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Introduction

Heel pain accounts for a large number of patient visits to foot and ankle specialists. The most common cause of this heel pain is “plantar fasciitis” (also known in some circles as “heel spur syndrome”) [1]. More than two million Americans receive treatment for plantar fasciitis each year [2]. Patients classically complain of intense heel pain after periods of rest that improves with activity. Fortunately, plantar fasciitis is treatable. 65% to 95% of patients suffering from plantar fasciitis respond to conservative (non-surgical) therapies [3]. When conservative measures fail, surgery may be the necessary alternative to alleviate the pain.

What is Plantar Fasciitis?

Plantar fasciitis is an inflammation of the plantar fascia-a band of dense fibrous tissue (i.e., fascia) located along the bottom of the foot (i.e., plantar surface) extending from the heel bone (i.e., calcaneus) to the ball of the foot (figure 1 below). It is the most important structure in maintaining the longitudinal arch of the foot [4]. With every step forward, bodyweight follows-starting at the heel, progressing through the midfoot (arch area), ending with the toes pushing off the ground. When bodyweight is shifted to the midfoot, the arch normally flattens, and in doing so, acts as a shock absorber to the body by dissipating forces from the ground. The extent to which the arch flattens is limited by the degree at which the plantar fascia can hold it. Herein lies the problem. Unlike tendon, the plantar fascia is not elastic and therefore cannot stretch when forces on the foot to flatten the arch become too great. If it was elastic, the arch would collapse and rebound excessively with every step-imagine bouncing down the street without need of a pogo stick. Because of its inelasticity, the plantar fascia begins to separate from its weakest point of attachment, often the heel bone, resulting in pain and inflammation that is distinct and treatable.

Think of the foot as an archer's bow where the bowstring is your plantar fascia and the bow is your arch. If the tips of the bow were brought closer together, the bowstring would be limp. In the case of plantar fasciitis, the tips of the bow are brought further apart, thus increasing the tension on the bowstring to a point where it will snap, tearing the plantar fascia from its heel bone insertion resulting in heel pain.

Plantar Fasciitis & Heel Spurs

Over time, the inflammatory reaction at the heel bone may produce projections of new bone called "heel spurs." When this occurs, physicians may begin to call it "heel spur syndrome." Doctors frequently use plantar fasciitis and heel spur syndrome interchangeably. Are plantar fasciitis and heel spur syndrome the same? No, but they are related. The two share a common lineage in which plantar fasciitis can progress to heel spur syndrome over time. The heel spur that appears at the origin of the plantar fascia is a direct result of the fascia being torn from the heel bone-these spurs are a result, not a cause. They indicate severity and duration. For this reason, many doctors will x-ray the feet to assess the severity of your condition and rule out other causes of heel pain.

What causes Plantar Fasciitis?

Increased tension on the plantar fascia can be caused by many different problems. People with flat feet or rigid high-arched feet are most prone to plantar fasciitis-these foot structures put the greatest pressure on the plantar fascia. Because foot structure is passed from one generation to the next, plantar fasciitis is commonly inherited. Other factors that contribute to plantar fasciitis include walking on soft-terrain (sand or gravel), sudden weight increase, sudden increase in activity, poor shoe support, tight calf muscles, and leg length discrepancy. Anything that can increase the strain and stretch placed on the inelastic plantar fascia can lead to plantar fasciitis. The success of treatment depends on successful identification of the underlying cause.

Signs and Symptoms

It is not unusual for a patient to go months, if not years before seeking medical attention [5]. Patients usually cannot recall a traumatic event preceding their initial heel pain. The pain is usually sharp, ranging from mild to debilitating, and localized to the inside heel with occasional tenderness through the arch. Classically, the pain is most intense with the first few steps after prolonged periods of rest (medical term: post-static dyskinesia), most notably when getting out of bed in the morning. Why? Rest permits the heel to heal as no stress is placed on the plantar fascia. When standing up, the arch flattens, suddenly separating the plantar fascia from the calcaneus and destroying whatever healing took place. Because some healing did occur, it hurts more as the newly formed fibers are torn from the heel. The pain tends to slowly settle with activity. In more severe cases, the pain will only subside with rest.

Symptoms may be exacerbated by a nerve around the heel becoming trapped due to the inflammatory process and/or resulting scar tissue. When this occurs, patients generally experience a more intense pain that is burning and tingling in nature that may radiate into the arch or the ankle.

Treatment Options

There are two objectives in treating plantar fasciitis: alleviate the symptoms (pain and inflammation) and correct the underlying deformity (excessive tension on the plantar fascia). Conservative therapies can meet both objectives. Surgery is usually warranted only after conservative therapies have failed over a period of 6 months or more. Without response to conservative measures, a doctor is more likely to question his/her original diagnosis than schedule your trip to the operating room. There are many different causes of heel pain and perhaps your pain might be caused, at least in part, by another condition (such as nerve entrapment, muscle strain, bursitis, arthritis, or stress fracture of the calcaneus).

Conservative Treatment (Non-Surgical)

Because plantar fasciitis is so common, many physicians have developed their own protocols of conservative treatment for plantar fasciitis. Above all, treating plantar fasciitis requires patience. It may take months to resolve. The following are the most commonly prescribed conservative therapies.

Ice: Ice is a mainstay anti-inflammatory of acute injuries. Applying an ice compress for 15-20 minutes several times a day can reduce the inflammation and pain of plantar fasciitis. A bag of frozen vegetables works well as it is readily available and conforms to the heel. (Note of Safety: Diabetics and individuals with poor circulation and/or decreased sensation should not use ice or other forms of cold (or hot) therapy.)

