Plantar fasciitis: Symptoms, causes, and treatments

What is plantar fasciitis?

Plantar fasciitis is a common and often painful foot condition that affects millions of people worldwide. The vast majority of people who experience plantar fasciitis are active adults between the ages of 25 and 65 years old.

Plantar fasciitis occurs when the plantar fascia, a fibrous band of tissue on the bottom of the foot that helps to support the arch, is overloaded or overstretched. With overuse or over time, the fascia loses some of its elasticity or resilience and can become inflamed, resulting in pain.

What are the symptoms of plantar fasciitis?

Plantar fasciitis symptoms can develop gradually over time or, in some cases, develop suddenly after engaging in intense physical activity. Recognizing symptoms is essential for early intervention and proper management.

It's important to keep in mind that the severity and duration of symptoms can vary from person to person. The most common symptoms of plantar fasciitis include:

• Pain on the bottom of the foot, near the heel. This is the most prevalent and telltale sign of plantar fasciitis. This pain can be a dull ache or a sharp, stabbing sensation. The arch along the bottom of the foot may also ache or burn.
• Severe heel or foot discomfort after getting out of bed in the morning, or after extended periods of rest. This pain tends to subside after a few minutes of walking.
• Heel or foot pain that tends to worsen after physical activity but is not typically experienced during exercise. Climbing stairs can be particularly painful.
• Tenderness when touching the affected area, especially near the heel.
• Stiffness in the foot is common, particularly upon waking up or after prolonged periods of sitting. This stiffness can make it difficult to walk comfortably.

What causes plantar fasciitis?

Plantar fasciitis occurs when the thick band of tissue on the bottom of your foot (the fascia) becomes overstretched or experiences excessive strain caused by repetitive stress from activities like standing or running. It can also occur if there is a significant weight gain, including during pregnancy.

This constant stretching and strain of the plantar fascia can lead to chronic degeneration, or the development of small tears in the fascia fibers, particularly where the fascia connects to the heel bone. In addition to tears, ultrasound evaluations often show calcifications, and thickening of the plantar fascia.

Certain risk factors can make you more susceptible to plantar fasciitis:

• foot arch problems (both flat feet and high arches)
• long-distance or downhill running on uneven surfaces
• excess weight
• a tight Achilles tendon
• shoes with inadequate arch support or soft soles
• abrupt changes in activity levels.

Plantar fasciitis diagnosis

If you suspect you have plantar fasciitis or are experiencing persistent foot pain, you should see your doctor for a proper diagnosis and treatment plan. Early intervention and appropriate management can help alleviate symptoms and improve your quality of life.

Your doctor will examine your foot, looking for the following signs or risk factors of plantar fasciitis:

• an area of maximum tenderness on the bottom of your foot, just in front of your heel bone
• a high arch or flat foot (a risk factor)
• limited dorsiflexion, or "up" motion, in your ankle
• the absence of symptoms from other foot conditions that may share similar symptoms with plantar fasciitis, such as insertional Achilles tendinitis, calcaneal (heel) stress fracture, or plantar nerve entrapment.

In addition to a physical exam of your foot, your doctor may consider obtaining x-rays or ultrasound evaluation if your history or physical exam indicates other injuries or conditions such as heel spurs, fractures, or arthritis. Additionally, ultrasound may show thickening and swelling of the plantar fascia, which is a typical feature of the condition.

Your doctor may also consider ordering magnetic resonance imaging (MRI) or ultrasound if your pain is not relieved by initial treatment methods, or if your doctor is concerned that a different problem is causing your pain.

How to treat plantar fasciitis

The vast majority of patients with plantar fasciitis improve within nine to 12 months of starting nonsurgical treatment methods.

The common treatments for plantar fasciitis typically include:

• Rest. Taking a break from the activities that aggravate the pain is usually the first step in treatment. A rest period will give the plantar fascia time to heal. During this rest time, you may try low-impact exercise such as cycling or swimming, or activities that put less stress on your feet than walking or running.
• Ice. Applying ice to the affected area can help reduce inflammation and alleviate pain. You may try rolling your foot over a cold water bottle or applying an ice pack to the sore area. Ice should be applied for 15 to 20 minutes at a time, several times a day, especially after activities that trigger pain.
• Stretching. Plantar fasciitis is aggravated by tight muscles in your feet and calves. Specific stretching exercises can help lengthen these muscles, reducing tension on the plantar fascia.
• Night splints. Night splints are devices worn while sleeping that stretch the plantar fascia. This prevents the plantar fascia from tightening overnight, reducing morning pain and stiffness. Although it can be difficult to get used to, a night splint can be effective at reducing heel pain from plantar fasciitis.
• Supportive shoes. You should wear shoes with good support and cushioning to avoid plantar fasciitis pain. Avoid shoes that do not provide support or are worn out. If your pain persists, your doctor may recommend custom-made shoe inserts (orthotics).
• Physical therapy. Your doctor may recommend that you work with a physical therapist on an exercise program that focuses on stretching your calf muscles and plantar fascia. A physical therapy program may also involve specialized ice treatments, massage, and other therapies to decrease inflammation around the plantar fascia.
• Nonsteroidal anti-inflammatory drugs (NSAIDs). Over-the-counter NSAIDs, such as ibuprofen, can reduce pain and inflammation. NSAIDS should be used under the guidance of a health care provider and for a limited duration to avoid potential side effects.

