Patient education: Heel pain (caused by plantar fasciitis) (Beyond the Basics)
- Rachelle Buchbinder, MBBS, MSc, PhD, FRACP
Rachelle Buchbinder, MBBS, MSc, PhD, FRACP
- Rheumatologist and Director, Monash Department of Clinical Epidemiology
- Cabrini Hospital
- Professor, Department of Epidemiology and Preventive Medicine
- Monash University
PLANTAR FASCIITIS OVERVIEW
Plantar fasciitis is one of the most common causes of foot pain in adults. Plantar fasciitis is caused by a strain of the ligaments in an area of the foot called the plantar fascia (figure 1). The plantar fascia (pronounced FASH-uh) is a thick, pearly white tissue with long fibers that starts at the heel bone and fans out along the under surface of the foot to the toes. The fascia provides support as the toes bear the body’s weight when the heel rises during walking. Jumping or prolonged standing may strain the plantar fascia. The outcome for people with plantar fasciitis is generally good, with approximately 80 percent of people having no pain within one year.
PLANTAR FASCIITIS SYMPTOMS
The most common symptom of plantar fasciitis is pain beneath the heel and sole of the foot. The pain is often worst when stepping onto the foot, particularly when first getting out of bed in the morning or when getting up after being seated for some time.
PLANTAR FASCIITIS RISK FACTORS
Plantar fasciitis is more likely to occur in a person whose lifestyle or occupation causes repetitive impact to the heel. Activities such as running, marching, or dancing may trigger or worsen symptoms. Possible other factors that increase the risk of plantar fasciitis include obesity, prolonged standing, and limited ankle flexibility.
Plantar fasciitis occurs more frequently among runners, and, in this group, possible factors that increase the risk include:
●Excessive training (particularly a sudden increase in the distance run)
●Improper running shoes
●Running on unyielding surfaces
●Prolonged standing or walking on hard surfaces
However, evidence of an association for many of these factors is limited or absent.
Plantar fasciitis usually occurs in people without underlying medical problems, but it can be associated with other rheumatic disorders such as ankylosing spondylitis or psoriatic arthritis. (See "Patient education: Ankylosing spondylitis and other spondyloarthritis (Beyond the Basics)" and "Patient education: Psoriatic arthritis (Beyond the Basics)".)
PLANTAR FASCIITIS TESTS
To diagnose plantar fasciitis, a health care provider will take a medical history and examine the feet to locate painful areas (picture 1). It is important to notify the provider if there are other areas of tenderness or pain not found during the examination.
If you have typical symptoms of plantar fasciitis, then no X-rays or other tests are required. This is the case for most people. In some instances, depending upon the nature and severity of pain as well as other individual factors, the provider may recommend X-rays to determine if another issue (such as a fracture) is causing the pain.
PLANTAR FASCIITIS TREATMENT
Conservative treatment of plantar fasciitis — Plantar fasciitis is usually treated conservatively. However, many commonly used treatments have not been proven to improve the symptoms of plantar fasciitis.
Commonly used treatments for plantar fasciitis include the following:
Rest — Limiting athletic activities and getting extra rest may help to reduce symptoms. Excessive and repetitive heel impact from jumping, walking, and using a trampoline should be avoided. A complete lack of physical activity, though, can lead to stiffening and a return of pain and is not recommended.
Icing — Applying ice to the area, for example for 20 minutes up to four times daily, may relieve pain. Ice and massage may also be used before exercise.
Stretching — Stretching exercises may be helpful. Home exercises include the calf-plantar fascia stretch (picture 2), foot/ankle circles (picture 3), toe curls (picture 4), and toe towel curls (picture 5). Be sure to perform these exercises with care to avoid causing more pain.
Pain medication — A clinician may recommend a short course of a nonsteroidal antiinflammatory drug (NSAID) such as ibuprofen or naproxen to relieve pain. However, these medications have many possible side effects, and it is important to weigh the potential risks and benefits. (See "Patient education: Nonsteroidal antiinflammatory drugs (NSAIDs) (Beyond the Basics)".)
