Dr. Anthony DeMaria, DPM, ABFAS recently wrote and published an article about Plantar Fasciitis as well as heel pain. The article features signs and symptoms of Plantar Fasciitis and what options you have to treat the ailment.
If you are suffering from heel pain or have the symptoms of Plantar Fasciitis, please contact Ability Foot & Ankle at (859) 746-3668 to schedule a consultation.
Heel Pain and Plantar fasciitis – A physician’s perspective
As a physician and surgeon, I am constantly treating heel pain, as this is one of, if not the – most common problems in my practice. Plantar fasciitis and heel spurs are a common condition that can be very challenging to treat. There are many opinions about this condition among doctors, and treatment options are numerous. It is my intent to try and explain the condition, and discuss treatment options as they pertain to the standard of care, which is considered the general consensus between physicians in the same community on how to treat a problem. I will also offer some home / self-treatment options that patient’s may want to explore before seeing a physician, and finally, dispel some common myths regarding treatment of the condition.
The plantar fascia is a structure on the bottom of the foot, also called an “aponeurosis” – which very similar to a ligament. It originates from the bottom of the heel, and extends forward to the forefoot area, just behind the toes. It is a very thick, fibrous tissue that functions to support the load that is imposed on your foot as you place your weight on your foot. If you think of archery, it kinda resembles the string to a bow. If a hunter’s bow is placed on the ground (bow end up, string side down) and pressure is placed on tbe bow pushing it down to the ground, the string on the bow will become tighter as the bow collapses, preventing it from completely collapsing. Much in the same fashion, the plantar fascia tightens when you place weight on your foot as your body moves forward over your foot when you walk, preventing the arch from collapsing. There are other tendons and ligaments that help to support the arch, but the plantar fascia is one of the main structures primarily designed for arch support.
So where and why does the pain to the heel develop ? Although pain can present suddenly, it usually sets in gradually, over a period of days to weeks. The first symptom commonly shared by patients is a sharp pain to the bottom of the heel, usually noticed after getting out of bed or after sitting for a long time. Often times, this is followed by a gradual reduction in symptoms after several minutes of standing or walking, only to have the pain return later at the end of the day with prolonged activity. Over the years, I have noticed that this condition often shares common characteristics:
- Patients who stand all day on concrete (warehouse / industrial workers, postal workers, etc.)
- Patients who suffer from obesity or have experienced a gain in weight of 20 or more pounds
- Patients who have “high arches” or “flat feet”
- Patients who commonly wear “high heels” or boots with a heel
- Patients who smoke
- Patients who recently gave birth
- Patients who transition from sedentary lifestyle to a very active one (ie new military recruits)
- Patients who like to use treadmills
As excessive pressure is applied to the plantar fascia, the fascia pulls at its attachment to the bottom of the heel bone, increasing tension, causing the structure to “pull away” from the heel bone, thus creating strain and tearing at the attachment site. This tearing causes inflammation and pain. Please note, the “tearing” is most often a gradual process that occurs on the microscopic level, over a period of weeks to months. It is extremely rare to rupture the fascial, or to have the fascia “tear completely in two” unless a sudden and dramatic injury or trauma occurs (ie, a fall from a height).
The body responds to the inflammation by trying to heal itself, and does so by forming “new bone” at the site where the fascia pulls away from the heel. If this process goes on long enough,, eventually a bone spur will form, which is better known as a “Heel Spur”. It is important to note that this is the RESULT of the problem, NOT THE CAUSE. Many patients insist that the heel spur is the cause of their pain. This is somewhat incorrect, as the term “spur” sounds painful, and can look bad on an xray, but in this particular instance – it is not really the cause of the pain. It is merely bone, like any other bone in your body. It is really the plantar fascia and its inflammation that is causing the pain, not the spur. The spur is again merely the result of the problem, not the cause of the problem.
To illustrate this point, I have seen spurs that are an inch long on the bottom of the heel, and the patient had no pain. I have also seen patients with NO spur, and they were in so much pain that they could NOT walk on their foot!
Before you see your physician regarding this condition, there are several steps you can take to try and reduce your pain.
Stretching exercises: These are very important in helping to reduce pain. They should be performed at least 5 or more times a day, for a minute each time. This helps to work out the stiffness” of the plantar fascia, and allows for a more elastic fascia, which is less likely to tear resulting in pain and inflammation. * This treatment is a long-term treatment, and generally will not provide immediate relief.
Arch supports and heel cushions: Heel cushions help to absorb the “shock” to the bottom of the heel, thereby reducing the strain and inflammation to the fascia. Arch supports help by bringing the floor “up to the bottom of your foot” thereby reducing the pressure to the heel because your weight becomes redistributed over the length of the foot, lessening the pressure to the heel.
