“I wake up in the morning and with my first steps out of bed, I feel a sharp pain under my heel. After a while the pain becomes more of a dull ache..”
Is this you? Heel pain (or Plantar Fasciitis) is the most common foot complaint, experienced by thousands of Australians every day. This article offers a detailed explanation of the symptoms, causes and treatment options available for Plantar Fasciitis:
Plantar Fasciitis is the Latin term for "inflammation of the plantar fascia". The plantar fascia is a thick, fibrous ligament that runs under the foot from the heel bone to the toes. It forms the arch of the foot and functions as our natural shock-absorbing mechanism. Unlike muscle tissue, the plantar fascia is not very elastic and therefore is very limited in its capacity to stretch or elongate. Herein lies the problem: when too much traction is placed on the plantar fascia (for various reasons) micro-tearing will occur, resulting in irritation, inflammation and pain.
Plantar Fasciitis usually causes pain under the heel. However some people may experience pain under the arch of the foot. Both heel pain and arch discomfort are related to Plantar Fasciitis, with heel pain being far more common than arch pain.
A heel spur is a bony growth at the front/underside of the heel bone. This type of calcifcation is also referred to "calcaneal spur" (calcaneus is Latin for heel bone). The reason for the development of a spur is that the body 'responds' to the constant traction and pulling from the plantar fascia ligament away from the heel bone. The ligament itself cannot become any longer, so instead the bone will 'assist' the ligament and grow.
A heel spur will show clearly on an X-Ray of your foot. After diagnosis of the Plantar Fasciitis, some doctors will recommend you have X-Rays taken. However, it should be noted that calceneal spurs are not painful. They are not the problem. Pain is only caused because of inflammation of the tissue surrounding the heel spur.
It is interesting to note that most people suffering from Plantar Fasciitis pain do not have a heel spur! And vice-versa, there are people with a spur under one or both heels, but they have never experienced any foot pain. Spurs take many years to develop, they can also be found at the back of the heel (near the Achilles Tendon) or in other parts of the body.
Heel pain is in most cases experienced in the centre of the underside of the heel, or at the front or sides of the underside of the heel. The pain is more intense with your first steps out of bed in the morning or after sitting for a while. The reason for this is that during rest our muscles and ligaments tend to shorten and tighten up. The tightening of the plantar fascia means more traction on the ligament making the tissue even more sensitive. With sudden weight-bearing the tissue is being traumatised, resulting in a stabbing pain.
After walking around for a while the ligament warms up, becomes a little bit more flexible and adapts itself, making the pain go way entirely or becoming more of a dull ache. However, after walking a long distance or standing for hours the pain will come back again.
To prevent the sudden sharp pain in the morning or after sitting, it is important to give the feet a little warm-up first with some simple exercises. Also, any barefoot walking should be avoided, especially first thing in the morning, as this will damage to the plantar fascia tissue.
Aparty from pain in the heel or symptoms may include a mild swelling under the heel. In addition, heel pain is often associated with tightness in the calf muscles. Tight calf muscles are a major contributing factor to Plantar Fasciitis.
The main cause of heel pain is overstretching of the plantar fascia ligament under the foot. So why is the ligament being overstretched? There are different factors:
An important contributing factor to Plantar Fasciitis is 'excess pronation' (or over-pronation). This is a condition whereby the feet roll over, the arches collapse and the foot elongates. This unnatural elongation puts excess strain on the ligaments, muscles and nerves in the foot.
When the foot is not properly aligned, the bones unlock and cause the foot to roll inward. With every step taken your foot pronates and elongates, stretching the plantar fascia and causing inflammation and pain at the attachment of the plantar fascia into the heel bone. Re-alignment of the foot should therefore an important part of the treament regime.
Fortunately there's a lot you can do yourself before seeking any specialist medical treatment:
The body is capable of healing itself and can overcome inflammation, provided you give it some rest. Avoid any running, sports, walking distances, walking up or down hills and standing for prolonged periods for at least 6 weeks. Completely avoid any barefoot walking on hard tiles and floors, especially first thing in the morning!
Many people have tightness in their calf muscles and Achilles tendons, which can hamper a natural walking pattern which places excess strain on the plantar fascia. Flexible muscles are very important in the treatment and prevention of most foot and leg injuries. Read more below
Two or three times a day, apply an ice pack directly onto the heel and hold it for 5 to 10 minutes. This will help cool down the inflammation and provide temporary pain relief. Anti-inflammatory medications like Ibuprofen (found in Nurofen™ and Advil™) will help decrease the inflammation of the plantar fascia. Rapid™ is another nicely potent anti-inflammatory drug and can be helpful for temporary pain relief.
Orthotics are corrective foot devices. They are not the same as soft, spongy, rubber footbeds, gel heel cups etc. Gel and rubber footbeds may cushion the heels and feet, but they do not provide any biomechanical correction. In fact, gel can do the opposite and make an incorrect walking pattern even more unstable!
Orthotic insoles work by supporting the arches while re-aligning the ankles and lower legs. Most people’s arches look quite normal when sitting or even standing. However, when putting weight on the foot the arches lower, placing added tension on the plantar fascia, leading to inflammation at the heel bone. Orthotics support the arches, which reduces the tension and overwork of the plantar fascia, allowing the inflamed tissue to heal.
Orthotics needn’t be expensive, custom-made devices. A comprehensive Heel Pain study by the American Orthopaedic Foot and Ankle Society found that by wearing standard orthotics and doing a number of daily exercises, 95% of patients experienced substantial, lasting relief from their heel pain symptoms.
