Plantar Fasciitis

Pain under the heel with the first steps out of bed is, more often than not, plantar fasciitis. It is the commonest cause of heel pain in adults, it is rarely serious, and the great majority of cases settle without an operation — but it can drag on for months, and a heel that has hurt for a year is a different problem from one that has hurt for a fortnight. This page covers what the condition is, what actually helps, and what is on offer when the usual measures have not worked.

What plantar fasciitis is

The plantar fascia is a thick band of tissue that runs from the underside of the heel bone to the base of the toes. It holds up the arch and tightens with every step as the toes bend, which is why it works hardest when you push off. Plantar fasciitis is a breakdown of the fascia where it attaches to the heel. Despite the name it is not really an inflammation: under the microscope the tissue looks worn and disorganised rather than inflamed, which is part of why anti-inflammatory tablets help less than people expect.

A heel spur on X-ray is often blamed but is usually a bystander. Plenty of people have a spur and no pain, and plenty have pain and no spur. The spur is not what surgery removes.

Symptoms

• sharp or stabbing pain under the heel, felt at the front and inner part of the heel pad

• worst with the first steps in the morning or after sitting, easing as you warm up, then returning after a long day on your feet

• an ache along the arch, and often a tightness in the calf

• one foot more often than both, though both can be affected

• symptoms that come and go over weeks and months rather than steadily worsening

Why it happens

The fascia fails when the load going through it outstrips its capacity to repair. Common contributors are a tight calf or Achilles, which pulls the heel up and loads the fascia; a sudden increase in walking, running or standing; a job spent on hard floors; weight gain; flat or high-arched feet; and shoes with a worn or unsupportive sole. Runners tend to get it after a change in distance, surface or footwear. Often there is no single cause, just several small ones adding up.

Other causes of heel pain

Not every sore heel is plantar fasciitis, and the treatment differs. Pain at the back of the heel rather than underneath is more likely to be Achilles tendinopathy. A bruised or thinned heel fat pad hurts in the centre of the heel and does not have the morning pattern. A trapped nerve on the inner side of the heel gives burning or tingling. A stress fracture of the heel bone follows a jump in activity and hurts with every step, not just the first ones. Heel pain in both feet in a younger adult, particularly with back stiffness, occasionally points to an inflammatory condition. Part of a consultation is making sure the label is right before treating it.

How it is assessed

The diagnosis is usually made from the history and examination: tenderness at the inner front of the heel where the fascia attaches, pain on stretching the toes back, and a check of calf tightness, arch shape and the way you walk. A weightbearing X-ray is taken if the pain is unusual, has followed an injury or has not behaved as expected. An ultrasound can measure the thickness of the fascia and is useful before an injection; an MRI is reserved for cases that are not adding up.

Treatment that settles most cases

Most people improve with a consistent programme over a few months, and roughly four in five are better within a year. The pieces that matter are:

• Stretching the fascia itself — pulling the toes back and holding the stretch, first thing in the morning and before standing up after a rest. This outperforms calf stretching alone, though both are done.

• Loading the calf and arch — slow, heavy heel-raise exercises with the toes propped up, which build the capacity of the fascia rather than just stretching it.

• Footwear — a cushioned heel, a firm sole and some arch support, and not going barefoot on hard floors while it settles.

• A heel cup or orthotic — an off-the-shelf insole works as well as a custom one for most people; the point is to support the arch and cushion the heel.

• Managing the load — cutting back the activity that brought it on rather than stopping altogether, then rebuilding gradually.

• Taping or a night splint — a splint keeps the fascia stretched overnight and helps some people with severe morning pain.

• Short courses of anti-inflammatories where they help with sleep or a bad spell, and weight loss where it is relevant.

A physiotherapist or podiatrist can run this programme, and it should be given a proper trial — several months, done properly — before anything more is added.

When it does not settle

For heel pain that has resisted a good programme, the next steps are:

• A corticosteroid injection — gives some form of relief in most people and can break a cycle of pain. It is done under ultrasound guidance and used sparingly, because repeated injections thin the heel fat pad. It is not a treatment to repeat every few months.

• Shockwave therapy — pulses of sound energy delivered to the heel over a course of sessions. It is not painless, but it is non-invasive and has reasonable evidence in chronic cases.

• Platelet-rich plasma (PRP) — an injection of concentrated cells from your own blood. The evidence is mixed and it is not rebated in the same way, so it is discussed case by case rather than offered routinely.

Surgery

Only a small minority of people with plantar fasciitis end up having an operation. Non-surgical treatment should have been given at least six to twelve months, and the diagnosis re-examined, before it is considered. Two procedures are used:

• Partial plantar fascia release — dividing the fascia at the heel through a small incision. How much is divided is judged case by case; in most feet only part of it is released, since the fascia contributes to the arch and there is some evidence that dividing more of it can shift load to the outer border of the foot.

• Gastrocnemius release — where the calf is tight, lengthening the upper part of the calf muscle through a small incision in the upper calf takes the pull off the heel.

Both are day procedures. You walk on the foot straight away in a supportive shoe or boot, with the wound reviewed at two weeks; desk work is possible within a week or two and standing work at around six weeks. Improvement after a fascia release is gradual and can take several months to reach its full extent.

Risks

Every procedure carries risk. For plantar fascia surgery the specific ones are nerve irritation or numbness on the inner heel, wound problems and infection, a flattening of the arch or pain on the outer border of the foot if too much fascia is released, blood clots, and heel pain that persists. For a calf release the main issues are a temporary loss of push-off strength and numbness behind the knee. These are weighed against what the heel is doing now and how long it has been going on.

Dr Janan's approach

Dr Janan Chandrananth is a foot and ankle orthopaedic surgeon who completed fellowship training in Bristol and in Tokyo, the latter under a past president of the Japanese Society for Surgery of the Foot. Heel pain is one of the commonest reasons people come to see him, and most of them do not need an operation.

His approach is to make sure the diagnosis is right, to check that the simple measures have been done properly rather than half-heartedly, and to reserve injections and surgery for the minority who need them. Where an operation is indicated, the calf is looked at as closely as the fascia.