Patient information: Heel pain due to plantar fasciitis

PLANTAR FASCIITIS OVERVIEW

Plantar fasciitis is one of the most common causes of foot pain in adults. Jumping or prolonged standing often causes strain on the plantar fascia, although plantar fasciitis can occur in other situations as well. The outcome for people with plantar fasciitis is generally good, with approximately 80 percent of people having no pain within one year.

Plantar fasciitis is caused by a strain of the ligaments in an area of the foot called the plantar fascia (figure 1). This 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 (figure 2). It functions to provide support as the toes bear the body's weight when the heel rises during walking.

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 getting up after being seated for some time.

PLANTAR FASCIITIS RISK FACTORS

Plantar fasciitis is more likely to occur in people whose lifestyle or occupation causes an abnormal amount of stretching of the plantar fascia.

Factors that increase the risk include:

• Long-distance running, especially during intensive training
• Poorly fitted shoes
• Obesity
• Standing for long periods of time
• Dancing, especially ballet and aerobic dance
• Repeated squatting or standing on the toes

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 information: Ankylosing spondylitis" and "Patient information: Psoriatic arthritis".)

PLANTAR FASCIITIS TESTS

To diagnose plantar fasciitis, a healthcare 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.

Depending upon the duration of symptoms, the severity of pain, and other individual factors, the provider may recommend x-rays to determine if another disorder, such as a fracture or infection, 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.

Effective treatments for plantar fasciitis includes the following:

Rest — Limiting athletic activities and getting extra rest can help to reduce symptoms. Excessive and repetitive heel impact from jumping, walking, and use of 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, might relieve pain. Ice and massage may also be used before exercise.

Exercise — Exercise 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 non-steroidal anti-inflammatory drug such as ibuprofen or naproxen to reduce swelling and relieve pain. However, these medications have many possible side effects and it is important to weigh the potential risks and benefits. (See "Patient information: Nonsteroidal antiinflammatory drugs (NSAIDs)".)

Doses of nonprescription anti-inflammatory medications are available in table 1 (table 1).

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 can 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.

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 (figure 3). 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 healthcare 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 (picture 6). 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.

Shock wave therapy — Some clinicians recommend shock wave therapy (the generation of sound waves that provide a burst of energy to the sole of the foot). The treatment is initially painful, and has not been proven to be more effective than sham treatment (treatment with a low, non-therapeutic dose of shock wave therapy).

Surgery — Surgery is rarely required for people with plantar fasciitis. It would only be recommended if all other treatments fail and the person had persistent symptoms for at least 6 to 12 months.

WHERE TO GET MORE INFORMATION

Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two people are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.

This discussion will be updated as needed every four months on our web site (www.uptodate.com/patients). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.

Some of the most pertinent include:

Patient Level Information:
Patient information: Ankylosing spondylitis
Patient information: Psoriatic arthritis
Patient information: Nonsteroidal antiinflammatory drugs (NSAIDs)

Professional Level Information:
Clinical features and management of heel pain in the young athlete
Evaluation of foot and ankle pain in the young athlete
Overview of running injuries of the lower extremity
Plantar fasciitis and other causes of heel and sole pain
Undifferentiated spondyloarthritis: Clinical manifestations, definition and diagnosis

A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable.

• National Library of Medicine

       (www.nlm.nih.gov/medlineplus/healthtopics.html)

• American Academy of Orthopedic Surgeons

       (http://orthoinfo.aaos.org/)

• American Podiatric Medical Association

       (www.apma.org/)

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