If the pain does not respond to the above treatments, your doctor may recommend:

• A walking boot and crutches. Used for a short period of time, these will allow your foot to rest.
• Corticosteroid injections. In cases of severe pain and inflammation that do not respond to other conservative treatments, corticosteroid injections may be recommended. These injections can provide short-term relief. However, your doctor may limit this treatment or avoid it because steroid injections can weaken the plantar fascia and lead to a rupture (tear), which can lead to flattening of the foot and chronic pain.
• Extracorporeal shockwave therapy (ESWT). ESWT is a noninvasive procedure that uses high-energy shockwaves to promote healing in plantar fascia tissue. However, the therapy does not work for everyone. And some studies have shown no benefit of ESWT for plantar fasciitis.
• Botulinum toxin (as in Botox and other brands). This treatment uses a protein produced by the bacterium Clostridium botulinum. In plantar fasciitis treatment, botulinum toxin injections help relax the tissues in and around the plantar fascia, relieving pain.
• Dry needling. In this technique, a sterile, thin needle is inserted into the skin to stimulate a myofascial trigger point. Though dry needling is a common treatment for plantar fasciitis, its effectiveness is controversial. One meta-analysis found "low-quality evidence" that dry needling reduces pain intensity in the short term.
• Laser therapy. Your doctor may use low-level laser therapy to reduce pain and inflammation associated with plantar fasciitis. One review of studies found that low-light laser therapy may relieve plantar fasciitis-associated heel pain for up to three months.
• Foot surgery. Though nonsurgical treatments almost always improve plantar fasciitis pain, surgery may be needed in some cases where improvement has not been seen.

Surgery for plantar fasciitis

As more than 90% of patients with plantar fasciitis recover with nonsurgical treatment, surgery is generally the last resort.

Most patients experience good results with surgery. However, surgery carries risks and can result in chronic pain and dissatisfaction.

Surgical procedures for plantar fasciitis include:

• Gastrocnemius recession. In this surgical procedure, a small incision is made on the inside of the calf (gastrocnemius), and the calf muscles are lengthened using a special instrument. The surgery increases ankle flexibility, releasing tension on the plantar fascia. Gastrocnemius recession can result in nerve damage and calf weakness, but the risk is low.
• Partial plantar fascia release. A partial plantar fascia release involves making an incision on the bottom or side of the heel to relieve tension in the tissue. The most common complications of release surgery include nerve damage.

What are the best shoes for plantar fasciitis?

Choosing the right shoes is crucial if you have plantar fasciitis. Proper footwear can significantly reduce the risk of developing or exacerbating the condition.

These are some key features to look for in shoes if you have plantar fasciitis:

• Arch support. Proper arch support helps distribute pressure evenly across the foot, reducing strain on the plantar fascia.
• Cushioning. Shoes with ample cushioning in the heel and forefoot can help absorb shock and reduce impact on the plantar fascia.
• Heel support. Choose shoes with a firm heel counter (the back part of the shoe that surrounds the heel). As you step and your heel strikes the ground, a large amount of tension is placed on the fascia, which causes microtrauma (tiny tears in the tissue). Soft silicone heel pads are inexpensive and work by elevating and cushioning your heel.
• Shock absorption. Look for shoes with good shock absorption properties, especially in the heel area. Cushioned soles or gel inserts can help with shock absorption.

You may want to consult with a podiatrist or orthopedic specialist who can recommend suitable footwear based on your foot structure and the severity of your plantar fasciitis. In addition, off-the-shelf or custom-fitted arch supports, called orthotics, can help distribute the pressure on your feet more evenly.

Stretching exercises for plantar fasciitis

Studies show that plantar fascia–specific stretching can be helpful as part of treatment. One study found that heel pain improved by 52% after eight weeks of stretching the plantar fascia. Keeping your calf muscles flexible is also important for preventing plantar fasciitis.

You can do these stretches three times a day: morning, midday, and before bed.

Calf stretch. Lean forward against a wall with one knee straight and your heel on the ground. Place your other leg in front, with the knee bent. Push your hips toward the wall. You should feel a pull in the calf during the stretch. Hold the position for 15 to 30 seconds. Be sure to stretch both legs.

Plantar fascia stretch. Sit in a chair with one foot on the floor. Raise your other leg and rest the ankle on your knee in a figure 4 position. Grasp the toes of your raised foot with your hand. Gently pull your toes back until you feel a stretch in the sole of your foot. Gently massage the stretched plantar fascia with your other hand. Hold this for 10 seconds. Repeat 10 times on each foot.