Plantar Fasciitis is a painful inflammatory heel condition affecting the large ligament-type structure in the base of the foot that can cause arch pain and heel pain. The Plantar fascia can become thick and inflamed due to the irritation at its attachment, at the base of the heel. In some patients, small tears can develop and these people suffer with acute pain that can be excruciating. Sometimes, on x ray, heel spurs can be seen, but these are not usually the cause of the patients heel pain.
It should be noted that “Heel Spurs” is a misleading diagnosis that has been used by podiatrists and doctors for many years. More and more practitioners today are open to the fact that heel spurs are not the problem and that the spurs don’t cause the pain. Instead, the source of pain is the inflammation within the plantar fascia surrounding the spur itself.
Patient’s with plantar fasciitis usually feel pain under the ball of the heel and it can represent a stone bruise sensation. Arch pain is less common but is also a key symptom of plantar fasciitis. The heel pain is common first thing in a morning when climbing out of bed and after periods of rest, such as driving or being seated. The pain in the heel can be erratic and often, there are pain free periods when the person feels like they are healing. If there is a very sudden onset of pain, as opposed to a gradual onset, this may be due to tearing of the plantar fascia. It is important that the podiatrist differentiate between regular plantar fasciitis and plantar fascia tearing as the treatment is different. Ultra sound imaging may be necessary.
Initially, these heel pain patients may feel a dull ache in the base of the heel. There may be an awareness of a problem in the afternoons, or after they have been weight bearing for long periods of time. It is possible that they feel some pulling in the Plantar Fascia, which they describe as a tightness in the arch or the sole of the foot.
Early treatment or intervention of plantar fasciitis, at this stage is crucial, and may inhibit the development a more chronic heel pain condition. Unfortunately, many patients ignore the early symptoms, presuming or hoping that the tightness or the dull ache in the heel will settle down and dissipate. In some people this is the case, but others can develop severe heel pain and/or chronic plantar fasciitis.
As sports podiatrists, the typical symptoms that we hear, in these early stages, are the feeling of a pebble in the shoe or a stone bruise sensation. Patients with mild Plantar Fasciitis sometimes inform us that they felt like they had stepped on a small pebble or stone. In these early stages that we describe above, the Plantar Fasciitis will not always induce heel pain throughout the day time. The symptoms may only be present in the morning when getting out of bed and can be very sporadic. Some patients are asymptomatic for a day or two only to find the pain returning.
In the early stages of Plantar Fasciitis there can also be some heel pain in the morning when the foot hits the floor, but this is usually mild and is often little more than a feeling of tightness.
When the condition is fully developed, the symptoms of Plantar Fasciitis are more acute. The condition will become chronic if the strain on the plantar fascia goes on for long enough and remains untreated.
The pain in the heel is more consistent and patients will usually report pain, not just stiffness, each morning when hopping out of bed. Most patients hobble for at least 5 minutes after getting out of bed due to extreme heel pain from the plantar fasciitis. The pain in the heel usually subsides within 15 minutes and patients are usually more comfortable after taking a hot shower. Walking throughout the day isn’t always a problem as the inflammatory change in the plantar fascia is less consistent and the heel pain isn’t always present.
However, mid-afternoon, after several thousand steps the foot fatigues, and the heel pain returns. Patients with Plantar Fasciitis will sometimes report pain when getting out of their car after a drive home from work. They hobble again for the first few minutes and find some relief after walking a short distance.
Podiatrists are often informed by their patients that they also limp when they stand up after being seated for dinner in the evenings or after sitting on the couch watching television. An ultra sound report will often show thickening of the plantar fascia, due to inflammatory change.
If the condition comes on very quickly, during a one-off event or during a particular day / activity then the plantar fasciitis can feel severe / acute. Alternatively, chronic Plantar Fasciitis left untreated, can lead to the same state. The strain on the Plantar Fascia has been so great and so repetitive that acute inflammation develops as does an extreme pain. Patients with severe Plantar Fasciitis will usually describe to the sports podiatrist and extreme level of pain which is present for most of the day. It’s not uncommon to hear these people use the words “excruciating” or “relentless”. These patients will experience throbbing when sitting or lying down and are starting to feel the psychological effects of having a condition that is both chronic and acute. Plantar fasciitis affects the lives of these people who have stopped exercising and are often struggling to walk during day to day movements.
