Is your Heel Hurting? How to recognise Plantar Fasciitis
Plantar fasciitis is a common cause of heel pain in adults and is typically a self-limiting condition. It arises due to biomechanical overuse, leading to degenerative changes where the plantar fascia attaches to the calcaneus. The plantar fascia, which originates from the posteromedial calcaneal tuberosity and extends to the metatarsal heads, is crucial for maintaining foot biomechanics. It supports the longitudinal arch and functions as a shock absorber during movement. Structurally, it consists of three segments: the medial band, which provides minor arch support; the central band, the thickest and strongest portion, playing a key role in shock absorption; and the lateral band, which contributes to foot stability. Among these, the central band is most commonly affected in plantar fasciitis.
Symptoms:
Patients with plantar fasciitis typically experience a gradual onset of pain localized to the medial aspect of the plantar heel. The discomfort is often most pronounced during the first few steps in the morning or after prolonged periods of rest. While the pain may temporarily improve with movement, it tends to return with activities involving prolonged standing, walking, or running. Many patients report that heel pain worsens after resuming weight-bearing activities following rest, such as standing up after sitting for an extended period.
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The pain is commonly felt at the anteromedial prominence of the calcaneus and can be aggravated by passive dorsiflexion of the toes. Symptoms often persist for weeks or months before patients seek medical attention. While the discomfort may lessen as the day progresses, it rarely fully resolves and tends to worsen with activities that involve prolonged weight-bearing, especially on hard surfaces. By the time of presentation, many patients may have already attempted using over-the-counter shoe inserts or heel cushions.
The area most affected in plantar fasciitis is the medio plantar region of the heel, where applying pressure during a physical examination or walking often triggers significant pain.
Diagnosis:
Plantar fasciitis is primarily diagnosed based on the patient's history and physical examination. Patients typically report sharp pain in the anteromedial region of the heel. The windlass test can aid in diagnosis, where forced dorsiflexion of the toes at the metatarsophalangeal joints while stabilizing the ankle reproduces heel pain. Research suggests the windlass test has a specificity of 100% but a sensitivity of 32%.
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In most cases, clinical evaluation is sufficient to confirm plantar fasciitis. However, if symptoms persist beyond three months despite treatment, imaging may be necessary to rule out other conditions. According to the American College of Radiology guidelines, although radiographs are not highly sensitive for diagnosing plantar fasciitis, they are recommended as the initial imaging modality. Magnetic resonance imaging (MRI) has been shown to be effective in confirming the diagnosis, while ultrasound is a cost-effective alternative for differentiating plantar fasciitis from other soft tissue conditions.
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X-rays can help identify bony abnormalities, such as heel spurs, but the presence of a spur is not definitive for plantar fasciitis since it is also found in asymptomatic individuals. Although chronic heel pain is more commonly associated with a bone spur, the spur itself persists even after symptoms resolve. Ultrasound is a practical and affordable tool for assessing soft tissue changes, with findings such as plantar fascia thickness exceeding 4 mm and hypoechoic areas supporting the diagnosis. MRI, though more expensive, is beneficial for evaluating persistent heel pain, showing increased thickness of the plantar fascia with higher signal intensity on T2-weighted and short tau inversion recovery (STIR) sequences.
Mechanism of Injury:
The plantar fascia extends from the heel bone (calcaneus) to the toes, with most of the load falling on its medial edge, particularly from the medial calcaneal process to the first toe. The fascia helps to support the medial arch of the foot, so any weight-bearing activity (such as standing or walking) that impacts the arch can cause the fascia to stretch. This is especially true when the big toe dorsiflexes, as in forefoot running, which engages the windlass mechanism that further loads the plantar fascia.
In conclusion, factors that mechanically load the plantar fascia, whether intrinsic or extrinsic, significantly contribute to the development of plantar fasciitis.
Risk Factors:
Intrinsic Factors:
1. Body Mass Index (BMI > 27 kg/m²):
- Excessive body weight places additional strain on the foot, particularly on the plantar fascia, increasing the risk of injury.
2. Pes Cavus (High Arch):
- A high arch can increase the stress on the plantar fascia, as it results in altered load distribution during walking and running.
3. Pes Planus (Excessive Foot Pronation):
- Flat feet lead to excessive stretching of the plantar fascia, especially when the foot excessively pronates, or rolls inward during weight-bearing activities.
4. Reduced Ankle Dorsiflexion:
- Limited ankle flexibility can alter foot mechanics during movement, resulting in increased tension on the plantar fascia, particularly during activities like walking and running.