Protective footwear — Athletic shoes, arch-supporting shoes (particularly those with an extra-long counter, which is the firm part of the shoe that surrounds the heel), or shoes with rigid shanks (usually a metal insert in the sole of the shoe) may be helpful. Cushion-soled shoes with gel pad inserts or heel cups may provide temporary pain relief. Silicone inserts have been found to provide better support than felt pads or rubber heel cups. Magnetic insoles have not been found to provide any additional benefit.
Although unproven, splints may be helpful when worn overnight to position the foot and heel to provide pain relief and a gentle stretch. These splints can usually be purchased in pharmacies that carry orthopedic supplies.
People who work or reside in buildings with concrete floors should use cushion-soled or crepe-soled shoes.
Wearing slippers or going barefoot may cause symptoms to return, even if the floors are carpeted. Thus, the first step out of bed should be made with a supportive shoe or sandal on.
Tape support — Taping the affected foot with a technique known as low-Dye taping may be beneficial for some people, particularly those with “first step” pain. Four strips of tape are applied as illustrated in the figure (picture 6). The tape should not be applied too tightly. Hypoallergenic tape may be recommended for people with allergic reactions to tape.
Other modes of plantar fasciitis treatment — If these noninvasive measures fail to improve the pain, a health care provider may recommend one of the following treatments:
Steroid injection — An injection of a steroid (glucocorticoid) medication may be given into the foot to relieve pain, although the effect may wear off after a few weeks. The doctor will press on your foot in order to locate the tender area and give the injection there. The injection can be repeated, although many clinicians limit the number of times they will give injections because they believe repeated injections may weaken the tissues of the sole of the foot. However, this belief is unproven.
The injection can be painful and has a very small risk of causing infection.
Casting — Another option is a short walking cast, which begins at the calf and covers the ankle and foot up to the toes. This type of cast has a rocker-shaped bottom that allows you to continue walking while wearing it. This treatment has not been tested in clinical trials.
Shock wave therapy — Some clinicians recommend shockwave therapy (the generation of sound waves that provide a burst of energy to the sole of the foot). The treatment is initially painful. In high-quality studies, it has not been proven to be more effective than placebo treatment (treatment with a low, nontherapeutic dose or pretend shock wave therapy). In people with acute symptoms (less than six weeks), it is less effective than steroid injection.
Surgery — Surgery is rarely required for people with plantar fasciitis. It would only be recommended if all other treatments had failed and if the person had persistent symptoms for at least 6 to 12 months.
WHERE TO GET MORE INFORMATION
Your health care provider is the best source of information for questions and concerns related to your medical problem.
This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for health care professionals, are also available. Some of the most relevant are listed below.
Patient level information — UpToDate offers two types of patient education materials.
The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.
Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.
Patient education: Ankylosing spondylitis and other spondyloarthritis (Beyond the Basics)
Patient education: Psoriatic arthritis (Beyond the Basics)
Patient education: Nonsteroidal antiinflammatory drugs (NSAIDs) (Beyond the Basics)
Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.
Heel pain in the active child or skeletally immature adolescent: Overview of causes
Foot and ankle pain in the active child or skeletally immature adolescent: Evaluation
Overview of running injuries of the lower extremity
Clinical manifestations and diagnosis of peripheral spondyloarthritis in adults
The following organizations also provide reliable health information.
●National Library of Medicine
●American Academy of Orthopedic Surgeons
●American Podiatric Medical Association
- Cole C, Seto C, Gazewood J. Plantar fasciitis: evidence-based review of diagnosis and therapy. Am Fam Physician 2005; 72:2237.
- Buchbinder R. Clinical practice. Plantar fasciitis. N Engl J Med 2004; 350:2159.
- Thomson CE, Crawford F, Murray GD. The effectiveness of extra corporeal shock wave therapy for plantar heel pain: a systematic review and meta-analysis. BMC Musculoskelet Disord 2005; 6:19.
- Porter MD, Shadbolt B. Intralesional corticosteroid injection versus extracorporeal shock wave therapy for plantar fasciopathy. Clin J Sport Med 2005; 15:119.
All topics are updated as new information becomes available. Our peer review process typically takes one to six weeks depending on the issue.