Some patients with severe Plantar Fasciitis have developed deep surface or laminar tears in the fascia. As sports podiatrists, we arrange ultra sound scans, to help confirm or exclude torn fascia. X rays are less helpful in the case of this soft tissue injury, plantar fasciitis.
Plantar Fasciitis can affect men and women equally, but there is a trend in terms of the age of the patients that we treat. Fewer people younger than 30 years of age develop the condition, and the majority of patients with Plantar Fasciitis are over 60. In between those ages there are a large percentage of male and female patient’s in their 40’s and 50’s.
Occasionally we see juvenile onset plantar fasciitis which affects children who are engaged in sport and physical activity. It is important that we differentiate between other heel pain conditions such as Severs disease and Achilles Tendonitis. Our sports podiatrist have extensive experience in these conditions and can determine which one your child has, by carrying out a careful physical examination. We will refer for x ray or ultra sound scans if we deem them necessary.
There is no single cause of plantar fasciitis. The cause is multi factorial, as is the treatment. Ultimately, there is an increased load on the plantar fascia which causes it to become pathological. Tight calf muscles and soft shoes are a big problem, as are flat feet and an increase in body weight. Biomechanical issues leading to poor foot function can also trigger the condition. Patients who suddenly increase the amount or frequency of sporting activity / exercise are also at risk.
We often hear patients saying
…“I was looking to get fit after Christmas and was training several times a week, and then my heel became extremely painful”
Commonly, people with plantar fasciitis have been using flat, flexible and less supportive shoes. The lack of support is stressful on the plantar fascia and the heel, especially for those people with a weaker foot type. If these patient’s use the softer shoes for long enough periods, or as a main shoe, the stress can lead to plantar fasciitis or other types of heel pain. In these circumstances, it is essential that the patient have their foot type and shoes assessed. This will help to treat the plantar fasciitis. Interestingly, higher heeled shoes for women are not the cause of plantar fasciitis, although these shoes do cause tightness in the calf muscles. Most women report, “my heel pain feels better in a high heel”.
People with higher arches receive less support from shoes and their liners, as there is less contact through the sole / arch area. The plantar fascia runs through this arch area and can become taught and strained. Functional running shoes and hiking shoes still lack the arch support that some feet need. The lack of support and the tightness can lead to heel pain and plantar fasciitis.
The flat foot (pes planus) is often caused by weak ligaments (ligament laxity). The plantar fascia works harder, along with other muscles and tendons, to compensate for this inherent weakness. The increased load can lead to plantar fasciitis or heel pain in general if the increased load is sufficient to cause strain, tearing and inflammation.
The most common calf stretches place a certain amount of strain through the sole of the foot and therefore, the plantar fascia. Plantar fasciitis can come about when the patient stretches too much, or too hard. Some patients go through a rehab period following an injury or surgery and will develop plantar fasciitis due to the stretching technique they used. This is not to say that calf stretching should be avoided, but more so that technique is important.
A large percentage of patients that we treat with plantar fasciitis are carrying more body weight than they want to or used to. They often report being overweight and are sometimes attempting to shed a few kilos. The increase in body weight adds more load to the feet and hence more strain on the plantar fascia. Furthermore, the increased body mass means that the calf muscles must work harder to push the patient forwards and so theses muscles become tighter and stiff. As mentioned previously, tight calf muscles pull harder on the heel and will most certainly cause a heel pain condition such as plantar fasciitis or Achilles Tendonitis. The irony lies in the fact that these patients are unable to lose weight through their desired walking or other exercise programme as their feet hurt too much. The only way they can lose weight is to engage in non weight bearing activities such as swimming.
Regardless of the cause, Plantar Fasciitis is not a condition that we have to live with, like arthritis. It is reversible. https://www.sydneyheelpain.com.au/how-we-treat-heel-pain/Written by Karl Lockett