Anti-inflammatories: These help by reducing the inflammation brought on from the plantar fasciitis. It is important to note that they only help to reduce the inflammation (which is a by-product of the condition), they do NOT help the cause of the problem. Patients should exercise caution when taking them, as they can cause stomach problems. They can also cause damage to liver and kidneys with prolonged or excessive use. Also, it is important to remember that when the medication is digested, it circulates throughout the entire body, and only a fraction of the of the medication actually reaches the heel where the inflammation resides.
Treatment from your physician:
If self-treatment options fail, then an appointment should be made to see your physician. There are many options that can be implemented to try and reduce symptoms. It is important to remember that through all of it, the CAUSE of the problem needs to be addressed first, NOT JUST THE SYMPTOMS. Otherwise, the patient will continually have to make repeat appointments to treat their symptoms, leading to dissatisfaction and increased frustration in their condition. Each of the treatments below have a “pro” and a “con”, or you might say a “risk” and a “benefit”; for the purpose of this short course educational piece, not all of them are listed, and ask that you discuss them fully with your doctor if you have further questions about the treatments listed.
Cortisone / Steroid injections: Cortisone is a medicine, but is also a chemical that is produced in your body. Many times a cortisone injection is performed to help reduce the inflammation of the condition. It does NOT treat the problem, but it can significantly help to reduce the pain and inflammation. Unlike an anti-inflammatory pill – where very little of the actual medication reaches the heel – a cortisone injection has all of the medication focused at the site of inflammation, and therefore are often more effective in alleviating the pain.
Night Splint Therapy: This modality works on the premise of constantly placing the plantar fascia under a stretch, counteracting the contracture of the fascia, reducing the stiffness and increased tension. It is meant to supplement stretching exercises, and works on the same premise. Normally, when you sleep, the foot is in a relaxed position and the fascia contracts, and tries to heal in the contracted position; however, when you wake up, you stand up and the fascia is placed under tension, and stretches suddenly. (That is why many patients report pain after getting out of bed in the morning). The idea with using a night splint is to have the fascia placed under tension while sleeping, and gives the facia a chance to heal in a “lengthened position”, which in turn, (hopefully) results in avoidance of any sudden tearing or lengthening of the fascia as the patient puts weight on their foot as they get out of bed.
Prescription Orthotic Inserts: These are arch supports that are prescribed by your doctor. It is important to remember that much like faces, no two set of feet are identical. Prescription orthotics differ from over-the-counter arch supports that you buy in a store in that they are formed or casted to your foot to mimic the specific shape of your foot, and are generally made out of materials that can withstand the abuse of day-to-day activities over a long period of time. They are very similar to prescription eyeglasses; they help to support your arch, reducing weight to your heel, and help to “refocus” the muscles and joints of the foot to work more efficiently. Please remember they are prescription, which means they are specifically made to address your foot only. You wouldn’t expect your family member to wear your prescription glasses, would you ? Prescription orthotic inserts are no different. Your podiatrist or orthopedic physician should have an intimate knowledge you the biomechanics of the foot, and how your particular foot-type relates to the problems you are having. Many variables go into designing prescription orthotics: Here are a few that your doctor typically considers…
Weight and activity level of the patient – determines the materials used to make the orthotic
Foot type (high arch, low arch, flat-foot, arthritis, etc.) – determines the shape of the orthotic
Foot abnormalities (bunion, hammertoes, tight heel cord, etc) – determines need for possible modifications to the orthotic.
It is important to note that prescription orthotic inserts typically only work with certain types of shoes, so sometimes it is necessary to accept this reality, as many patients desire for them to work in tight-fitting dress shoes; however, you have to keep in mind that there is only so much room inside a shoe for both your foot and an orthotic insert.
One of the most frustrating aspects of this treatment is the patient who has spent hundreds of dollars on shoes and ineffective “custom made” arch supports by a local shoe store, only to have them not work. When they finally come in to see me, their minds are already made up that this type of therapy “will not work for me”. There is a difference in custom versus prescription inserts! I often catch myself telling the patient, “If you only would have come to see me first”, then they may have avoided wasting hundreds of dollars on ineffective shoes and inserts, not to mention many weeks or months of trying to solve this problem on their own.
Feet are like snowflakes – no two are exactly the same. While I do attempt to strike the perfect casting for orthotic inserts, sometimes this falls short, and the prescription insert is therefore modified after it is dispensed to more accurately accommodate the patient’s foot type. This is often aided with X-rays of the foot. I prefer to tame mold impressions of the feet, as opposed to the newer “computer aided” scanners or“3-D” scanners that are seen at many shoe stores and pharmacies which only provide a digital image of the patient’s foot. The foot changes shape when you’re standing vs. when you’re sitting, and also depending on what phase of walking your in. While I realize cast impressions are a more archaic technology, it still provides a truer impression of your foot, which in-turn leads to a more accurate casting for your orthotic. This cuts down on the need for additional modifications to the inserts after they are dispensed.
