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Plantar Fasciitis

Plantar Fasciitis

Topic Overview

Bones of the foot

What is plantar fasciitis?

Plantar fasciitis (say "PLAN-ter fash-ee-EYE-tus") is the most common cause of heel pain. The plantar fascia is the flat band of tissue (ligament) that connects your heel bone to your toes. It supports the arch of your foot. If you strain your plantar fascia, it gets weak, swollen, and irritated (inflamed). Then your heel or the bottom of your foot hurts when you stand or walk.

Plantar fasciitis is common in middle-aged people. It also occurs in younger people who are on their feet a lot, like athletes or soldiers. It can happen in one foot or both feet.

What causes plantar fasciitis?

Plantar fasciitis is caused by straining the ligament that supports your arch. Repeated strain can cause tiny tears in the ligament. These can lead to pain and swelling. This is more likely to happen if:

  • Your feet roll inward too much when you walk (excessive pronation).
  • You have high arches or flat feet.
  • You walk, stand, or run for long periods of time, especially on hard surfaces.
  • You are overweight.
  • You wear shoes that don't fit well or are worn out.
  • You have tight Achilles tendons or calf muscles.

What are the symptoms?

Most people with plantar fasciitis have pain when they take their first steps after they get out of bed or sit for a long time. You may have less stiffness and pain after you take a few steps. But your foot may hurt more as the day goes on. It may hurt the most when you climb stairs or after you stand for a long time.

If you have foot pain at night, you may have a different problem, such as arthritis, or a nerve problem such as tarsal tunnel syndrome.

How is plantar fasciitis diagnosed?

Your doctor will check your feet and watch you stand and walk. He or she will also ask questions about:

  • Your past health, including what illnesses or injuries you have had.
  • Your symptoms, such as where the pain is and what time of day your foot hurts most.
  • How active you are and what types of physical activity you do.

Your doctor may take an X-ray of your foot if he or she suspects a problem with the bones of your foot, such as a stress fracture.

How is it treated?

No single treatment works best for everyone with plantar fasciitis. But there are many things you can try to help your foot get better:

  • Give your feet a rest. Cut back on activities that make your foot hurt. Try not to walk or run on hard surfaces.
  • To reduce pain and swelling, try putting ice on your heel. Or take an over-the-counter pain reliever like ibuprofen (such as Advil or Motrin) or naproxen (such as Aleve).
  • Do toe stretches, calf stretches and towel stretches several times a day, especially when you first get up in the morning. (For towel stretches, you pull on both ends of a rolled towel that you place under the ball of your foot.)
  • Get a new pair of shoes. Pick shoes with good arch support and a cushioned sole. Or try heel cups or shoe inserts (orthotics). Use them in both shoes, even if only one foot hurts.

If these treatments do not help, your doctor may recommend splints that you wear at night, shots of medicine (such as a steroid) in your heel, or other treatments. You probably will not need surgery. Doctors only suggest it for people who still have pain after trying other treatments for 6 to 12 months.

How long will it take for the pain to go away?

Plantar fasciitis most often occurs because of injuries that have happened over time. With treatment, you will have less pain within a few weeks. But it may take time for the pain to go away completely. It may take a few months to a year.

Stay with your treatment. If you don't, you may have constant pain when you stand or walk. The sooner you start treatment, the sooner your feet will stop hurting.

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Cause

Exactly what causes plantar fasciitis is not well understood. But it probably develops as the result of repeated small tears in the plantar fascia. Normally when you walk, your plantar fascia stretches as your foot strikes the ground. If the plantar fascia is strained by the way you walk or by repeated stress, it can become weak, swollen, and irritated (inflamed), and it can hurt when you stand or walk.

