Plantar Fasciitis

Definition

Plantar fasciitis is a condition in which the plantar facia—the arch tendon in the foot—becomes very painful, swollen, irritated, or inflamed when tiny tears occur on its surface. The condition is one of the most common orthopedic complaints relating to problems of the foot. Athletes are especially at risk from the condition due to excessive running, jumping, dancing, and other such activities that add stress to the foot and the plantar facia.




The most common complaint voiced by people suffering from plantar fasciitis is aching, burning, or stabbing pain near the bottom of the heel, which is usually worse in the morning and may improve throughout the day.

Description

The plantar facia is a deep, wide band of fibrous connective tissue located on the bottom of the foot. It extends from the calcaneus (heel bone) to the sole of the foot and the proximal phalanges bones of the toes. This band that acts similar to a stretchy rubber band supports the muscles and arch of the foot. It continually contracts and lengthens as the foot moves, helping the foot absorb forces acting down upon it, such as the weight of the body.

When the plantar fascia is extremely over-stretched or repeatedly overused, such as from daily physical activities, exercising, and sporting events, it can develop the condition called plantar fasciitis. One result of the condition is pain caused by pointed, bony fragments that extend from the heel bone—known as heel spurs. The condition is frequently the cause of heel pain in humans—making for a painful foot, and even more so while walking.

Demographics

The Plantar Fasciitis Organization states that heel pain—the primary symptom of plantar fasciitis— affects almost two million Americans each year, causing mild discomfort to debilitating pain. The condition is common among athletes participating in high-impact sports and physical exercises in which excessive force is brought onto the heel and attached tissue. Such high-stress activities include ballet dancing, dance aerobics, volleyball, basketball, and long-distance running (especially running downhill or on uneven surfaces). Runners who roll their feet or flatten them (overpronate) are at high risk for plantar fasciitis because the action adds excess stretching to the plantar fascia. In addition, it is frequently found in non-athletes who are overweight or obese.

Plantar fasciitis is most commonly found in physically active people between the ages of 40 and 70 years of age. Women are more likely to get plantar fasciitis than are men. Pregnant women are more likely to get it than are women who are not pregnant or have not been pregnant. Obese people (or people who gain weight quickly) are more likely to get plantar fasciitis than normally weighted people because the excessive weight places more pressure on the feet.




People with flat feet or high arches are at increased risk for developing plantar fasciitis. Wearing the right type of shoe, correctly fitted and with proper support for the heel, arch, and ball of the foot, can help to reduce the threat.

People with problems of the arches, such as those with flat feet, tight Achilles tendons, or high arches, are more prone to have the condition. An abnormal pattern of walking is also more likely to cause plantar fasciitis because body weight is not evenly distributed while walking. People who work at jobs that require long hours of standing or walking are especially prone to plantar fasciitis. Such occupations include teachers, factory workers, retail clerks and workers, postal carriers, and others.

Causes and symptoms

Causes

The plantar fascia absorbs the shock from impacts to the foot, such as in exercises, physical activities, and general walking around. The plantar fascia provides this support through the arch in the foot. However, if tension becomes too great, small tears can develop within the fascia. Excessive stretching and tearing of the fascia can cause it to become irritated or inflamed, leading to plantar fasciitis.

The most common cause of the condition is overly tight calf muscles. When the calf muscles are excessively tight for long periods, excessive pronation (abnormal rotational movement, also called overpronation) of the foot can occur. Foot overpronation leads to excessive stretching of the plantar fascia, eventually causing inflammation and pain, along with thickening of the tendon. As the tendon thickens, strength and flexibility are lost.

Increased risk of developing plantar fasciitis is caused by:

Symptoms

Symptoms include pain on the underside of the heel that becomes worse and increases to stabbing pain after first getting out of bed after sleeping, or after sitting or standing for long periods during the day. Normally, the pain goes away after a few steps. Another symptom of plantar fasciitis is difficulty bending the affected foot. Athletes, such as runners, often develop plantar fasciitis when they have knee pain.

Diagnosis

A medical professional diagnoses plantar fasciitis with a physical examination and a detailed medical history of the patient. Data about previous physical activities, foot problems, and other related information is gathered. The feet are examined, along with a visual observation of the patient walking and standing. Images may be taken of the feet, including computed tomography (CT) scans, magnetic resonance imaging (MRI) scans, and diagnostic sonography scans (also called ultrasonography). Other possible medical problems of the foot are eliminated before a diagnosis of plantar fasciitis can be made. Typical findings for plantar fasciitis from a medical examination includes redness and mild swelling and inflammation of the foot, along with tenderness on the bottom of the heel.

Treatment

Treatment for plantar fasciitis includes:

If symptoms from plantar fasciitis continues, it may be necessary to seek medical help from a doctor or podiatrist (a doctor specializing in problems of the feet). The widely held recommendation from the medical community is to seek help before the symptoms become excessive because by that time it is less likely that the pain will go away by itself. More advanced stages of the condition may necessitate surgery. When the treatment process is performed early on, conservative (less invasive) treatment options usually solve the problem.

