Plantar Fasciitis: Healing the Heel

Jogger’s heel, tennis heel, and policeman’s heel are common names for a common problem. All of them are actually plantar fasciitis, and approximately 1 million Americans visit health care providers every year because they have inexplicable—and often excruciating—pain in their feet.

Patients with plantar fasciitis describe pain that’s severe when they rise and attempt to walk after a night’s sleep or prolonged inactivity. Once the pain starts, sitting or elevating the foot is of no help, and the pain persists.

The word “fasciitis” implies inflammation, but plantar fasciitis isn’t inflammatory. Rather, it’s chronic degenerative irritation at the insertion of the plantar fascia on the medial process of the calcaneal tuberosity.

Plantar fasciitis can develop after a trauma to the foot, but most cases are simply overuse injuries. Precipitous changes in athletic training (fast increase in distance, intensity, or duration of activity); running on poorly cushioned surfaces; footwear that’s inappropriate for the task at hand; flat-footedness or overpronation; aging and heel fat pad atrophy; and spondyloarthropathies (eg, ankylosing spondylitis) are often causative factors for plantar fasciitis.

Adults of any age can develop plantar fasciitis, but women 40 and 60 years old are at double the risk compared with men. Factory workers, teachers, mechanics, warehouse workers and other professions in which workers are continually on their feet are also at increased risk.

For patients presenting with plantar fasciitis, clinicians should stress the following:

· Emphasize that stretching is the best treatment for plantar fasciitis, especially in the morning and before exercise.

· Counsel patients to wear appropriate shoes with adequate arch support and cushioned heels. For active patients, clinicians should also advise them to discard old athletic shoes when they show signs of wear in the midsole (which tends to wear out before the shoe tread does) or have accrued 250 to 500 miles of use.

· Advise patients to avoid long periods of standing and to stretch the plantar fascia for at least 30 seconds before walking after long periods of inactivity. Weight loss may also help alleviate the pain.

· Athletes should rest for 4 to 6 weeks, and resume athletic activities slowly starting at 50% of their pre-injury activity and increasing very slowly. Suggest applying ice for 10 to 20 minutes after running or jogging, and at day’s end for 6 weeks.

· Warn patients that walking barefoot or running on hard surfaces can cause and will likely exacerbate the condition.

· Consider OTC orthotics or arch support for their shoes.

· Remind patients not to ignore pain. Nonsteroidal anti-inflammatory drugs may help alleviate discomfort.

If pain persists for 6 weeks or more despite treatment adherence, patients may need referral to a podiatrist for corticosteroids, botulinum toxin type A, splinting, shoe modifications, extra corporeal shock wave treatments, or orthoses.

Oftentimes, the most difficult aspect of treatment for patients with plantar fasciitis is the amount of time it takes. Although frustrating, approximately 80% report relief with nonsurgical treatment within 12 months. Just 5% of patients will need surgery for plantar fascia release after conservative measures fail.

In all cases, it’s critical to manage patient expectations and emphasize that conservative treatment usually works.