Conditions or activities that may lead to plantar fasciitis include:

  • Things that affect how the feet work (biomechanical factors). These include abnormal inward twisting or rolling of the foot (pronation), high arches, flat feet, tight calf muscles, or tight tendons at the back of the heel (Achilles tendons).
  • Repetitive activities, such as jobs that require prolonged walking or standing on hard or irregular surfaces or sports such as running.
  • Things that put extra stress on the feet, such as being overweight or wearing shoes that are poorly cushioned, don't fit well, or are worn out.
  • The natural process of aging. Plantar fasciitis is most common in middle-aged adults.
  • In rare cases, a single injury to the foot.

Symptoms

The classic symptom of plantar fasciitis is heel pain when you take your first steps after getting out of bed or after sitting for a long period of time. You may also have:

  • Stiffness and pain in the morning or after resting that gets better after a few steps but gets worse as the day progresses.
  • Pain that gets worse when you climb stairs or stand on your toes.
  • Pain after you stand for long periods.
  • Pain at the beginning of exercise that gets better or goes away as exercise continues but returns when exercise is completed.

Plantar fasciitis may be mistaken for other conditions with similar symptoms, such as arthritis or a nerve problem such as tarsal tunnel syndrome.

What Happens

Plantar fasciitis usually develops gradually. You may have heel pain only when you take your first steps after getting out of bed or after sitting for a long period of time. If you do not rest your feet, the pain will get worse. Other things, such as the repetitive stress of walking, standing, running, or jumping, will add to the injury, inflammation, and pain. The injured ligament may never heal completely if you are not able to stop the activity or change the condition that caused it.

As plantar fasciitis progresses:

  • The heel pain gradually gets worse.
  • You may change the way you walk to relieve the pain. This eventually may lead to more discomfort and pain and other problems with your foot, leg, hip, or back. Daily activities or sports may become even more limited.
  • You eventually may have pain with any weight-bearing activity. Running and jumping may no longer be possible.
  • A heel spur may form as a result of continued stress as the plantar fascia pulls on the heel bone. (By itself, a heel spur does not cause plantar fasciitis and does not usually cause problems. And you can have plantar fasciitis and not have a heel spur.)

If the condition is not treated, plantar fasciitis can cause constant heel pain when you stand or walk.

What Increases Your Risk

You have a greater chance of developing plantar fasciitis if you:

  • Are middle-aged or older.
  • Walk with an inward twist or roll of the foot (pronation) or have high arches or flat feet.
  • Are overweight or suddenly gain a lot of weight.
  • Have tight Achilles tendons (which attach the calf muscles to the heel bones) or tight calf muscles.
  • Have habits or do activities that increase the stress on your feet, such as:
    • Wearing shoes with poor cushioning.
    • Walking or running without being conditioned for these activities.
    • Changing your walking or running surface (for example, from grass to concrete).
    • Having a job that involves prolonged standing on hard surfaces.
  • Are an athlete or a member of the military. Some athletes, especially runners, are more likely to get plantar fasciitis because of:
    • Things that affect the way their feet strike the ground, such as not having enough flexibility in the foot and ankle or having stronger muscles in one leg than in the other.
    • The repetitive nature of sports activities.
    • Improper training.

If you are a runner, you increase your chance of developing plantar fasciitis if you:

  • Abruptly change how hard or how long you run.
  • Run on steep hills.
  • Wear running shoes that do not have a cushioned sole, lack good arch support, or are worn out.

When should you call your doctor?

If you think you might have plantar fasciitis, call your doctor. The earlier a doctor diagnoses and treats your problem, the sooner you will have relief from pain.

Call your doctor immediately if you have heel pain with fever, with redness or warmth in your heel, or with numbness or tingling in your heel.

Call your doctor if you have:

  • Pain that continues when you are not standing or bearing any weight on your heel.
  • A heel injury that results in pain when you put weight on your heel.
  • Heel pain that does not getter better after a week, even though you have tried rest, ice, over-the-counter pain medicine (such as ibuprofen or acetaminophen), and other home treatment.

