Ten tips to cure PLANTAR FASCIITIS (Heel Pain)

Plantar fasciitis (pronounced PLAN-TUR-FASH-E-ITIS) is the commonest cause of pain in the heel.  Heel pain affects celebrities, athletes, ballet dancers, and in fact 1 in 10 of us at some point in our lives. In this article we look at 10 top tips to curing plantar fasciitis.

What Causes Plantar fasciitis?

The plantar fascia is a thick band of tissue that runs from your heels to your toes. It acts like a bowstring which is responsible for the spring in your step. Plantar fasciitis is inflammation of the plantar fascia. Which results from microtears caused either by an acute injury or repetitive overuse.

Initially, this causes an acute inflammation which over time becomes chronic. This causes the plantar fascia to become thickened and swollen. New nerve pain fibres sprout into the inflamed tissue which hurts every step you take. I often tell my patients that it is like a tennis elbow of the foot. Whilst you can rest your arm easily in tennis elbow, its not so easy to rest your foot as you need to walk on it.

What are the symptoms of plantar fasciitis?

Plantar fasciitis causes a stabbing pain that is mostly felt when you first step out of bed in the morning. As you get up and walk around the pain may settle a little. But then after lots of activity may return especially after hours of standing. This is where the term Policeman’s heel came from. The pain from plantar fasciitis is often worse after exercise rather than during it, and it can affect one or both of your feet.

What about my heel spurs?

Plantar fasciitis is often mistakenly called heel spurs. The issue of heel spurs causes huge confusion, especially if they have been noted on an X-ray and cause a lot of unnecessary worry.  In fact an article in the New York Times famously accused Donald Trump of avoiding the draft to Vietnam because of heel spurs.

It is true that a lot of people with plantar fasciitis have heel spurs but the bone spurs themselves are not the cause of plantar fasciitis pain. We know that because 1 in ten (10%) healthy people have heel spurs. But only 1 out of twenty (5%) of those with heel spurs have plantar fasciitis. It’s probable, although unproven, that the heel spur forms because of repeated traction or pulling on the heel bone by the muscles in the foot just above the attachment of the plantar fascia. The most important point is that plantar fasciitis can be treated without taking off the heel spur.

What are the risk factors for plantar fasciitis?

Plantar fasciitis is most common during the ages of 40-60. It is often triggered by a change in walking or running habits. So if you have increased your levels of activity, changed from running on grass to running on hard surfaces, or changed your shoe wear then you are at higher risk of developing plantar fasciitis.

Because about ten times your body weight can go through your foot when you jump, hop or skip, then being overweight clearly increases the stresses on your feet and can make plantar fasciitis much worse. Also, your foot shape may be a factor. In people with flat feet the plantar fascia is often stretched and in people with high arches the plantar fascia is often tight.

Another really important factor is tight heel cord or tight calf muscles (known as the gastrocnemius muscle) as when these are tight there is less give in movements, and higher forces are transferred to the foot during running or walking.

How is plantar fasciitis diagnosed?

The diagnosis is usually a clinical one but a specialist opinion is helpful to rule out other potentially more serious conditions like stress fractures, arthritis or pinched nerves.  Your specialist may suggest an investigation like ultrasound scans, or MRI scans to rule out these other conditions. Also its important to rule out a tear of the plantar fascia which may suggest a period of rest is needed. If your pain is severe, and you have had a history of a sudden injury then ruling out a tear is important.

What happens if I ignore my plantar fasciitis?

If you ignore the symptoms of plantar fasciitis (often mis-spelt "planters fasciitis", "plantar fashitis" or "planter tendon") then you may compromise the way you walk or exercise. So aside from the progressively worsening foot symptoms, you may also start to develop pains that involve other parts of your body like knee, hip or back pain. It's important to try and deal with plantar fasciitis and the underlying causes as early as possible.

What is the treatment for plantar fasciitis?

Most people who have plantar fasciitis heel pain recover fully but it can sometimes take months or even longer providing you do the right things. Self-help plantar fasciitis treatments are really hard to find which is why I wrote this article. I think its important that you calibrate your expectations at the outset,  as there is no miracle cure for plantar fasciitis and even if you work at it, it could be months before things improve but rest assured, most cases do improve. Below are my plantar fasciitis treatment recommendations, many of which you can do straight away, others will require the help of a specialist:

Pain killers

Paracetamol (acetaminophen)  which includes brand names such as Panadol, Tylenol, Biogesic, Fervex, Saridon, or Actamin can be useful. As well as anti-inflammatory drugs such as ibuprofen, which includes brand names such as Nurofen, Advil, or Motrin. Taking paracetamol and ibuprofen together is a useful combination for plantar fasciitis pain relief. You must of course always speak to your healthcare professional before taking any medication to check they are safe for you and that you don't have risk factors such as stomach ulcers. There are some topical pain-killing medications like anti-inflammatory creams that can be purchased over the counter, such as Voltarol gel, Ibulieve, Voltaren gel, Fisiocrem, etc. Providing you follow their instructions they can be useful as well.

Ice

Icing the area using a cold compress or rolling your foot over a frozen bottle of water for 10 minutes can help settle the pain. Remember to pour out a quarter of the plastic bottle of water before you put it into the freezer or it may explode. Always wear a sock or place a thin towel over the ice to avoid an ice burn. Nowadays cool gel socks or foot wraps are available and are very useful.

