Along the bottom of the foot, from the heel to the ball of the foot, is a thick band of tissue that helps keep the arch of the foot up. Due to all the stress this band of tissue undergoes it can develop tiny tears in it. These tiny tears are normally healed throughout the day and during sleep. But sometimes the healing process does not keep up with your activity level, and those tiny tears become painful. Most of the time this occurs where the fascia (thick band of tissue) attaches to the heel bone. Sometimes it occurs under the midfoot and rarely near the ball of the foot.

You will notice the attachment is not under the center of the heel, but towards the inside of the foot. The big toe is on the inside of the foot, and the pinky toe is on the outside of the foot.

What is Plantar Fasciitis?

Plantar fasciitis is caused by stress and stretching of the plantar fascia on the bottom of the foot. The plantar fascia is stressed by flattening the arch of the foot. Little tiny tears develop in the fascia as people bear weight. This is normal and the body is constantly repairing itself. But sometimes during the repair process the body gets stuck in the inflammatory part of the repair process, and this is when it gets painful.

There are two main causes of stress on the plantar fascia, activity and structural. A minority of cases are caused by direct trauma, such as stepping on a Lego, a rock, or falling onto the feet from a height.

• Activities that flatten the arch include walking, running, jumping, standing, standing on ladders, and carrying heavy objects.

• Structural. People with high arched feet or flat feet both have abnormally high levels of stress under the foot. Another structural issue is something called equinus. This is when the calf muscles are too short, and in turn, prevents the ankle from letting the foot go up. By preventing the foot from dorsiflexing, or going up, it causes a large amount of stress that flattens the foot.

• There is one factor that makes every situation worse, and that is being overweight. In every instance whether structural, activity, or trauma, being overweight can impede the healing process and can cause problems to return after a successful treatment.

Now lets discuss something that does not cause plantar fasciitis, and that is heel spurs. Some people get them, and some people don’t. If we take 1,000 xrays of feet with and without heel spurs it would not be possible to predict who has plantar fasciitis.

So if heel spurs do not cause plantar fasciitis, why does everyone say they are related? You may be saying right now, “I know someone who had their heel spur removed with surgery and it fixed their plantar fasciitis.”

You are correct, it did help. Let me explain. The plantar fascia, and some foot muscles, attach to the bottom of the heel. Over the years as these tissues pull on the bone, the area connecting the tissues to the bone can heal by depositing more bone. This slowly causes the formation of a spur on the bottom of the heel. Now when people do have plantar fasciitis it is most likely at the location of the spur. After all, that is where it pulls the most. And treatment, whether surgical or nonsurgical, helps take pressure off the spur. So when that person you know, that family friend, had their heel spur surgically removed, yes, it did help. Because removing the spur also detached the tissues from the heel bone and stopped the stress that caused the inflammation that resulted in pain. More detail on treatmemt is in the treatment section.

Causes

Symptoms

• The distinguishing feature of plantar fasciitis is pain when first standing in the morning and standing after rest. The bottom of the heel, and sometimes midfoot, will be most painful upon standing and then decrease over the next few minutes as a person walks it out and stretches out the bottom of the foot.

• Pain is mostly located on the bottom of the heel towards the inside of the foot. It can also extend toward the arch and rarely the pain is just under the midfoot and not at the heel at all.

• A podiatrist may check the structure of your foot while standing and while sitting. Plantar fasciitis in flat feet and high arched feet are, for the most part, treated the same; but severe deformities could lead to a whole other type of treatment plan that will not be discussed here.

• Another factor to check is the calf muscle group. The ankle range of motion is important to note. Does the forefoot go up high enough? If not, this will significantly increase pressure that flattens the foot, and may need to be adressed by surgically lengthening those muscles or tendons. It is a relatively easy and highly effective procedure but is not appropriate for everyone.

Treatment

Plantar fasciitis is most often caused by pulling of fascia on the heel bone. The goal of treatment is to decrease this pulling action and allow the body time to heal itself. We will also discuss options that target inflammation directly.

The treatment plan I recommend is composed of 6 parts. Parts 1-4 are all recommended at the first visit and to start at the same time. Part 5 is optional but recommended. Part 6 is between you and your physician.

The treatment discussion is divided into 3 sections. First section is a list of parts. Second is an explanation of each part. Third is a detailed discussion of how to perform each part and types of products/devices that can be used.

Part Names

1. Stretching

2. Arch supports

3. Ice or Frozen water bottle rolling

4. Steroid injection and/or anti-inflammatory medications

5. Night splint (optional)

6. After 12 months of consistent conservative treatment consider surgery

Brief Explanation of Parts

• Part 1: Stretching

  • Stretch 5 times a day for 30 seconds each. The goal is to stretch the plantar fascia into a more lengthened position. The fascia heals during rest in a shortened position and gets restretched each time a person stands. This isn’t going to over-flatten the foot. It is going to help prevent the healing process from over shortening.

