My heel hurts!  Plantar Fasciitis is one of the most common injuries I treat in the office.  Heel pain can happen for several common reasons, and these causes can vary depending on your age, activities, and nature of the pain.  In this post I talk about symptoms- what you're feeling, outline some anatomy- so that you understand what is hurting, and my recipe for relief. 

Plantar Fasciitis.  You may have heard this term before.  The suffix “itis” means that a structure of your body is inflamed. The term inflammation refers to a localized physical condition in which part of the body becomes reddened, swollen, hot, and often painful, especially as a reaction to injury or infection. 

I like to define terms with my patients before spitting out treatment recommendations. I feel that if you can visualize what is happening,  then you can understand what can make it better or worse.  You will be able to make the right choices for yourself and that will lead to success! Resolution of your pain! 

Now that we know Plantar Fasciitis is inflammation of our Plantar Fascia, let’s learn a bit more:  

The Plantar Fascia is a fibrous band that has an anchor point at the heel bone then continues to span the bottom of the foot ending its span and inserting at the base of the toes. This fibrous band helps to hold up the arch of your foot. The band of the plantar fascia is pulled tight when you push off of your toes when walking- as seen in the picture above. It is important to know these facts to best understand how to nip that pain in the bud. 

Plantar fasciitis is diagnosed based on your medical history and physical examination. Before the physical exam you will have a chat with the doctor so that they can get a better understanding of your condition. The answers to these interview questions also help focus your treatment plan.

Here are my go to interview questions for heel pain patients and what the answers say about your foot pain: 

• Do you have pain upon the first step in the morning ?
  Often the answer is yes! And many remark that it feels like they are stepping on something sharp.

• Do you have pain at rest?
  I will want to focus my exam to make sure there isn't a tear or fracture

• Do you stand for work?
  If you often spend long hours on your feet, does the heel hurt more at the end of the day rather than the first step in the morning? If yes, then we need to help heal inflammation, and give more support and cushioning while standing.

• Are you barefoot at home?
  A supportive cushioned house slipper may be your new best friend. 

Show me what types of shoes you wear. You would be surprised how often it’s the shoe and not you! 

During the exam, your doctor will check for areas of tenderness in your foot. The location of your pain can help determine its cause. Sometimes X-rays are needed, and there are even times when I order advanced imaging such as an MRI. When deciding the best treatments it's important to first identify your foot type.  The biggest misconception is that there is one best treatment plan for everyone- truth is different foot types need a different kind of TLC. 

Here’s how you can determine your foot type by doing an at home self assessment of your arch height.  When stepping out of the shower or bath, look at the imprint your wet foot leaves on the floor. Your foot type will help to tailor your treatment plan to your foot’s needs. Arch height is not the only factor for determining foot type, heel position and other measurements are taken during your physical exam. But for this general discussion arch height is our key factor.

Treatment plans 

I always divide the treatment into 3 categories. You should use at least one modality from each of the 3 categories. If not, your likelihood for success will dramatically decrease.

Category 1:  SUPPORT 

We need to support the plantar fascia and help lighten its load. Remember how I said that the plantar fascia supports our arch. Pain at the plantar fascia is a clear sign that it has been working over time. By giving the PF some help, it can begin to heal. 

The kind of support needed goes back to foot type. Depending on your foot type we will look for different types of “support” from shoe gear. Support can also be achieved by using an orthotic or arch support and adding it to your shoe. 

Flat foot: If you have a Flat foot or low arch showing a full imprint you will need shoes that offer stability. This means a rigid outer sole and heel helping to control your foot and prevent the plantar fascia from over working. You want an insert to support your arch and prevent further collapse. Power Step Pinnacle

High Arch: This is different from a High arch foot showing a minimal imprint. You need support but in a different way. You want to cushion and decrease impact on your foot. A shoe having a thickened outer sole with lots of foam and cushioning throughout. You may want to add an insert to limit empty space you feel between your arch and the inner sole of the shoe; You want full contact. This will prevent stretching and pulling on the plantar fascia: Superfeet Insoles

I don’t love the term “normal foot”, the other foot types are highly prevalent in the general population. So let's refer to the 3rd foot type as medium or neutral. This foot type will benefit from a generally neutral, good quality shoe that is engineered walking or sport. An arch support here is still helpful, your arch may be “normal” but the plantar fascia is still injured. An orthotic will take the stress off this overworked structure. Think of it as a sling for a shoulder injury: Protalus Insoles

Sometimes an orthotic can even make a “bad shoe” better. Here’s my go to pair for casual and dress shoes:  

Superfeet Easyfit for Women

Superfeet Easyfit for Men

Lets recap: different foot types require different types of support. A doctor may even recommend custom orthotics if you don’t get relief by using the over the counter type. Orthotics take some time to get used to, break them in slowly at first.

Category 2:  Strengthening versus stretching 

A lot of things you read will mix the two together and tell you to stretch and strengthen your arch. Well, which is it? When do I stretch versus strengthen?  Which to do when depends on your foot type and your symptoms. Using the answers to the questions we asked at our initial interview you can determine what stage you are in.

If you have pain when you first step out of bed- that is a sign of a tight plantar fascia. If you have very tight calf muscles- you likely have a tight plantar fascia. If you have a high arched foot- you likely have a tight plantar fascia. 

