Our feet give us a solid place to stand, and take us where we want to go—tasks that demand the coordination of 26 bones and 33 joints, connected by over one hundred tendons and ligaments. This intricate mechanism stands up to quite a beating: With every step you take, and the average person has walked 75,000 miles by the time he or she is fifty, according to the Arthritis Foundation, it absorbs an impact of one-and-a-half to four times your body weight. A lot can go wrong.
A frequent problem is heel pain, and its most common cause is plantar fasciitis—an often persistent condition that brings a million people to see their doctors each year, and will afflict 10 percent of us during our lifetime.
What is plantar fasciitis?
The plantar fascia is a thick band of connective tissue, similar to a ligament, that runs from the metatarsal bones in the front of the foot to the calcaneous, the main bone in the heel. It supports the arch, absorbs shock, and plays a key role in the mechanism that flexes the toes to propel you forward in each step of walking and running.
Plantar fasciitis develops when the band becomes too thick and stiff. This happens when the wear and tear of walking and standing causes micro-tears, particularly in high-impact conditions like running. The body heals by producing scar tissue, thickening the fascia. The thicker the fascia, the less flexible and more prone to more microtears it becomes, in a downward spiral. Eventually, the abused fascia becomes inflamed.
Are you at risk?
Although anyone can develop plantar fasciitis, at any age, certain conditions, anatomical peculiarities, and behaviors make you particularly vulnerable:
- The more you weigh, the more impact on the plantar fascia.
- Jobs that require long periods of standing or walking
- Being sedentary allows the plantar fascia to stiffen, making it more prone to tears.
- Excessive high-impact exercise, such as running, causing repetitive microtrauma.
- High arch or low arch (flat feet)
- Tightness in muscles and connective structures of the leg, like the calf, hamstring, and Achilles tendon
- Footwear that lacks sufficient arch support, or walking barefoot
What are the symptoms of plantar fasciitis?
The principal symptom is heel pain, usually in the inner part of the bottom (plantar) surface of the heel, although it can occur anywhere on the bottom of the foot.
The pain generally follows a particular pattern. It is worst on the first steps you take on arising in the morning, gets better as the day goes on, may worsen again after prolonged sitting, and becomes painful at the end of the day.
The reason: the prolonged inactivity of sleeping (or to a lesser extent, prolonged sitting) makes the plantar fascia tighten and increases pressure-sensitivity. As you walk on it, the fascia loosens, and the pain lessens. Microtears and swelling accumulate during a day of activity, so pain returns.
The pain of plantar fasciitis may be relatively slight, or severe enough to bring tears. Most often it’s a dull, constant ache, but it may be sharp or stabbing when the heel is subjected to pressure.
Plantar fasciitis treatment
Although you can attempt to treat heel pain on your own, it’s best to see a doctor—preferably a podiatrist or orthopedist specializing in the foot and ankle—soon after it begins to cause you distress or interfere with your daily activities. He or she can rule out other possible causes, such as stress fracture or nerve entrapment, and give you detailed instructions on treatment.
Usually, the doctor can diagnose plantar fasciitis simply by physical examination and your description of the pain, although he or she may take x-rays as well.
Prompt treatment is essential. Untreated, plantar fasciitis is likely to get worse, and the tearing/scar formation/healing cycle will continue to thicken the fibrous band, making it more resistant to treatment.
Some rest is usually required. This could mean a week-long break from sports or exercise, or at least a change in routine from walking or running to low-impact activities like swimming, stationary bike, or elliptical workouts. Stay off your feet as much as possible at work.
Icing and an anti-inflammatory medication like ibuprofen (Motrin, Advil) or naproxen (Aleve) are usually part of treatment. So are exercises designed to stretch the fascia, the calf, and the Achilles tendon, and possibly massage to break up scar tissue, as well. A night splint (available over the counter), will hold the foot at a 90-degree angle to keep the fascia stretched during sleep.
Proper footwear is an essential part of treatment. Good, supportive shoes with sufficient cushioning should be chosen depending on the anatomy of your foot. Orthotics are often helpful. Over-the-counter inserts, such as Powerstep, Superfeet, or Protalus insoles may be sufficient if you have a low or normal arch, but for a high arch, you will probably need them custom-made.
It may take time, but this regimen usually provides 50 percent improvement within six weeks, and gradual improvement thereafter.
If the pain persists, more advanced techniques may be necessary. After three months of unsuccessful conservative treatment, you may be a candidate for extracorporeal shock-wave therapy (ESWT), which targets high-energy sound waves to break up scar tissue in the fascia (the technique is also used for tennis elbow and Achilles tendinitis). Because it’s not approved for these uses, health insurance will probably not pay for it.
If plantar fasciitis has resisted treatment even longer, minimally invasive surgery, such as radiofrequency ablation, which uses electromagnetic waves to generate heat to thin out thickened tissue, may be the next step.
Plantar fasciotomy, invasive surgery to cut through much of the fascia and release tension, is a last resort and rarely necessary.
Don’t come back
If you’ve had plantar fasciitis, you’re at risk of recurrence. And if you’ve never had it, you don’t want to start. To minimize the chances:
- Don’t overdo high-impact exercise like running.
- Continue stretching to keep the fascia from tightening.
- Don’t walk barefoot, or in sandals without support.
- Wear shoes with the right amount of support for your foot type. Replace them at least once a year, every six months if you’re active.
- If you have high arches, consider wearing orthotics indefinitely.