5. Foot and Calf Muscle Tightness:
- Tight calf muscles, particularly the gastrocnemius and soleus, limit ankle dorsiflexion, placing more strain on the plantar fascia.
Extrinsic Factors:
1. Excessive Running:
- Running, particularly on hard surfaces, puts repetitive stress on the feet and increases strain on the plantar fascia.
2. Sudden Increase in Running Intensity/Volume:
- An abrupt change in running intensity or volume can overload the plantar fascia, especially if the body is not accustomed to the increased activity.
3. Prolonged Standing/Walking:
- Occupations or activities that require long periods of standing or walking can place continuous load on the plantar fascia, increasing the risk of inflammation and pain.
4. Running on Hard Surfaces:
- Hard surfaces do not absorb shock effectively, resulting in higher impact forces transmitted to the feet and increasing the risk of plantar fasciitis.
5. Walking Barefoot:
Walking barefoot, especially on hard or uneven surfaces, can increase strain on the plantar fascia, particularly if the foot lacks adequate support.
Treatment for Plantar Fasciitis
The majority of plantar fasciitis cases (90%-95%) resolve with non-surgical treatments within 12–18 months.
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Activity Modification:
The first-line treatment involves rest from activities that aggravate the condition. Ice after exercise, along with oral or topical NSAIDs, can alleviate pain. Studies suggest that deep friction massage, shoe inserts or orthotics, and night splints can provide additional relief. Educating patients on the treatment's expected duration is essential. High-impact activities like running should be avoided initially, but low-impact exercises such as cycling, swimming, and rowing are helpful for maintaining cardiovascular fitness. Patients can gradually return to regular activity after being symptom-free for 4–6 weeks.
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Plantar Fascia Stretching and Ice Massage:
Stretching the plantar fascia and calf muscles has shown to be more effective than Achilles tendon stretches. A plantar fascia-specific stretch involves dorsiflexing the toes while palpating the fascia to ensure its taut. Hold the stretch for 30 seconds, repeating it three times per session, especially before the first steps in the morning. Ice massage (rolling a frozen can under the foot) for 5–10 minutes daily also helps reduce pain.
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Physical Therapy Options:
Various therapies, including eccentric stretching and myofascial massage, can help manage chronic cases. Eccentric exercises, which lengthen muscles under load, show promise but need more research for plantar fasciitis. Myofascial massage improves blood flow to the fascia, aiding healing. Iontophoresis, which uses electrical currents to enhance medication absorption, has shown some effectiveness but requires further study.
Recent studies indicate that plantar fascia-specific stretching may be more beneficial than Achilles tendon stretching. One study found a 52% improvement in heel pain after eight weeks of plantar fascia stretching compared to 22% with Achilles tendon stretches.
Foot Orthoses:
Orthotics help reduce strain on the plantar fascia by supporting the medial arch and minimizing direct pressure on inflamed areas. For individuals with swelling, orthotics can be designed with an aperture to relieve pressure. Semi-rigid orthotics are recommended for athletes, and when prescribing, specifying "semi-rigid orthotics with plantar fascia accommodation and aperture" ensures proper customization by a podiatrist.
Research suggests that both prefabricated and custom-made orthotics effectively alleviate plantar fasciitis pain. Studies indicate that prefabricated insoles perform comparably to custom-made ones, offering a cost-effective option for individuals without significant biomechanical abnormalities such as pes planus or cavus. Commonly used orthotics include viscoelastic heel cups, arch supports, and full-length insoles, all of which help prevent overpronation and reduce tension on the fascia. A meta-analysis confirmed that both prefabricated and custom orthotics improve foot function and decrease rearfoot pain. While custom orthotics may not provide superior pain relief compared to prefabricated ones, combining them with a night splint may enhance symptom relief.
Night Splints:
Night splints maintain the ankle in a dorsiflexed position during sleep to prevent contracture of the gastrocnemius-soleus complex. By keeping the foot at a 90-degree angle, they prevent plantar fascia shortening, which can contribute to morning pain.
Evidence on their effectiveness is mixed. One randomized controlled trial (RCT) with 116 participants found no additional benefit when night splints were added to NSAIDs and Achilles stretching. However, another RCT with 28 participants showed that a combination of foot orthoses and night splints resulted in better pain relief than orthoses alone over two to eight weeks. Although night splints have been shown to improve plantar fasciitis symptoms when used alone, compliance is often poor due to sleep disturbance and discomfort. Anterior night splints tend to be better tolerated than posterior ones.