Call your doctor if you have been diagnosed with plantar fasciitis and the home treatment you agreed on is not helping to control your heel pain.

Watchful waiting

If you have heel pain:

  • First, try resting and icing your heel. If possible, stop or reduce activities that cause the pain, such as running, standing for long periods of time, or walking on hard surfaces.
  • Try different shoes. Make sure they have good arch support and well-cushioned soles. Or if your current shoes are in good shape, try heel cups or shoe inserts (orthotics) to cushion your heel.
  • Switch to other activities or exercises that don't put pressure on your heel. After your symptoms are completely gone, gradually resume the activity that was causing pain.
  • If you are an athlete, do not ignore or attempt to "run through" the pain. This can lead to a chronic problem that is more difficult to treat successfully.

Who to see

The following health professionals can evaluate and diagnose plantar fasciitis and recommend nonsurgical treatment:

If nonsurgical treatments fail to relieve your pain, your doctor may refer you to a specialist such as an orthopedist or podiatrist. If you are an athlete, your doctor may refer you to a sports medicine specialist to look for problems with how your feet strike the ground, how your feet are shaped, or your training routine.

The following health professionals can do surgery:

  • Podiatric surgeon
  • Orthopedic surgeon, especially one who specializes in foot and ankle conditions
  • Sports medicine surgeon

Exams and Tests

To diagnose plantar fasciitis, your doctor will ask questions about your symptoms and your past health. He or she will also do a physical exam of your feet that includes watching you stand and walk.

X-rays aren't helpful in diagnosing plantar fasciitis, because they do not show ligaments clearly. But your doctor might take X-rays if he or she suspects a stress fracture, bone cyst, or other foot or ankle bone problems. X-rays may show whether a heel spur is present, but a bone spur does not necessarily mean that a person has plantar fasciitis.

If the diagnosis is not clear, you may have other tests. Tests that are done in rare cases include ultrasound, MRI, blood tests, bone scans, and vascular testing, which can evaluate blood flow in the foot and lower leg. If your doctor suspects nerve entrapment, you may have neurological testing.

Treatment Overview

The goals of treatment for plantar fasciitis are to:

  • Relieve inflammation and pain in the heel.
  • Allow small tears in the plantar fascia ligament to heal.
  • Improve strength and flexibility and correct foot problems such as excessive pronation so that you don't stress the plantar fascia ligament.
  • Allow you to go back to your normal activities.

Most people recover completely within a year. Out of 100 people with plantar fasciitis, about 95 are able to relieve their heel pain with nonsurgical treatments. Only about 5 out of 100 need surgery.footnote 1

Treatment that you start when you first notice symptoms is more successful and takes less time than treatment that is delayed.

Initial treatment

There are many methods you can try to relieve the heel pain of plantar fasciitis. Even though their effectiveness has not been proved in scientific studies, these methods, used alone or in combination, work for most people.footnote 2

  • Rest your feet. Limit or, if possible, stop daily activities that are causing your heel pain. Try to avoid running or walking on hard surfaces, such as concrete.
  • To reduce inflammation and relieve pain, put ice on your heel. You can also try a nonsteroidal anti-inflammatory drug (NSAID) such as ibuprofen (Advil or Motrin, for example) or naproxen (Aleve, for example). NSAIDs come in pills and in a cream that you rub over the sore area.
  • Wear shoes with good shock absorption and the right arch support for your foot. Athletic shoes or shoes with a well-cushioned sole are usually good choices.
  • Try heel cups or shoe inserts (orthotics) to help cushion your heel. You can buy these at many athletic shoe stores and drugstores. Use them in both shoes, even if only one foot hurts.
  • Put on your shoes as soon as you get out of bed. Going barefoot or wearing slippers may make your pain worse.
  • Do simple exercises such as toe stretches, calf stretches, and towel stretches several times a day, especially when you first get up in the morning. These can help your ligament become more flexible and strengthen the muscles that support your arch. (For towel stretches, you pull on both ends of a rolled towel that you place under the ball of your foot.)

