Plantar Fasciitis

by Amanda G. Maxey, M.D.

Nearly two million patients are treated for plantar fasciitis each year in the United States. It is estimated that one in 10 people will develop plantar fasciitis during their lifetime.

The plantar fascia is a broad band of fibrous tissue that starts at the bottom of the heel and extends out to the toes. The tissue is not very flexible and is placed under significant tension during walking and running. The tension is concentrated at the heel bone or calcaneus and is believed to be the cause of pain.

The problem is frequently referred to as "heel spurs." In fact, only about 50 percent of patients with heel pain have a spur. The spurs occur above the fascia in one of the muscles, and although spurs can occur with heel pain, they are not considered the cause.

The pain is typically gradual in onset and is generally worse with the first few steps after awakening or after prolonged rest. There is rarely a specific injury.

In most cases, the diagnosis can be made by discussing symptoms and history and a physical exam. Other studies are seldom needed. An X-ray can help rule out other causes of pain such as a fracture. An MRI scan is only used in difficult-to-diagnose cases or in someone who is not responding to conservative treatment.

Non-operative treatment is truly the main remedy of heel pain. A home stretching program is the primary treatment in addition to education and activity. It is important not to stretch rapidly or too aggressively as this can actually increase pain by doing more damage. The stretching is designed to increase the flexibility of both the plantar fascia and the Achilles and in doing so, decreases the tension on the heel bone. Pre-stretching after prolonged rest is particularly important to avoid re-injuring the fascia when standing after prolonged rest such as sleeping, eating and driving.

Treating the inflammation with ice or an anti-inflammatory such as Aleve or Ibuprofen can also help. Support and cushions can also help relieve the pressure on the heel and the fascia. Steroid injections may also be part of the treatment, but typically only provide temporary relief. Other treatment options include physical therapy and/or massage therapy, night splints, and on occasion, for severe cases, a cast or boot to rest the fascia.

Generally, surgery or more invasive procedures are not considered until all conservative options have failed over several months. The procedure of choice is commonly considered to be an open plantar fascia release. Results are generally good, but the recovery can be long, especially when trying to get back to walking on ones feet or to athletic activities. Endoscopic plantar fascia release is another option. Some believe the return to activities is more rapid but the results leave many questions.