In these circumstances you would benefit from a stretching regimen. There are some simple stretches when performed regularly can gradually release the tension at the plantar fascia and eventually decrease the repetitive tugging at its anchor point on the heel bone. It is that tightness, pulling and tugging that caused your inflammation and pain. 

Night splints and other stretching devices hold the plantar fascia and Achilles tendon in a lengthened position to promote stretching. The Strassburg sock has been my go to both personally and professionally. Your doctor or physical therapist might recommend that you wear a splint that stretches your calf and the arch of your foot while you sleep.  If you are able to tolerate the device overnight, great. I recommend beginning with a 30 minute interval before bed and working up to overnight if tolerated. I never made it the whole night but using it 30 minutes before bed worked great for me. 

If your heel aches more at the end of the day or after activity, avoid stretching initially. This aching is a sign that your foot needs recuperation. Jumping into a full on stretching regimen can aggravate an already inflamed structure and make the situation worse. Your foot needs some rest and support. Before adding on any stretches or strengthening exercises, modify your activity, start an icing routine and change your shoe gear; more on that below.

When the heel is not so tender you can safely begin a stretching regimen.  Strengthening exercises for plantar fasciitis are designed to strengthen the intrinsic structures of your foot to help internally support the fascia. Again key note here is,  to begin these exercises after your pain has been managed. Often these strengthening exercises are done too early, while you are still inflamed and in pain. This can just make matters worse. If you feel you are ready, but pain returns after starting the strengthening exercises, pause, rest and wait 1-2 weeks longer before starting again. I know it’s hard but your body needs time to heal before rebuilding. 

Over time when it's safe to do so, strengthening exercises can help to prevent this injury from returning. Strengthening will better equip your foot to deal with the normal stressors of your daily activities. Try some of these effective strengthening exercises from The Sporty Doctor

Category 3: Treat the inflammation; put out the fire in your foot.

We know that the area is inflamed because it hurts.  The degree of inflammation may not be clear just from reading this article but use your pain as your guide. Constant pain, worsening pain, unable to put your foot down- you should head to a doctor.

If you haven’t made it to the doc yet; there are some simple things you can do to help combat the inflammation that is causing your pain. 

REST

Easier said than done. But taking a load off can do a lot of good. If you can, do a combination of sitting and standing at work. Change your work commute to incorporate less walking. Do the old 1990’s tennis shoes for the commute and dress shoes when you arrive at the office ( whenever Covid lets us out again ). Change up your exercise routine to put less stress on the fascia. The elliptical will put constant strain on this area, try a stationary bike instead, limit running and try to find an alternative- swimming? If you can’t let go of running completely, alternate biking and runs.  Even small modifications will help take the load off. If not you can further damage the fascia and healing can be jeopardized.

ICE

Ice is a natural anti-inflammatory. 10 minute sessions of icing at least 2 times a day will do a whole lot of good at the first signs of pain. Wear a sock or make sure there is a thin layer of fabric between ice and skin, kick your heels up and chill out. 

An Ice roller is another great way to apply cold right to the area, these also can provide a bit of a massage while icing.  (a frozen water bottle or can works great too).

Recruit help from over the counter anti-inflammatories, as in well known oral medications like advil, motrin, aleve, ibuprofen, topical medications like Aspercreme, Biofreeze, or even CBD formulations like Canodyne if your state allows.  You may need to use these medications for several days, so be sure it's safe first, if you have any pre-existing conditions or over the age of 65 consult a doctor. Don't use the medication longer than recommended on the label- read the fine print.  

When to call the doctor? 

• If your pain is a result of a trip or fall- Call or visit a doc before starting any at home treatments. 

• If you have tried some at home treatments and the pain has worsened or not gotten any better. 

• If you tried at home treatments the pain got better at first and has now returned. 

• I recommend either a podiatrist or orthopedic as the best type of doctor to consult for plantar fasciitis. 

Within each of the 3 categories of treatment, there are many more treatment options available that a doctor can offer you. The trick is to make sure you are employing something from each category, whether at home or doctor prescribed.

If conservative measures fail to relieve your pain. Below is a comprehensive list (link mayo clinic ) of top treatments available at your doctors office. 

• Injecting steroid medication into the tender area can provide temporary pain relief. Multiple shots aren't recommended because they can weaken your plantar fascia and possibly cause it to rupture. 

• Using ultrasound imaging, platelet-rich plasma obtained from the patient's own blood can be injected to promote tissue healing.

• Extracorporeal shock wave therapy. In this procedure, sound waves are directed at the area of heel pain to stimulate healing. It's usually used for chronic plantar fasciitis that hasn't responded to more-conservative treatments. Some studies show promising results, but it hasn't been shown to be consistently effective.

• Ultrasonic tissue repair. This minimally invasive technology was developed in part by Mayo Clinic doctors. It uses ultrasound imaging to guide a needlelike probe into the damaged plantar fascia tissue. Using ultrasound energy, the probe tip vibrates rapidly to break up the damaged tissue, which is then suctioned out.

• Surgery. Few people need surgery to detach the plantar fascia from the heel bone. It is generally an option only when the pain is severe and other treatments have failed. It can be done as an open procedure or through a small incision with local anesthesia.

By reading this article, I hope you will get a jumpstart on your treatment and have a better understanding of your condition.  If this injury has gotten ahead of you, don't delay the call to a doctor and make an appointment ASAP. Fast appropriate treatment leads to the best outcomes. 

-Be well, Dr. D