Easing the pain of plantar fasciitis

To relieve heel pain, simple therapies may be all you need.

Getting out of bed in the morning marks the beginning of a new day, but it can be an excruciating start for people with plantar fasciitis, one of the most common causes of heel pain in adults.

The main symptom is intense pain that feels like a deep bruise on the bottom of the foot, just in front of the heel. It's usually at its worst first thing in the morning and when you get up after sitting for a long time. The pain may go away as you walk around, but it's likely to return at the end of the day if you spend a considerable part of it on your feet.

The cause of the pain is inflammation of the plantar fascia, a band of tendon-like tissue that extends along the bottom of the foot (the plantar surface) from the heel bone to the ball of the foot, where it fans out to attach to the toe bones. When pressure or strain damage or overstretch the plantar fascia, swelling, tearing, or bruising can occur. Plantar fasciitis results mainly from high-impact activities, such as running and jumping, but it can also occur after prolonged periods of standing. It's more common in people who are obese or flat-footed and also in older people, because the plantar fascia loses its elasticity with age, making it more vulnerable to injury.

Diagnosing plantar fasciitis

Your clinician will ask you to describe the symptoms and say when they started and what makes them worse. She or he will examine your foot and confirm the diagnosis by eliciting pain while pressing on a specific area of your heel (see illustration) or when flexing your foot upward, which stretches the fascia. Sometimes magnetic resonance imaging (MRI) is ordered to rule out other possible causes of heel pain, such as a stress fracture.

About 50% of people with plantar fasciitis will also have a heel spur — a bony projection arising from the heel bone (calcaneus) that is visible on an x-ray. Some physicians believe that heel spurs develop when the plantar fascia pulls away from the heel from overuse, poor support, weight gain, or flattening of the arches. The heel spurs themselves don't cause pain, but the plantar fascia or other tissues around the spur may become inflamed and start to hurt.

Treating plantar fasciitis

Most plantar fasciitis improves with home-based treatments — usually within weeks, although it can take several months. It may be sufficient to avoid activities that put excessive strain on the heel — jumping or running, for example — for two weeks. But be careful not to stop exercising entirely, because inactivity can cause the plantar fascia to stiffen and then become painful again when you start to move around. Instead of jogging or aerobics, substitute bicycling or swimming. Also, be sure to perform exercises specifically recommended for treating plantar fasciitis (some examples are below). Although data on effectiveness are limited, many people have found one or more of the following approaches to be helpful:

Reduce pain and inflammation. Apply ice to the bottom of the foot near the heel for 20 minutes, several times a day. A nonsteroidal anti-inflammatory drug, such as aspirin, ibuprofen, or naproxen, can also help relieve pain and inflammation. These drugs can have serious side effects, so talk to your clinician if you need to take one of them for more than two or three weeks. You can also wear a splint at night that is designed to hold the foot upright and flexed back slightly while you sleep, stretching the plantar fascia to relieve morning pain.

Protect the heel. Putting orthotic devices into your shoes can help decrease any impact on the heel and reduce the chance of further inflammation. Various heel cushions and cups are available in most drugstores. A cutout heel pad can help reduce pressure on a heel spur. If off-the-shelf orthoses don't do the trick, you can custom-order them. Whatever cushioning device you use, be sure to put it in every pair of shoes you wear.

Support the foot. The time to recovery and the chance of re-injury are affected by the kind of footwear you use. Athletic shoes are a good choice, because most have cushioned soles and internal arch support. If you stand or walk on hard surfaces a lot, wear cushion-soled or crepe-soled shoes. Leaving the foot unsupported is likely to worsen your symptoms, so avoid going barefoot or wearing slippers. When you get out of bed in the morning, step into a supportive shoe.

Stretch the foot. There is evidence that a gentle plantar fascia–stretching exercise (see "Stretching the plantar fascia") can restore flexibility and reduce pain. In a study of 66 patients with chronic plantar fasciitis, researchers at the University of Rochester found that two years after learning the exercise, 92% of participants diagnosed with plantar fasciitis reported total or near-total satisfaction with their recovery, and 94% reported decreased pain. A randomized trial by the same research group showed that stretching the plantar fascia reduced pain and improved function more effectively than stretching the Achilles' tendon. (People with certain connective tissue disorders, such as Ehlers-Danlos syndrome, should avoid stretching exercises.)

Other treatments

If your pain doesn't respond to these home-based measures, your clinician may suggest a steroid injection. Steroids reduce inflammation and pain and can speed healing in the short term, but repeated injections can cause the heel pad to atrophy and raise the risk of a ruptured plantar fascia. Another risk of injection is that it may encourage overuse of the temporarily painless foot before the plantar fascia is completely healed. Don't suddenly boost your activity level because your heel feels better after an injection.

Some clinicians recommend extracorporeal shock wave therapy (ESWT), which supposedly triggers the body's healing response by directing high-energy sound waves at the painful part of the plantar fascia. This procedure can be painful at first, with some temporary bruising or swelling. It may cost more than $1,000 and is not always covered by insurance. In any case, there is no proof that ESWT relieves pain any better than a placebo, or sham treatment.

Up to 5% of people with plantar fasciitis have persistent symptoms that require surgery. Fasciotomy involves cutting part of the fascia and disconnecting it from the heel bone to release tension in the tissue. Sometimes this procedure is performed endoscopically, using instruments inserted through small incisions. Heel spurs that can be felt through the skin of the heel pad may require surgery.

Some foot care specialists use a form of cryosurgery to treat plantar fasciitis. In this technique, a handheld probe is pressed against the painful area of the heel to freeze the nerves affected by the inflamed plantar fascia. Unfortunately, the relief may be temporary, and the pain may shift to elsewhere in the foot.

Preventing heel pain

There are several things you can do to avoid getting plantar fasciitis or prevent it from returning. If you're overweight, lose weight. Warm up before working out or participating in sports by doing the stretching exercises described above. Choose shoes that support your arch and cushion your heel. If you're already prone to plantar fasciitis, you might also consider exercises to stretch the Achilles' tendon and the calf muscles as well as those that stretch the plantar fascia.