Avoid using only heat on your foot, such as from a heating pad or a heat pack for at least the first 2 or 3 days. Heat tends to make symptoms worse for some people. If you use contrast baths, which alternate hot and cold water, make sure you end with a soak in cold water. If you try a heating pad, use a low setting.

If your weight is putting extra stress on your feet, your doctor may encourage you to try a weight-loss program.

Ongoing treatment

If nonsurgical methods such as rest, ice, and stretching exercises help relieve your plantar fasciitis symptoms, continue using them. If you have not improved after 6 weeks, your doctor may recommend that you continue those methods but add other nonsurgical treatments, such as:

  • Custom-made shoe inserts (orthotics). Custom-made orthotics require a prescription. If your foot has an unusual shape or if you have a certain problem that the device will help, then a custom-made insert may fit better and control pain better than a nonprescription one.
  • Night splints. A night splint holds the foot with the toes pointed up and with the foot and ankle at a 90-degree angle. This position applies a constant, gentle stretch to the plantar fascia.
  • A walking cast on the lower leg. Casting is somewhat more expensive and inconvenient than other nonsurgical treatments. And after the cast is removed, you will need some rehabilitation to restore strength and range of motion. But a cast forces you to rest your foot.

Formal physical therapy instruction can help make sure you properly stretch your Achilles tendon and plantar fascia ligament. Doctors usually consider surgery only for severe cases that do not improve.

Treatment if the condition gets worse

Your doctor may suggest corticosteroid shots if you have tried nonsurgical treatment for several weeks without success.footnote 1 Shots can relieve pain, but the relief is often short-term. Also, the shots themselves can be painful, and repeated shots can damage the heel pad and the plantar fascia.

Out of 100 people with plantar fasciitis, about 95 are able to relieve their heel pain with nonsurgical treatments. Only about 5 out of 100 need surgery. footnote 1If you are one of the few people whose symptoms don't improve in 6 to 12 months with other treatments, your doctor may recommend plantar fascia release surgery. Plantar fascia release involves cutting part of the plantar fascia ligament in order to release the tension and relieve the inflammation of the ligament.

What to think about

If you are trying to lose weight and you develop plantar fasciitis when you begin exercising, especially jogging, talk with your doctor about other types of activity that will support your weight-loss efforts without making your heel pain worse. An activity like swimming that doesn't put stress on your feet may be a good choice.

If your plantar fasciitis is related to sports or your job, you may have trouble stopping or reducing your activity to allow your feet to heal. But resting your feet is very important to avoid long-lasting heel pain. Your doctor or a sports medicine specialist may be able to suggest a plan for alternating your regular activities with ones that do not make your pain worse.

If you exercise frequently, ask your doctor whether physical therapy or referral to a sports medicine specialist, podiatrist, or orthopedist is appropriate.

Some questions you may want to ask about exercise include:

  • Should I cut back on my exercise? How many days per week, how long, and what exercise should I do instead?
  • Should I ice my foot after I exercise? If so, for how long each time, and how long should I continue the icing?
  • Should I use nonsteroidal anti-inflammatory drugs (NSAIDs) either before or after I exercise?
  • Are there exercises I can do to make my foot and ankle more flexible? What are they, and how often and how long should I do them?

Prevention

The following steps will help prevent plantar fasciitis or help keep the condition from getting worse if you already have it:

  • Take care of your feet. Wear shoes with good arch support and heel cushioning. If your work requires you to stand on hard surfaces, stand on a thick rubber mat to reduce stress on your feet.
  • Do exercises to stretch the Achilles tendon at the back of the heel. This is especially important before sports, but it is helpful for nonathletes as well. Ask your doctor about recommendations for a stretching routine.
  • Stay at a healthy weight for your height.
  • Establish good exercise habits. Increase your exercise levels gradually, and wear supportive shoes.
  • If you run, alternate running with other sports that will not cause heel pain.
  • Put on supportive shoes as soon as you get out of bed. Going barefoot or wearing slippers puts stress on your feet.