Physical Therapy: Having appointments scheduled with a physical therapist can also be very beneficial in reducing the symptoms of plantar fasciitis. The therapist can implement a multitude of modalities aimed at reducing inflammation of the heel. One such therapy is iontophoresis, which uses cortisone and ultrasound-guided waves to drive the topical cortisone into the skin and deeper tissues. This is generally painless and has been show to significantly help reduce the pain from inflammation. Similar modalities also include infrared light therapy, ultrasound, soft-tissue mobilization, dry-needling, and message. The therapist also educates the patient on how to properly perform stretching exercises at home which are vital to eliminating symptoms.
Extracorporeal Shock Wave Therapy: This in a newer technology, which was introduced in the late 1990s, and involves the use of a machine that emits shockwaves which are used to “break up” scar tissue and stimulate blood flow and development of blood vessels to the area involved, thereby reducing inflammation and pain. Simply put – more blood flow, more healing. This therapy is similar to the one used in patient’s with gall bladder stones.
Studies have shown to be quite good, ranging from 57% to 80% good or excellent results. This treatment can be performed at your doctor’s office or in an operating room, and the distinct advantage to this therapy is that no incision is performed.
Unfortunately, many insurance companies classify this as “experimental” and will not cover this effective treatment. I personally find their labeling of a treatment “experimental” that has been around for 2(+) decades somewhat ironic, because many of the machines used to implement the therapy are actually FDA approved.
Platelet Derived Growth Factor Injections: this is also an newer technology that involves the use of growth factors, which are naturally occurring biologic factors in your blood that your body uses to heal injured tissue. Blood is taken from your body, and those healing factors are extracted, and then re-injected back into your foot to help resolve the inflammation and promote healing where tearing and trauma are located. This also, is considered (at the time of this writing) an “experimental treatment” by most health insurance companies, and as such, I have yet to find any insurance plans that provide coverage for this therapy. While they have shown to be effective, both shock wave therapy and Platelet Derived Growth Factor injections can be quite costly and are almost always an “out-of-pocket” expense to the patient due to insurance companies that often deny coverage for this therapy, so you will have to take this into consideration prior to proceeding with this treatment.
Surgery: Fortunately, surgery is seldom necessary for plantar fasciitis, as the condition is considered by many doctors considered a “self-limiting condition”. This means that if nothing is done, it will eventually get better with time. Unfortunately, there is no set “time-line” for improvement as the patient’s condition is considered a “case-by-case” basis. The time required to experience a reduction in pain may take months, even years. Many patients cannot afford to be disabled for that period of time. Conservative care (ie treatment outside the operating room) generally provide between 85% – 92% relief in symptoms, and thereby bypassing the need for operation. In my opinion, surgery should be considered only when conservative care has been exhausted.
There are physicians who advocate for NEVER having surgery for this condition. Some doctors simply will refuse to offer this surgery. They maintain that heel surgery has the highest dissatisfaction rate of all foot surgeries – and they would be a statistically correct statement. Many who subscribe to this school of thought on treating this condition with only conservative care note that with time, it eventually will result in some form of relief. Unfortunately, the “how long till I get better with conservative care” question cannot be answered accurately. If you are employed in a workplace that requires your standing and walking – this is a BIG DEAL. This is unfortunate, as the patient who is disabled with this condition can possibly lose employment, experience a reduced quality of life, and even possibly succumb to depression. However, despite a physician’s best efforts, there always seems to be a small percentage of patients that will fail all conservative measures, and surgery is usually a considered option at this point. I typically never recommend surgery unless at least 6 months of conservative care has been attempted.
Within the world of surgery, there are generally two approaches. The first involves a more traditional, “open” surgery involving a surgical release of the plantar fascia. An incision is made through the heel down to the level of the fascia, where it is cut and released from the heel. If it is no longer attached to the heel, then it cannot pull and cause inflammation, and hopefully the patient will experience reduction in pain as they heal from the surgery.
The second approach is similar to above, but measures are taken to minimize the trauma of the surgery, and thereby minimize the recovery. This is often referred to as a “Minimally Invasive Approach” surgery. Such an example would be an Endoscopic assisted plantar fascial release. Visualization of anatomy is somewhat limited, which may lead to some controversy, but the recovery is generally faster than the traditional approach. This can be beneficial for those who cannot afford to take extended periods off from their workplace.