Spikey Ball

A spikey ball (can be spelt spiky ball) should become your best friend. I recommend purchasing an 8cm firm but semi-squishey spikey ball, about the size of a tennis ball. I do not recommend the rock-hard spikey balls as they can be very painful. I tell patients to place this onto their mobile phone when they go to bed at night. Why onto their mobile phone I hear you ask? Well because its usually the first thing you go to in the morning, and I want you to pick up the spikey ball before you get out of bed!!.

This is a really important point. You must not stand up out of bed. Instead, as soon as you wake up, swivel round the bed with your legs hanging off the side of the bed. Place the ball on the floor under your affected heel and roll the ball under your heel from your toes to your heel. Do this for 1-2 minutes to get a deep local stretch of the plantar fascia. Then stand onto the ball and roll it under your body weight for 1-2 minutes before getting on with your day. Do the same after getting up from a chair and before going to bed at night.

Some people recommend a rolling pin or a tennis ball as a replacement for a spikey ball and there is nothing wrong with these, but personally I don’t find they are as good at treating plantar fasciitis because they don’t provide as much localised deep tissue massage, nor are they as good at stimulating the nerve fibres in your feet. Birkenstock shoes use the same pointed prongs and a lot of patients really like this as well.

Weight loss

Losing excess weight can really help reduce the stresses on the plantar fascia. I often have to help patients that say they cannot exercise because of the pain. In these situations we used off loading exercises that get the heart working such as cycling, walking in water exercise (hydrotherapy) and Pilates based mat-work.

Physiotherapy

Also known as physical therapy is extremely important to treat plantar fasciitis. Exercises to stretch any tight heel cords (which must be with a straight knee), as well as work on your core-stability, and gluteal muscles is important. Assessment of your walking and running patterns are really important as well in the treatment of plantar fasciitis to get you back to walking and running pain-free.

Night Splints

Another way to stretch a tight heel cord is to wear a splint at night time. “Why would I want to wear a night splint?” I hear you ask. Well the reason is because at night time we tend to sleep with our toes pointed out and so the calf muscles are relaxed. A night splint keeps a gentle stretch on them as you sleep, which can help relieve plantar fasciitis. This is not a replacement for physical therapy and proper stretching exercises, but it is certainly a good adjunct.

A lot of patients find night splints uncomfortable so these are not my first choice of treatment. Some patients have tried plantar fasciitis socks which have a clip to the front of the shin to pull the toes up and if these work for you I have no issue with that.

Silicone heel cups

Some patients find wearing of silicone heel cups helpful. Aside from the shock absorbing role they play, they do of course also take some strain off from the Achilles tendon and tight calf muscles. So again these can be used as an adjunct but not a substitute for calf stretching exercises.

Orthotics, Shoe inserts and Shoes

Orthotics for plantar fasciitis is one of the commonest questions I am asked about.  Off-the-shelf or custom orthotic insoles or inserts can be useful to provide support for the foot arches. I always recommend full length inserts and never half or two thirds length because its important to replace the insole inside your shoes and not add to them, as for most of us our feet don’t fit well into our shoes anyway, and there is no logic in trying to stuff an additional insole into your shoes. Just as important as the insert is a good pair of supportive shoes with good shock absorption such as Kybun shoes (see figure below).

Shock wave therapy

Extracorporeal shock wave therapy fires high-frequency sound waves into the tissues to encourage healing. It is usually reserved for failure of all the other treatments where the condition is becoming chronic. It usually involves three treatments each given a week apart.

Steroid Injections

Steroid injections are sometimes used to treat plantar fasciitis, but they need to be done very carefully and only by an experienced specialist. That’s because if the steroid is injected into the wrong area—especially the fat pad in your heel—it can cause that fat to shrink or break down. This fat acts like a cushion for your heel bone when you walk, so if it gets damaged, it can lead to long-term pain that’s very difficult to fix.

Steroids can also make tissues weaker and more prone to tearing. In my practice, I sometimes use steroid injections for patients who have bone swelling or bruising (called bone marrow oedema) on their MRI, as it can help reduce inflammation and pain. But again, it must be done with great care.

Surgery

This is rarely needed to treat plantar fasciitis but can be helpful in refractory cases which aren’t responding to other treatments. Surgery may involve releasing overtight calf muscles or even releasing the plantar fascia from the bone using a minimally invasive (or keyhole) techniques. You are always advised to seek a second opinion before undergoing surgery for plantar fasciitis.

What about nutritional supplements for plantar fasciitis?

As with any musculoskeletal problems its important to have a healthy and balanced diet. I am often asked if there are any nutrition and supplements that can help with plantar fasciitis. Having studied the literature I can tell you that the evidence to support the use of supplements is weak.  Certain nutrients have been proposed to help build strong tendons and ligaments such as magnesium, Zinc, Vitamin C, Vitamin B5 (pantothenic acid), and fish oils with omega-3 fatty acids.  Whilst the evidence to support their use is lacking, I do hear a lot of positive feedback from my patients and so I have no problem in them taking these supplements as long as they are on top of (and not a replacement) for a healthy diet.

Questions to ask your doctor if you suffer from plantar fasciitis.

• What is causing my symptoms?
• Do I need any special tests?
• How long will it take for this to get better?
• What’s the best treatment plan for me?
• Are there any alternatives to what you are suggesting?
• Is there anything I need to avoid?
• Do you recommend any patient information guides or websites for more information?

This article was written by Mr Andrew Goldberg OBE MD FRCS(Tr&Orth), a Consultant Orthopaedic Foot & Ankle Surgeon for Adults and Children from London. If you would like to organise a consultation with Mr Goldberg please call his office on +44(0)207 042 1828 or email info@goldbergpp.com

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