Developed by Australian podiatrists, Footlogics orthotics support the arches and substantially reduce the tension on the plantar fascia, the root of your pain issues. They are designed with a shock-absorbing heel pad, which limits impact on the painful heel, lessening further damage, and increasing comfort. For the relief of heel pain we recommend the Footlogics Plantar Fasciitis full-length orthotic, the Footlogics Comfort and the Footlogics Casual (3/4 length orthotic). Footlogics products are available from pharmacies across Australia, or can be purchased on-line or by phone: 1300 788 119 (delivery 2 -3 days).
Recommended by GP's, podiatrists and physiotherapists, Footlogics orthotics have been useful in the relief of plantar fasciitis for thousands of Australians, giving them the freedom to walk, run, and live their lives as they like. A recent study in Canada shows how orthotics are beneficial for Plantar Fasciitis.
There are some simple daily exercises you can do to help ease heel pain. One of the main causes of plantar fasciitis is tightness in the calf muscles and tightness under the foot. Making the calf muscles longer and more flexible means that there is a less strain placed on the plantar fascia and also the achilles tendons. This is referred to as the Windlass Mechanism.
Furthermore the plantar fascia ligament under the foot can become slightly more flexible by doing some simple exercises like the ball roll or towel stretch. Please visit this page for all recommended heel pain exercises.
Some people are more prone to experience heel pain than others, the following factors play a role:
There have been a number of studies in relation to heel pain and plantar fasciitis. The aim of these studies is to find out what treatments are most effective and if the effects are short term or long-term. Most of these studies suggests early intervention is often successful i.e. treating the condition it in its early stage is important, rather than leaving it untreated for a long period of time. Also most studies recommend conservative treatment (orthotics, exercises, massage therapy) over non-conversative treatment (cortisone injections and surgery). The use of orthotics (custom-made or premade) feature in most of these studies and are seen as a proven treatment for plantar fasciitis, especially if combined with daily exercises.
Cortisone is a powerful anti-inflammatory and when injected directly into the heel it will work almost immediately. Bear in mind however, that the treatment does not address the root cause of the inflammation, and needs to be repeated every few months. Also note, these injections are quite painful, and most doctors today will consider other, less invasive treatment options first.
ESWT (Extra Corporeal Shockwave Treatment). A specialist targets therapeutic shockwaves to the affected heel area. This will stimulate a healing response in the affected tissue and ligaments, resulting in reduced inflammation and pain. This treatment and may take from 3 to 4 months to be fully effective. Extracorpreal Shock Wave Therapy is the latest technology to treat chronic plantar fasciitis. It is a non-invasive treatment and highly recommended for people who have tried other treatment like cortisone-injections, accupuncture etc with little or no success.
Electroacupuncture and standard acupuncture are used in the treatment of plantar fasciitis and other foot problems such as neuromas and nerve impingement, numbness in the toes etc. In some cases there is nerve entrapment within the foot combined with referred pain from other areas of the body. Some research suggests that acunpuncture can be effective in the treatment of heel pain.
A trigger point is an irritable knot in the muscle tissue. When pressed trigger points are very tender and can cause pain in that specific spot or elsewhere in the body (referred pain). The response to pushing into the knot is a muscle twitch.
The foot contains 126 muscles, tendons and ligaments, so there are plenty of 'hiding places' for trigger points. Trigger points in the calf muscles often refer pain directly to the bottom of the foot. Trigger point therapy of the lower leg and foot can therefore be successful in the treatment of plantar fasciitis.
The Strassbourg Sock consists of a tubular fabric with two adjustable straps which extends from the toes to the lower leg. The aim is to keep tension on the plantar fascia ligament all night long, so no tightness occurs overnight and little or no pain is experienced in the morning. In combination with orthotic insoles and exercises, this device can be very effective indeed. In independent study published in the Journal of Foot and Ankle Surgery found some significant improvement in 55% of the participants.
A night splint is very similar to the Strassbourg sock, serving the same purpose. However, this boot-type device is very uncomfortable to wear at night and very cumbersome, this is why most peope prefer wearing the sock.
In very rare cases plantar fascia surgery is suggested, as a last resort. In this case the surgeon makes an incision into the ligament, partially cutting the plantar fascia to release it. If a heel spur is present, the surgeon will remove it. Plantar Fasciitis surgery should always be considered the last resort when all the conventional treatment methods have failed to succeed.
Endoscopic plantar fasciotomy (EPF) is a form of surgery whereby two incisions are made around the heel and the ligament is being detached from the heel bone allowing the new ligament to develop in the same place. In some cases the surgeon may decide to remove the heel spur itself, if present.
Just like any type of surgery, Plantar Fascia surgery comes with certain risks and side effects. For example, the arch of the foot may drop and become weak. Wearing an arch support after surgery is therefore recommended.
Heel spur surgeries may also do some damage to veins and arteries of your foot that allow blood supply in the area. This will increase the time of recovery.
If you suffer from plantar fasciitis, you might think perhaps you should rest your feet, but it’s actually better for you to keep on the move. Plantar fasciitis affects the band of tissue connecting your heel bone to your toes, and can cause stabbing pains when walking. A treatment for it is to keep moving, but make sure you don’t overdo it. Keep your mileage and speed down if you begin experiencing pain, and place an ice pack under your foot for 15 minutes after you’ve finished walking. An alternative is to roll a frozen bottle of water under your foot for 10 to 15 minutes instead. Adding support to your foot can also help, so using an insole in your shoe or wrapping your foot with athletic tape is also recommended. To find out more about this, read this guide to Walking With Plantar Fasciitis.