What is it?

The most common cause for heel pain is plantar fasciitis.  There are many other causes for heel pain such as stress fracture, fat pad atrophy, arthritis, compressed nerve, tendonitis or cyst.  Heel pain must be properly diagnosed to begin the right treatment course.  The plantar fascia is a tough, fibrous band composed of both collagen and elastin fibers that extend from the heel to the toes.  It is an extension of the Achilles tendon that is attached to the back of the heel. The plantar fascia is the major support of the arch during gait.  When there is prolonged, excessive tension in the plantar fascia usually secondary to excessive pronation (rolling in), inflammation of the plantar fascia results at its attachment in the heel causing heel pain.  A heel spur may or may not be present and is rarely the source of the pain. A heel spur is the formation of extra bone at the heel bone from the constant pull of the plantar fascia when it is tight.  A heel spur is only painful if it has been fractured from an acute injury. Sometimes patients have a large spur with no pain and other times patients have a very small heel spur and have severe pain.  If there is significant injury to the area the ligament can have larger tears or a partial rupture. The presence of a heel spur on radiographs tell the doctor that the plantar fascia has been tight for a long time, since a spur is formed over a long period of time.

What causes Plantar Fasciitis?

This is a unilateral condition occurring in both men and women who remain active by walking and performing standing activities.  Causes include poor foot mechanics such as patients with flatfeet or high-arched feet, as well as a tight Achilles tendon.  These type of foot structures affect the way weight is distributed when you're standing and added stress is placed on the plantar fascia.  Repetitive microtrauma to the ligament can begin to cause pain and inflammation at the heel because the micro tears have increased.  At night when the patient sleeps, the foot relaxes in a downward position allowing the inflamed fascia to shorten and tighten.  On the first step in the morning, the contracted fascia is stretched too quickly and therefore very painful. Inappropriate footwear such as flats can cause a strain on the plantar fascia.  Being overweight can also contribute because the extra pounds put extra stress on the plantar fascia. Certain types of exercises such as running, jumping, ballet and aerobic dance. Patients who spend most of their work hours walking or standing on hard surfaces can damage their plantar fascia. Other causes for heel pain other than plantar fasciitis is stress fractures, direct trauma, nerve entrapments, arthritis, infection, tumors and growth plate injuries which are seen in children.

Symptoms of Plantar Fasciitis

Patients usually describe a gradual onset of deep aching pain at the bottom, inner portion of the heel that is not associated with any specific injury.  The pain is well localized to the bottom inner aspect of the heel.  The patient’s history usually describes a recent increase in ambulatory activities prior to the onset of pain.  Patients often report pain that is most severe when they take their first few steps when arising from bed in the morning or standing up from a chair.  There can be burning or numbness in the skin of the heel. They also report that pain is aggravated by weight-bearing activities and relieved by rest.  Patients complain that walking barefoot, wearing flat shoes and shoes without support cause more pain. 

Diagnosing plantar fasciitis

Plantar heel pain syndromes are primarily defined by a detailed history and physical examination; however ancillary tests may be appropriate to confirm the diagnosis, since there are many causes for heel pain.  Digital x-rays of the feet will be obtained.  Sometimes heel spurs are found in patients, but these are rarely a source of pain.  If a heel spur is present, the condition is called “Heel Spur Syndrome.” If the problem becomes chronic or the ligament is ruptured, an MRI must be ordered.

Treatment for Plantar Fasciitis

• Conservative Treatment

90% of cases improve with nonsurgical treatment.  Treatment of plantar fasciitis begins with a protocol that can be done at home.  Exercises that stretch out the calf muscles as well as the plantar fascia effectively treat plantar heel pain.  These exercises are important to perform in the mornings before getting out of bed or after periods of rest. Since plantar fasciitis is an overuse inflammatory condition, avoiding high-impact activities and maintaining aerobic fitness by swimming, biking, or using an elliptical walker is recommended.  A period of rest may be beneficial to reduce the constant strain on the ligament while it is trying to heal.  You can reduce inflammation and pain by applying ice and taking anti-inflammatory medications (NSAIDs). Avoid going barefoot because when without shoes you put strain and stress on the plantar fascia. Also wear supportive shoes with an arch support and avoid wearing flats.  In the office, Dr. Fihman will recommend custom molded orthotics that slip into your existing shoe.  The purpose of orthotics is to hold the foot in its proper position and alignment.  The orthotic supports the plantar fascia when it is torn or inflamed.  The orthotic takes on all the pressure that the plantar fascia would normally.  A night splint is also recommended to assist the patient with stretching. A night splint has been shown to help alleviate pain on the first step in the morning by maintaining the fascia stretching during sleep.  The plantar fascia and Achilles tendon is in a lengthened position overnight.  A corticosteroid injection can also be administered to help alleviate pain, reduce the inflammation and break down any scar tissue within the ligament. Stem Cell therapy such as an Amniox Flo injection is an advanced treatment made up of treated human amniotic membrane and umbilical cord tissue.  The cells in this tissue are rich in healing factors like collagen, fibronectin, hyaluronic acid, and growth factors.  These factors decrease inflammation and regenerate new health tissue. Wearing supportive shoes, stretching and using custom orthotic devices are long term care for plantar fasciitis.

• Surgical Treatment

Most patients with plantar fasciitis respond to non-surgical treatment and a small percentage of patients require surgery.  Surgery may be considered if there has been at least 6 months of failed non-surgical treatment.  Dr. Fihman has found that the best surgical results are with a complete release of the plantar fascia from its attachment at the heel, which is accomplished with a small incision on the bottom of the heel or on the side of the heel. The ligament can no longer tear and cause inflammation.  The patient will be in a non-weightbearing cast to control the stress on the plantar fascia post-operatively for 4 weeks followed by a cam walker boot for an additional 2 weeks.  The surgery is generally performed in an outpatient surgical center or hospital operating room.  It is a good idea to wear orthotics following the surgery to reduce reoccurrence of the heel pain or other foot problems.