Extracorporeal Shock Wave Therapy (ESWT)
Introduced in the early 1990s for insertional tendinopathies, ESWT promotes healing by stimulating circulation, neovascularization, and growth factor release while disrupting unmyelinated nerve fibers. It can be delivered as low- or high-energy waves in focused or radial modalities, though there is no consensus on the optimal intensity or protocol for plantar fasciitis treatment.
ESWT is considered for patients who do not respond to conservative treatment after six months, offering a noninvasive alternative to surgery. While some studies show improvement in heel pain, clinical evidence remains mixed due to varying treatment protocols. A 2005 meta-analysis found minimal benefit on pain scales, whereas a 2007 review supported ESWT as a viable option for chronic cases.
Potential advantages include faster recovery compared to surgery, though side effects such as pain, swelling, and numbness may occur. Recent trials suggest ESWT may induce microdisruption of the plantar fascia, triggering an inflammatory and reparative response. A double-blind RCT demonstrated its effectiveness over placebo in recalcitrant cases. Given its noninvasive nature, ESWT may be preferable for patients who have failed conservative therapies but wish to avoid surgery.
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Injections for Plantar Fasciitis
Corticosteroid Injections
Corticosteroids are commonly used to reduce pain and inflammation, though plantar fasciitis is primarily a degenerative condition. Studies show short-term benefits, with one RCT demonstrating improved pain relief and reduced fascia thickness at three months following dexamethasone injection. Ultrasound-guided injections are more effective than palpation-guided ones. However, repeated corticosteroid injections increase the risk of plantar fascia rupture (2.4% incidence) and fat pad atrophy, particularly when administered away from the calcaneal side.
Autologous Blood-Derived Products
Platelet-rich plasma (PRP) and whole blood injections aim to stimulate tissue regeneration. While PRP has shown potential for immediate pain relief, its long-term effectiveness remains uncertain. Some studies report PRP as superior to corticosteroids, while others suggest minimal benefits based on low-quality evidence. Unlike PRP, whole blood injections require no additional processing, reducing costs. A comparative study found both PRP and whole blood to be around 80% effective at three months. However, PRP injections are typically not covered by insurance.
Botulinum Toxin (Botox) Injections
Botulinum toxin has demonstrated pain relief and improved foot function by inhibiting pain peptides, reducing inflammation, and decreasing neural discharge. Small RCTs and meta-analyses suggest that Botox injections provide superior pain relief compared to corticosteroids. A study comparing ultrasound-guided Botox and corticosteroid injections found greater benefits with Botox.
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Surgery
When non-surgical treatments fail to provide relief after 6 to 12 months, surgery may be an option. There are three main types of procedures: open surgery, percutaneous surgery, and endoscopic surgery.
Open Surgery
In this approach, the surgeon makes an incision in the foot to access and partially release the plantar fascia. Patients typically need to avoid putting weight on the foot for about three weeks, and full recovery can take up to three months. While effective, potential complications include scarring and arch instability.
Percutaneous Surgery
This minimally invasive procedure involves small incisions through which the fascia is released. It offers a shorter recovery time compared to open surgery, but the success rate varies, and there is a risk of incomplete release.
Endoscopic Surgery
A more modern and widely preferred technique, endoscopic fasciotomy uses a small camera and specialized tools to cut the fascia through tiny incisions. Studies show that this method allows for a quicker return to normal activities, with many patients back in regular shoes within a week. However, risks include nerve damage and changes in foot structure.
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Surgery is generally a last resort, as complications such as arch collapse and persistent foot pain can occur. A consultation with an orthopedic specialist is recommended before considering surgical intervention.
References
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American Academy of Family Physicians, ‘Plantar Fasciitis’, American Family Physician, 15 June 2019, https://www.aafp.org/pubs/afp/issues/2019/0615/p744.html
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· American Academy of Family Physicians, ‘Plantar Fasciitis: Diagnosis and Management’, American Family Physician, 15 September 2011, https://www.aafp.org/pubs/afp/issues/2011/0915/p676.html
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· Orthobullets, ‘Plantar Fasciitis’, NCBI Bookshelf, 2019, https://www.ncbi.nlm.nih.gov/books/NBK431073/
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· Maffulli, N., Longo, U. G., Gougoulias, N., et al., ‘Plantar Fasciitis: A Review of Its Treatment with an Emphasis on the Use of Extracorporeal Shockwave Therapy’, PMC, 2014, https://pmc.ncbi.nlm.nih.gov/articles/PMC3954277/
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· Lee, M., and Lin, H., ‘The Effectiveness of Botulinum Toxin for Plantar Fasciitis: A Systematic Review’, PMC, 2016, https://pmc.ncbi.nlm.nih.gov/articles/PMC4853481/