• Part 2: Arch supports

  • Arch supports are used to help support the arch during weightbearing activities and take some pressure off the plantar fascia.

• Part 3: Ice and/or Frozen water bottle rolling

  • Ice is used to decrease inflammation.

  • If using a frozen water bottle this can perform both icing and rolling functions at the same time.

• Part 4: Steroid Injection and/or Anti-inflammatory Medication.

  • These directly target inflammation, decrease pain, and help the body turn off the inflammatory process. You can only get a steroid injection from a physician/podiatrist.

• Part 5: Night Splint

  • Night Splints keep the foot at a 90 degree angle to the lower leg while sleeping. This allows the plantar fascia to heal at night time in a longer position instead of being over shortened by a limp, bent sleeping foot.

• Part 6: Surgery

  • If there is no improvement after 12 months of treatment consider surgery. Discuss this with your physician for more information and their treatment plans and preferences.

Detailed Discussion of Each Part

• Part 1: Stretching

  • Stretch 5 times a day 30 seconds each. Do not bounce while stretching, it should be one continuous pressure. The stretch should raise the front of the foot with the heel down and knee straight. You should feel tightness in the calf muscle. You can use stairs, a piece of wood, anything that you can put your foot on without making you fall over. You must use your body weight to get a good stretch. Sometimes people say they stretch because they roll their ankle around while sitting. This might feel good but it is not stretching. Putting a towel under the forefoot and pulling backwards will not be as effective as standing and using your body weight but it may help some.

  • It is very important to stretch consistently every day. Skipping days can delay healing for weeks or months.

• Part 2: Arch Supports

  • The goal of arch supports is to help keep the arch from flattening out and take some pressure off the plantar fascia. You will find that a lot of arch supports are not supportive at all. Most available at department stores are squishy and unsupportive. If you wear these and they help and feel nice then by all means continue using them. If you have foot pain and these do not help then know that they are not actually arch supports, but squishy insoles labeled as arch supports.

  • Arch supports have a stiff flexibility. When you get them, remove the insole that comes in your shoe so your feet are not squished inside your shoe. If you are not used to wearing arch supports you may need to do a break-in period. Wear them 1 hour the first day, 2 hours the second, 3 hours the third and so on until you are wearing them all the time. This will get your foot used to wearing arch supports.

  • There are two types of arch supports, over the counter and custom. Both are effective for the majority of people. The main motivator to get customs is to save money in the long term. Over the counter arch supports should be replaced every 6 months. Customs can last 10+ years and when the top cover is damage can be repaired. While both custom and OTC are effective, if you have a foot shape that is severe in flatness or an abnormally high arch then customs may work better for you. Find a podiatrist if you want custom orthotics. Call around to different offices and ask their cash prices as insurance usually does not cover custom orthotics. Make sure your foot is casted in foam, scanned with a laser, or molded in plaster. If the only thing they measure is your shoe size then they are not custom orthotics.

• Part 3: Rolling Object Under Feet and Ice

  • Rolling an object such as a tennis ball 15 minutes twice a day (or more if you want) under the arch can break up the adhesions that form in the fascia and help prevent the pain that occurs when standing after rest.

  • Roll a frozen water bottle under your foot for 15 minutes twice a day. This has the added benefit of ice.

  • If you only have access to an ice pack place it under the painful area for 10 minutes twice a day to help decrease inflammation.

• Part 4: Steroid Injection and/or Anti-inflammatory Medication

  • In my experience a steroid injection is the quickest and most effective treatment for plantar fasciitis. It directly targets inflammation where it is located and some people are fine within a few days. Other people will get them every 3-4 months and go through periods of ups and downs in pain. An alternative is oral steroids but I have found this to be much less effective. Steroid injections and steroid medications can only be given by a physician/podiatrist.

  • Over the counter anti-inflammatory medications include topical Voltaren (generic name Diclofenac), and orals such as Tylenol (acetaminophen), Aleve (naproxen), and Advil (ibuprofen). Contact your physician before taking any medications.

• Part 5: Night Splint

  • Night Splints keep the foot at a 90 degree angle to the lower leg while sleeping. This allows the plantar fascia to heal at night time in a stretched out position instead of being overshortened by a limp, bent, sleeping foot.

  • Half of patients I give this to will flat out refuse to wear it at night saying it is too uncomfortable. There are different types. The type that goes behind and under the heel get the most feedback for being uncomfortable, the ones that go on top of the foot and front of the ankle tend to be more comfortable. Look at the different types and see if one will be more tolerable than another for you.

• Part 6: Surgery

  • If there is no improvement after 12 months of treatment consider surgery. Discuss this with your physician for more information and their treatment plans and preferences.

I hope this educational article has been helpful for you. Feel free to share it with family and friends.

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