If you feel that work activities caused your heel pain, ask your human resources department for information about different ways of doing your job that will not make your heel pain worse. If you are involved in sports, you may want to consult a sports training specialist for training and conditioning programs to prevent plantar fasciitis from recurring.

Home Treatment

The first steps your doctor will recommend to treat plantar fasciitis are ones you can take yourself. Different people find that one method or a combination of methods works best for them.

Try the following methods:

  • Rest your feet. Stop or reduce any activities that may be causing your heel pain.
  • Wear supportive footwear. Wear shoes that have good arch support and heel cushioning. Or buy shoe inserts (orthotics). Shoe inserts may be made of plastic, rubber, or felt. Orthotics can reduce stress and pulling on the plantar fascia ligament.
  • Use ice on your heel. Ice can help reduce inflammation. Contrast baths, which alternate hot and cold water, can also be helpful. Heat alone may make symptoms worse for some people, so always end a contrast bath with a soak in cold water. If ice isn't helping after 2 or 3 days, try heat, such as a heating pad set on low.
  • Take ibuprofen (such as Advil or Motrin), naproxen (such as Aleve), or another nonsteroidal anti-inflammatory drug (NSAID) to reduce pain and inflammation. NSAIDs come in pills and in a cream that you rub over the sore area. Be safe with medicines. Read and follow all instructions on the label.
  • Wear night splints. Night splints gently stretch the plantar fascia ligament and Achilles tendon and keep them from getting tight during the night.
  • Do stretching and strengthening exercises. Exercises for stretching the Achilles tendon and plantar fascia will increase their flexibility. Exercises to strengthen the muscles of the foot and ankle will help support the arch.

Often athletes develop foot problems because they train in shoes that are worn out or don't fit properly. Replace your shoes every few months, because the padding wears out. Also, replace shoes if the tread or heels are worn down. While replacing shoes is expensive, it is less expensive—and less painful—than a long-lasting heel problem. Other sensible training techniques, such as avoiding uneven or hard surfaces, can help prevent plantar fasciitis from occurring or returning.

If your weight is putting extra stress on your feet, your doctor may encourage you to try a weight-loss program.

To be successful at treating plantar fasciitis, you will need to:

  • Be patient and consistent. The majority of cases of plantar fasciitis go away in time if you regularly stretch, wear good shoes, and rest your feet so they can heal.
  • Start treatment right away. Don't just ignore the pain and hope it will go away. The longer you wait to begin treatment, the longer it will take for your feet to stop hurting.

The healing process takes time—from a few months to a year. But you should begin to have less pain within weeks of starting treatment. If you have not improved after trying these methods for 6 weeks, your doctor will suggest other treatments.

Medications

Your doctor may recommend medicine to relieve the pain and inflammation caused by plantar fasciitis. Drug treatment does not cure plantar fasciitis. But by reducing pain, medicine may make it easier for you to follow other treatment steps, such as stretching. You should not use medicine as a way to continue the activities that are causing heel pain.

Medicine options include:

  • Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Advil or Motrin, for example) or naproxen (Aleve, for example). You can buy these medicines without a prescription. NSAIDs are often used if you have only had symptoms of plantar fasciitis for a few days or weeks. They are less likely to work if you have had symptoms for more than 6 to 8 weeks. NSAIDs come in pills and in a cream that you rub over the sore area.
  • Corticosteroid shots. Your doctor may recommend shots if you have tried other treatments for several weeks without success.footnote 3 Doctors may recommend shots sooner for some people.

Injections of botulinum toxin are being studied for use in plantar fasciitis.

