have failed. A custom orthotic is a custom contoured arch support that controls the abnormal foot pronation mechanics. Increase foot pronation is a causative factor that increases the likelihood of the development of plantar fascitis.

A majority of patients who experience symptoms associated with plantar fasciitis fully recover. A small percentage of patients despite all conservative attempts do not respond to conservative care and pursue surgical options for pain relief.

The surgical care of plantar fasciitis includes a minor outpatient surgical procedure to cut the plantar fascia at the level of its attachment to the heel bone. The surgical release of the plantar fascia decompresses the region and creates a plane of scar tissue related to the relative lengthening of the ligament from its insertional region.  Recovery after surgical repair is on average around ten weeks with the tenth week being the period at which patients should fully resume normal activity.

Chris Byrne, DPM