It should be noted that neither surgery is considered a “simple surgery” as there is extensive postoperative care involved, including possible use of cast or crutches, avoidance of weight on the foot for a set period of time, implementation of physical therapy, and a gradual return to weight bearing on the heel. Surgery is not without risk, and one should consider this very carefully due to the potential for complications which can include: infection, nerve damage, excessive scarring, prolonged swelling, and possibly chronic heel pain, and others too numerous to discuss in detail for this writing.
Common Myths / Misconceptions with treating plantar fasciitis
- “The type of shoe I use makes a big difference”. I typically find that this is most often untrue.
Today, shoes are mass produced with emphasis on volume and little consideration for your foot type, which is unique to you. Most of all athletic shoes that I have seen have a very flat insole, which fails to provide support. If you can take out the insole of the shoe, and place your finger on the arch and push it down – see how much support it offers. If it flattens out with only 5 pounds of pressure, think how little support its going to offer when you stand on it. Much like frames to eye glasses, it is the lens that helps you see better, not the frame.
Similarly, it is the insert or the orthotic that helps support your foot, and the shoe is merely the frame which houses it. There are now shoes with springs and air cushions placed at the heel. They are usually rather expensive, and can offer some relief to the patient; but the relief will vary considerably. Cushion in a shoe is good – and it is needed, but ultimately, these shoes fail at treating the cause of the problem (supporting the arch and removing strain to the plantar fascia). Don’t confuse cushion with arch support – they are different ! Please take this into consideration before investing your money on such expensive shoes
- “Arch supports make the condition worse”. Again, I find this often times be untrue. Arch supports are more of an art than a science, and the type of arch support used can have a huge impact on plantar fasciitis. There are many variables to take into consideration with custom inserts, including foot type (high arch, low arch, etc), employment type, weight, activity level, presence of arthritis, and age. If you were given hard plastic inserts for your shoes, you may have experienced increased pain, and likely uttered the above phrase. Chances are you could have benefitted from arch supports, but you were given supports that were made out of the wrong materials that didn’t correspond to your weight, or your foot type, or activity level.
A patient’s foot will, with enough time,– flatten over time. This causes the foot to elongate or lengthen. Its not uncommon for someone in their 60s to have to move up ½ to a full shoe size, especially if they have been employed in a job where they stand on hard concrete surfaces. Also, women will often experience reduction in arch after giving birth due to weight gain and hormonal changes that affect the ligamentous structures of the foot. As the foot’s arch decreases, the plantar fascia is placed under greater strain, pulling harder on the heel bone where it attaches, causing increased pain and inflammation. Arch supports will help to counter this process by “bringing the floor up to the foot” and helping to stop the process of arch collapse, and reducing the strain and inflammation to the heel.
- “Cortisone injections are bad for my body”. Again, I find this generally to be untrue. Your body naturally produces cortisone. The injection is typically a more concentrated form of what your body already produces. * please note, that cortisone injections for inflammation are considered catabolic steroids, NOT anabolic steroids. HOWEVER, too many cortisone injections, especially if administered over a short period of time, can cause damage, and injections are not themselves without risk. Risks should be weighted against the benefits, and if no improvement is noted after a few injections, I will typically cease this therapy. Risks (and benefits) will vary from patient to patient, so please discuss this issue with your doctor before considering such therapy.
- “Cortisone injections hurt more than the pain that is already present in my heel”. True and false. Many patients will express a deep fear of injections, particularly to the foot. There is often a psychological effect that can, in some patients, make the injection experience worse than it otherwise would normally be. Pain is a learned response, and pain is part of the injection – no one can get around this fact. However, there are things that your physician can do to help lessen the discomfort of the injection so the experience is not that unpleasant. I try to administer a local anesthetic into the cortisone injection so the pain after the injection is immediately reduced. Also, I try to spray a freezing agent over the skin to help reduce the discomfort before administering the injection.
Final Thoughts: There are other problems than can mimic the condition of plantar fasciitis. Sometimes when conservate care has failed, the physician has to consider and rule out the possibility of other conditions that can mimic the symptoms of plantar fasciitis. These conditions can include low back pain, and nerve damage, tarsal tunnel syndrome (much like carpel tunnel syndrome but it involves the ankles and heel), infection, cysts, tumors, and stress fractures to the heel. It is common for your physician to order studies and tests that are necessary to rule out other problems and diagnoses, before moving forward with your care.
Hopefully the discussion of this common condition and treatment options involved will help to provide you with a better understanding of what to expect and the options you have with your care.
Dr. Demaria is a licensed podiatric physician here in Northern Kentucky who is Board Certified with the American Board of Foot & Ankle Surgeons. He can be reached for appointment at (859) 746-FOOT