Surgery

Surgery is usually not needed for plantar fasciitis. About 95 out of 100 people who have plantar fasciitis are able to relieve heel pain without surgery. Your doctor may consider surgery if nonsurgical treatment has not helped and heel pain is restricting your daily activities. Some doctors feel that you should try nonsurgical treatment for at least 6 months before you consider surgery.footnote 1

The main types of surgery for plantar fasciitis are:

  • Plantar fascia release. This procedure involves cutting part of the plantar fascia ligament. This releases the tension on the ligament and relieves inflammation.
  • Other procedures, such as removing a heel spur or stretching or loosening specific foot nerves. These surgeries are usually done in combination with plantar fascia release when there is lasting heel pain and another heel problem.

Experts in the past thought that heel spurs caused plantar fasciitis. Now experts generally believe that heel spurs are the result, not the cause, of plantar fasciitis. Many people with large heel spurs never have heel pain or plantar fasciitis. So surgery to remove heel spurs is rarely done.

Other Treatment

Physical therapy may be helpful for some people who have plantar fasciitis. It can be especially useful for people who have problems with foot mechanics (biomechanical problems), such as tight Achilles tendons.

A technique called extracorporeal shock wave therapy (ESWT) uses pulsed sound waves to treat plantar fasciitis. Research is still being done, but some studies show that ESWT can help reduce symptoms in plantar fasciitis that has not responded to other treatment.footnote 4, footnote 5 New shock wave treatments are being studied. Most types of shock wave therapy, sometimes called "focused" ESWT, require anesthetic. Another type, called radial ESWT, can be done without anesthetic, because the shock wave is more spread out.

References

Citations

  1. American Academy of Orthopaedic Surgeons and American Academy of Pediatrics (2010). Plantar fasciitis. In JF Sarwark, ed., Essentials of Musculoskeletal Care, 4th ed., pp. 839–844. Rosemont, IL: American Academy of Orthopaedic Surgeons.
  2. Thomas JL, et al. (2010). The diagnosis and treatment of heel pain: A clinical practice guideline-revision 2010. Journal of Foot and Ankle Surgery, 49(3, Suppl): S1–S19.
  3. American Academy of Orthopaedic Surgeons and American Academy of Pediatrics (2010). Plantar fasciitis. In JF Sarwark, ed., Essentials of Musculoskeletal Care, 4th ed., pp. 839–844. Rosemont, IL: American Academy of Orthopaedic Surgeons.
  4. Malay DS, et al. (2006). Extracorporeal shockwave therapy versus placebo for the treatment of chronic proximal plantar fasciitis: Results of a randomized, placebo-controlled, double-blinded, multicenter intervention trial. Journal of Foot and Ankle Surgery, 45(4): 196–210.
  5. Gerdesmeyer L, et al. (2008). Radial extracorporeal shock wave therapy is safe and effective in the treatment of chronic recalcitrant plantar fasciitis: Results of a confirmatory randomized placebo-controlled multicenter study. American Journal of Sports Medicine. Published online October 1, 2008.

Other Works Consulted

  • Basford JR, Baxter GD (2010). Therapeutic physical agents. In WR Frontera et al., eds., Physical Medicine and Rehabilitation: Principles and Practice, 5th ed., vol. 2, pp. 1691–1712. Philadelphia: Lippincott Williams and Wilkins.
  • Digiovanni BF, et al. (2006). Plantar fascia-specific stretching exercise improves outcomes in patients with chronic plantar fasciitis. A prospective clinical trial with two-year follow-up. Journal of Bone and Joint Surgery, 88(6): 1775–1781.
  • Orchard J (2012). Clinical review: Plantar fasciitis. BMJ. Published online October 10, 2012 (doi:10.1136/bmj.e6603).
  • Pasquina PF, et al. (2015). Plantar fasciitis. In WR Frontera et al., eds., Essentials of Physical Medicine and Rehabilitation, 3rd ed., pp. 463–467. Philadelphia: Saunders.

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