Plantar Fasciitis

By Susan Rosso, DPM

Plantar fasciitis is the most common cause of heel pain. Approximately 1 million people are diagnosed with plantar fasciitis each year. It is debilitating at times, keeping people away from their ability to walk, exercise, and sometimes work.

The plantar fascia is comprised of three bands of dense connective tissue extending from the bottom of the heel to the base of the toes. Its action is to reinforce the arch of the foot when pushing off of our toes, giving us forward propulsion. Repetitive strain of the fascia results in thickening and fibrosis of the fascia, which causes pain. Plantar fasciitis is most commonly seen in patients between 45-64 years of age and in those with risk factors including flat feet, high arch feet, long distance runners, military personnel, occupations requiring prolonged standing, and obese or sedentary patients. Leg length differences also contribute significantly to unilateral heel pain. About 30% of patients will have bilateral foot pain.

Clinical symptoms include sharp, intense pain in the medial plantar heel upon first step out of bed or after periods of rest. The pain can worsen throughout the day with prolonged standing.

Physical examination will show pain with direct pressure to the medial plantar heel and quite often a reduction in range of motion of the ankle. An X-ray of the heel may show a heel spur, but most importantly, the X-ray is used to rule out a stress fracture or bone cyst within the large bone of the heel. Plantar heel pain may also have a neurologic origin from the lower back or tarsal tunnel impingement, and this must be evaluated clinically and/or with nerve conduction velocity studies (NCVs). Further imaging studies such as an ultrasound or MRI are sometimes used in cases of abnormal heel pain presentation.

Typically, plantar fasciitis is treated successfully with conservative treatment in 85-90% of cases. Initial treatment consists of rest, stretching exercises, ice, modifications of current shoes, non-steroidal anti-inflammatories (NSAIDs), night splints, and over-the-counter or custom orthotics. Corticosteroid injections may also be used to help reduce inflammation, especially with patients who are not responding to other forms of conservative treatment. Physical therapy modalities, especially ultrasound, can be very helpful in reducing inflammation and promoting healing, and the physical therapist can design and monitor a therapeutic stretching exercise program.

Platelet Rich Plasma (PRP) injections are a relatively new form of treatment and are showing relief of pain and return to function comparable to corticosteroid injections. Surgical options should be considered after 6-12 months of failed conservative treatment. Surgery consists of full or partial release of the plantar fascia through an endoscopic or open surgical approach. Endoscopy can provide for less risk of infection and less scar tissue development. Approximately 75% of patients undergoing surgery reported substantial or complete relief of symptoms. This gives a very successful outlook on achieving complete resolution of pain.

Plantar fasciitis is very treatable. If you are experiencing the symptoms discussed above, a thorough podiatric evaluation is the first step toward healing and resuming a full and active lifestyle.