KEY TERMS
Achilles tendon—
The tendon that connects the calf muscles to the heel bone.
Arthritis—
A condition of the joints that causes stiffness, swelling, or pain.
Calcaneus—
The heel bone.
Lupus—
Lupus erythematosus, a disease of the connective tissue.
Orthopedic—
Relating to disorders of the bones, ligaments, joints, and muscles.
Phalanges—
Bones forming the toes and fingers.
Plantar fascia—
Connective tissue that supports the arch in the foot.
Pronation—
Rotational movement of the foot at the subtalar and talocalcaneonavicular joints.
Rheumatoid arthritis—
An inflammatory condition that adversely affects the synovial joints of the body.

Surgery is an option when other possibilities have failed. One surgical technique is plantar fascia release that involves surgically cutting the plantar fascia ligament to relieve tension and reduce inflammation. Another technique, called coblation surgery, is a minimally invasive procedure that uses radio waves (a type of electromagnetic radiation) to remove the problem areas—what is called radio frequency ablation. Risks associated with surgery for plantar fasciitis include nerve damage, infection, rupture of the plantar fascia, and inability to reduce the pain and other symptoms.

Prognosis

If nothing is done to treat the problem, the pain is likely to become chronic. Other foot, knee, hip, or back problems may also result as the condition causes negative changes to occur in walking. If treated properly, the condition usually goes away without the need for surgery. Various outcomes are likely to result due to differences in the severity of the condition, along with other extraneous problems. Recovery times also vary widely.

QUESTIONS TO ASK YOUR DOCTOR
  • What specific exercises should I do to correct my problem?
  • What activities should I avoid when pain occurs?
  • What is likely causing my symptoms or condition?
  • Will I need surgery?
  • Will my health insurance pay for surgery or rehabilitation?
  • Do I need other tests to confirm the diagnosis?
  • What treatment do you recommend?
  • How long after treatment do you expect my condition to improve?
  • Is there anything else I can do to relieve my foot pain?
  • If I do nothing, do I risk long-term complications?
  • Should I see a specialist?
  • Where can I learn more about plantar fasciitis?

Prevention

Preventing plantar fasciitis from occurring is very important. One way to prevent it is to maintain a healthy weight-to-height ratio, known as the body mass index (BMI). The National Heart, Lung and Blood Institute maintains a BMI calculator at http://www.nhlbisupport.com/bmi/ . A proper weight helps to reduce stress on the plantar fascia. Shoes that fit correctly and provide sufficient support to the heel, arch, and ball of the foot is also key to reducing the risk for plantar fasciitis.

Walking barefoot; wearing old, worn-out shoes; and wearing sandals and other types of footwear that provide little support for the foot increase the risk of having foot problems, including plantar fasciitis. Foot problems can also be avoided by gradually building up intensity when exercising and performing everyday physical activities. Warming up and stretching exercises are recommended before doing physical activities because it helps to prevent sudden stress on the feet, along with allowing the muscles to stretch in the foot before they must perform more strenuous exercises.

A gait analysis on a person's walking style is performed by a doctor to determine if overpronation is a problem. Orthotics or insoles can help to correct any problems with the feet. Taping the feet during exercise is sometimes done, especially for professional athletes and others involved in frequent high-stress activities.

Resources

BOOKS

Berquist, Thomas, H., ed. Imaging of the Foot and Ankle. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2011.

Katch, Victor L., William D. McArdle, and Frank I. Katch. Essentials of Exercise Physiology, 5th ed. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins Health, 2016.

Miller, Mark D., Jennifer A. Hart, and John M. MacKnight, eds. Essential Orthopaedics. Philadelphia: Saunders/Elsevier, 2010.

Noyes, Frank R., and Sue D. Barber-Westin, eds. Noyes' Knee Disorders: Surgery, Rehabilitation, Clinical Outcomes, 2nd ed. New York: Thieme, 2016.

Yates, Ben, and Linda M. Merriman. Merriman's Assessment of the Lower Limb, 3rd ed. Edinburgh: Churchill Livingstone/Elsevier, 2012.

WEBSITES

Ma, C. Benjamin. “Plantar Fasciitis.” MedlinePlus. March 10, 2016. https://medlineplus.gov/ency/article/007021.htm (accessed January 22, 2017).

“Plantar Fasciitis, Heel Spurs, Heel Pain.” Plantar Fasciitis Organization. 2010. http://www.plantar-fasciitis.org (accessed January 22, 2017).

“Plantar Fasciitis.” Mayo Clinic. November 16, 2016. http://www.mayoclinic.org/diseases-conditions/plantarfasciitis/home/ovc-20268392 (accessed January 22, 2017).

“Understanding Plantar Fasciitis—The Basics.” WebMD. March 9, 2015. http://www.webmd.com/arthritis/understanding-plantar-fasciitis-basics (accessed January 22, 2017).

ORGANIZATIONS

American Association of Orthopaedic Surgeons, 9400 W Higgins Rd., Rosemont, IL, 60018, (847) 823-7186, (800) 626-6726, Fax: (847) 823-8125, customerservice@aaos.org, http://www.aaos.org .

American Pain Society, 8735 W Higgins Rd., Ste. 300, Chicago, IL, 60631, (847) 375-4715, info@american painsociety.org, http://americanpainsociety.org .

Plantar Fasciitis Organization, http://www.plantarfasciitis.org .

William A. Atkins, BB, BS, MBA

  This information is not a tool for self-diagnosis or a substitute for professional care.