Plantar fasciitis is a common condition affecting millions of American each year. The condition is marked by inflammation and/or micro-tearing of the plantar fascia, which is a broad ligament on the bottom (plantar) aspect of the foot. The plantar fascia stretches from the toes along the arch back to its insertion at the heel.

When you stand, the arch of the foot flattens slightly, putting a stretch or tension on the plantar fascia. When the attachment of the plantar fascia on the bottom of the heel becomes inflamed or injured, this is known as insertional plantar fasciitis (the most common type). Irritation or injury along the broad surface of the plantar fascia in the arch is known as diffuse plantar fasciitis.

Both types of irritation cause pain in patients’ feet and heels, particularly when the patient stands up during the day or initially wakes up in the morning.

The Causes

Causes of plantar fasciitis are many. They include:

  • Overuse injuries, such as a sudden increase in exercise activities seen in runners or in people who started a new exercise program.
  • Obesity and the increased weight load it puts on the plantar fascia.
  • Inflammatory conditions such as arthritis, lupus, ankylosing spondylitis and gallop (which can irritate the plantar fascia insertion).
  • Mechanical factors such as a tight Achilles tendon, hallux rigidus, or a stiff ankle (which can exert increased force on the plantar fascia).
  • A flexible flatfoot with increased pronation.
  • A stiff cavovarus foot that results in irritation the plantar fascia.
  • Direct trauma, such as stepping on a rock.

Note that not all heel pain is plantar fasciitis. Other conditions that may produce heel pain include:

  • A stress fracture of the heel (calcaneus).
  • Tibial nerve compression (tarsal tunnel syndrome) with irritation of the nerve to the ADQ muscle (factors nerve).
  • Atrophy or withering of the cushioning fat pad on the plantar heel.
  • Arthritis of the posterior ankle joint or subtalar joint.
  • Pain from the insertion of the Achilles tendon may reach down around to the bottom of the heel.

The Diagnosis

Diagnosing plantar fasciitis starts with a careful examination and discussion of a patient’s history, which will often highlight telltale signs of the condition.

Symptoms revealed in a patient’s history include:

  • Both sharp and dull chronic pain on the plantar aspect of the heel, usually near the medial insertion of the plantar fascia.
  • Usually, this pain is worse with the very first steps in the morning or after sitting down for a while. These symptoms occur because the plantar fascia has contracted and is stretching to a painful degree during those first steps. 
  • Patients may feel a constant burning pain in their feet or heels throughout the day.
  • Patients’ pain levels may worsen following increased weight-bearing and activities. While initial movements and exercise make the pain temporarily decrease, the aching will return when activities cease.

The examination itself often reveals exquisite tenderness at the medial insertion of the plantar fascia. Often the Achilles tendon is also tight to the touch. 

An exam must also rule out other causes of foot and heel pain:

  • X-rays and/or an MRI may be ordered to rule out a calcaneal stress fracture or other cause for the discomfort. 
  • A bone scan may also be used to distinguish between a calcaneal stress fracture and insertional plantar fasciitis. 
  • In cases where the nerve to the ADQ (factors nerve) is compressed or irritated, pressure or tapping over the nerve (Tinel's test) may reproduce pain in the medial and plantar heel.

The Treatment

Early Treatment

Treatment of plantar fasciitis initially begins with conservative action.

Multiple studies and (Dr. Bowman’s own personal experience) have revealed that 99% of patients can be successfully treated without surgery. Pittsburgh Foot & Hand Center has also enjoyed great success with our comprehensive conservative program to treat plantar fasciitis over the years. It consists of:

  • anti-inflammatory medication and applications (i.e. use of ice packs, massage, etc.)
  • proper orthotic management (i.e. proper footwear and arch support)
  • regular and frequent physical therapy (i.e. stretching by the patient to lessen tension in the ligament and Achilles tendon)

Even if you have tried these techniques in the past, we ask that you use them together per our specific treatment plan recommendations before giving up on your recovery

Long-Term Treatment

For patients with persistent plantar fasciitis, additional treatments may be utilized.

  • Patients may be asked to use a nighttime splint for Achilles tendon and calf stretching (and Ankle Dorsiflexion), which can relieve the tension that builds overnight.
  • An injection of cortisone Xylocaine at the insertion of the plantar fascia ligament may be performed to “calm down” the inflammation and allow therapy to continue. (Note that a cortisone injection is not a substitute for therapy, stretching or treatment. Frequently patient's will discontinue their therapy for stretching after getting relief from a single injection, which leads to a worsening of symptoms over time. Multiple frequent cortisone injections are to be discouraged, since they may weaken the plantar fascia and can result in rupture of the plantar fascia.) 
  • Casting or placement in a protective boot to “calm down” the plantar fasciitis has also been used in cases of chronic plantar fasciitis. 
  • Treatment of chronic resistant plantar fasciitis with electroshock wave (ESW) therapy has been successful (but should be reserved for cases that did not respond to the above conservative treatment).
  • Reducing the amount or intensity of running may be required during treatment. We try to avoid this if possible. 
  • Finally, relief of plantar fascia may require reduction of the load on the plantar fascia via a controlled weight loss program.

Additional Treatment Information

We are currently pioneering a new treatment for plantar fasciitis involving the use of platelet-rich plasma (PRP). In this situation, approximately 30 cc of blood is drawn from the patient, prepared in the special centrifuge, and the buffy coat-part of the plasma (containing platelets together with human growth factors) is obtained. That is then injected into the area of inflammation to promote healing. This new in an exciting treatment may develop into the common method of treatment.

Surgery

Surgery may be required for cases of plantar fasciitis that do not respond to the above nonsurgical treatments. This approach should be utilized less than 1% of the time. 

If needed, the surgery is performed on an outpatient basis with twilight local standby anesthesia. A small incision is made on the plantar heel, just in front of the main weight-bearing area of the heel. The medial one-third of the plantar fascia is released and the skin is closed. 

Patient's are placed in a protective boot post-op with no weight-bearing allowed for two weeks. At the two-week visit, the sutures are removed and progressive weight-bearing exercises are begun (together with initial therapy) to help restore range of motion. 

At 6 weeks the patient is placed back in their normal shoes with orthotics. 

Surgical risks with this condition and surgery include anesthesia-related risks, wound healing problems, infection, painful plantar incision, and continued post-op discomfort. 

Note that "Endoscopic" (one or two incision variations) for this procedure have been utilized elsewhere. Because of difficulty controlling the amount of plantar fascia release and permanent damage to the plantar nerves, we do not utilize this procedure. Unfortunately, we have inherited patients with both of these complications from elsewhere.