Stretching: Daily stretching of the calf muscles can improve motion at the ankle joint and reduce stress on the plantar fascia. Gently stretching the plantar fascia before getting out of bed can greatly alleviate the pain experienced on the first few steps. In severe cases, doctors may prescribe night splints or even apply a short leg cast to keep the foot in a stretched position.

Heel Lift: Often combined with stretching exercises, a half-inch heel lift that is placed in the shoe decreases the amount of motion necessary at the ankle joint, reducing tension on the plantar fascia.

Physical Therapy: Range of motion exercises, ultrasound (with or without therapeutic additives), hydrotherapy (whirlpool), and deep massage of the affected area can all relieve the pain associated with plantar fasciitis.

Anti-Inflammatory Medications: Oral anti-inflammatory medications (such as Ibuprofen) or a Medrol Dose Pack (a tapering corticosteroid therapy) can reduce the inflammation and pain associated with plantar fasciitis.

Taping/Padding: Your physician may employ any number of taping and padding techniques designed to support the arch and alleviate undue strain on the plantar fascia. A decrease in pain from strapping is a good indication that orthoses will be beneficial.

Orthoses: Orthoses are inserts placed in your shoes that control abnormal motion and provide additional support to the arch. These devices may be over-the-counter (OTC) or prescriptive/custom molded. OTC devices are less durable and may not provide support at the exact location that would be of most benefit to the patient. Some doctors will try OTC orthoses first to gauge the effectiveness of the device before asking you to part with $300-400 for a pair custom molded to your feet.

Proper footwear: Orthoses are only as good as the shoes in which they are used. All too often, patients come to the office wearing shoes offering little or no support that would provide more benefit as a chew toy to the family dog. Discard the chew toys. Select shoes with good arch support and a firm heel counter-these shoe types are usually referred to as "motion controlling." If the shoe can be twisted as if you were wringing out a wet towel, then it probably will not provide the support you need. Ladies should avoid the traditional pointed-toe shoes and excessively high heels. If work demands fashionable shoes, a small heel may provide some benefit in controlling abnormal motion and maintaining the longitudinal arch.

Cortisone Injections: Local anesthetic and corticosteroid injected directly to the point of pain can provide immediate relief. The local anesthetic will numb the area, while the corticosteroid will decrease the inflammation. In some cases, patients experience a 'steroid flare' in which symptoms become worse within 24-48 hours of the injection. After this period, symptoms can improve greatly. Cortisone therapy may consist of one to three injections dispersed over time. Many athletes are aware that corticosteroid injections (not to be confused with the anabolic steroids used by some athletes) can result in spontaneous rupture of tendon. This is a risk with injection therapy-10% of patients in one study suffered rupture of the plantar fascia attributed to corticosteroid injection [1]. Still, many doctors consider cortisone safe and regularly use it for plantar fasciitis for even if rupture occurs, it will likely heal anyway.

Additional Advice: Massaging the affected area before getting out of bed and after long periods of rest can reduce the amount of pain. Resting the affected foot will allow the plantar fascia to recover quicker. Avoid bearing weight without some form of arch support and never walk barefoot.

Surgical Treatment

Generally, surgery is usually considered only after six months to one year of failed conservative therapy. The type of surgery is indicated by severity and surgeon preference. Surgeons have the option of releasing the plantar fascia through conventional direct visualization (i.e., "open" surgery) or using an endoscopic technique (i.e., endoscopic plantar fasciotomy or EPF) in which small cameras are used to visualize the plantar fascia. The EPF requires smaller incisions, yields smaller scars, and usually provides a quicker recovery. The EPF cannot be used if the removal of a heel spur is required. All procedures can be done on an outpatient basis and usually require less than an hour to perform. Recovery time can range from two weeks to a couple of months depending on the selected procedure and patient condition. The most common complication of surgery is reoccurrence of pain. If surgery is warranted, your podiatrist will discuss in detail the best procedure for your specific condition.

The Latest Treatment

Extracorporal Shockwave therapy (ESWT) is the newest non-invasive artillery in the battle against plantar fasciitis bridging the gap between traditional conservative therapies and surgical intervention. Originating in Germany, it was initially employed in the treatment of kidney stones. Physicians have since found use in cases of heel pain, even though the exact theory as to why it relieves plantar fasciitis is still unknown. Like most new technologies, insurance companies are slow to pay for this modality and the out-of-pocket cost is prohibitive for most patients. As more research is done and the cost to patients drops, ESWT will likely find its niche-in fact, some doctors believe ESWT will render heel pain surgery obsolete.

Conclusion

People tend to forget the importance of their feet-how far they travel, how long they stand, and how much punishment they absorb. Plantar fasciitis is a powerful wake-up call to many individuals who have never experienced foot problems. The intense pain after rest, like a bruise in the heel, confirms the old adage "when your feet hurt, your whole body hurts." Fortunately, plantar fasciitis is often relieved without need for surgery. Unfortunately, it takes time. Your podiatrist will prescribe a combination of conservative therapies that have proven effective in their practice. Only when these therapies fail will your doctor consider surgery. The best way to protect your feet is not to ignore them.

References

1. Acevedo JI, JL Beskin: Complications of plantar fascia rupture associated with corticosteroid injection. Foot & Ankle Int, 19(2): 91-97, 1998.
2. Pfeffer G et al: Comparison of custom and prefabricated orthoses in the initial treatment of proximal plantar fasciitis. Foot & Ankle Int, 20(4): 214-221, 1999.
3. Japour CJ et al: Management of heel pain syndrome with acetic acid iontophoresis. JAPMA, 89(5): 251-257, 1999.
4. Huang CK et al: Biomechanical evaluation of longitudinal arch stability. Foot & Ankle, 14(6): 353-357, 1993.
5. Barrett S, R O'Malley: Plantar fasciitis and other causes of heel pain. Am Fam Phys, 59(8): 2200-2206, 1999.

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