Plantar fasciitis is inflammation in the plantar fascia in the foot, the fibrous attachment to the heel bone. It is the most common cause of heel pain.  The main symptom is pain in the bottom of the foot or the heel and the pain is usually the worst with the first few steps out of bed in the morning or when getting up after long periods of sitting. The pain is often relieved after walking for a while or after stretching. Generally, plantar fasciitis can heal on its own even without any treatment. However, getting proper treatment can help it heal faster and taking proper care of the soles can reduce the recurrence rate.

The causes of plantar fasciitis include the degeneration of the plantar fascia, overuse, and injury to the plantar fascia.  This condition is most often found in middle-aged people, especially among runners or people who have to walk a lot, those regularly wearing hard shoes or thin-soled shoes, those overweight, those with abnormal foot structure such as high arches or flat feet, and those with Achilles tightness. 

The main symptom of plantar fasciitis is sharp or stabbing pain, or feelings of “pins and needles” in the heel or in the sole when putting pressure on the feet.  The pain usually occurs when getting up or walking after there’s been no pressure on the feet for a long period, especially when getting out of bed in the morning or after sitting at work for a long time. In the initial stages, the pain usually subsides after moving or walking for a while. The symptoms usually come and go depending on the use and the degeneration of the plantar fascia. In the later stages, the pain may increase and will not subside even after use. This can become chronic without proper treatment. In fact, this condition can heal on its own even without treatment but that can take up to 6-12 months. Proper treatment can reduce the duration of the condition, enhance faster healing, and prevent it from becoming chronic. Patients with initial stages of plantar fasciitis may take care of themselves by taking breaks from walking or running, wearing proper shoes, and doing stretching exercise.  And if symptoms do not improve or become chronic, it’s best to see a doctor.

When the patient seeks medical advice, the doctor will take medical history and give a physical examination to make a correct diagnosis. This is because the heel pain can be due to causes other than plantar fasciitis such as compressed plantar nerve, heel bone bruises, or fatigue fractures. Patients may get an X-ray to check for heel spurs or abnormal foot bone structure or they may get an MRI to diagnose degeneration, inflammation, or plantar fascia tear.

Treatment of plantar fasciitis generally starts with rest, staying off the feet, not walking or running, to reduce pain and inflammation. However, high inflammation may suggest the use of a walking cast to reduce movement and inflammation for a while before wearing it only at night. Cold compresses and NSAIDs (nonsteroidal anti-inflammatory drugs) can also help ease inflammation. However, the drugs should be prescribed by a doctor and should not be taken continuously for a long period of time.
Additionally, patients with plantar fasciitis should follow these suggestions in taking care of themselves. First, maintain a healthy weight to reduce the pressure on the plantar fascia. Choose proper exercise during inflammation, such as cycling and swimming, avoiding activities that place high impact on the soles and the heels. Wear proper shoes - supportive and well-cushioned shoes with thick soles and arched insoles. Avoid walking barefoot and wearing hard-soled shoes.

Exercising by stretching the soles and the Achilles tendon can enhance rapid healing and prevent recurrence. It is recommended to exercise upon waking up in the morning. Here are a few sample exercises. 

Sit in a chair and cross one leg over the other knee, (Fig. 1) so your ankle is on top of your other leg. With one hand holding your ankle and the other holding your toes, gently pull the  toes backward until you feel a stretch in the sole. Use the other thumb to gently massage the fascia starting from the heel bone to the toes back and forth for about 5-10 minutes.
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Sit with your legs extended and knees straight. Place a towel around your foot just under the toes. (Fig. 2) Hold each end of the towel in each hand and pull the towel back towards you to stretch the plantar fascia and the Achilles tendon. Hold for 30 seconds. Repeat 10-20 times.
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In standing wall push stretch, stand upright facing a wall. Extend one leg straight backward, bending your front leg until you feel a stretch in the calf of your back leg, keeping both feet flat on the floor. Hold for 30 seconds and repeat 10-20 times.
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Extracorporeal Shock Wave Therapy or ESWT passes high energy sound waves through the skin to the affected area, the plantar fascia in this case. This procedure stimulates a little new inflammation, while improving blood flow in the area and triggering repair and regeneration of degenerated tissues. ESWT can also ease the pain by reducing certain pain-related substance. Meanwhile, the treated area may feel sore for a few days, for which Paracetamol can be taken as pain reliever. Typically, 6-8 once-a-week sessions are needed to keep the tissue repair process going.  

Proper shoe insoles that fit one’s feet, especially among those with abnormal foot structure such as high arches or flat feet, help spread the weight and pressure on the sole and the inflamed area of the heel, thus reducing pain while standing or walking. Pre-made insoles are available or doctors may prescribe custom-made orthotics molded to the exact shape of the patient’s foot. Meanwhile, during inflammation, heel cups can be used to reduce impact on the heel when walking and relieve pain.

Wearing an ankle brace while sleeping is also suggested. It helps reduce the shortening of the plantar fascia, which often occurs when not standing or walking for long periods of time such as while sleeping at night. When waking up in the morning and stepping out of bed, the plantar fascia is suddenly stretched and thus causes heel pain in the morning. This device  keeps the plantar fascia stretched during the night and thus reduces pain in the morning.

Steroid injections in the heel region can reduce inflammation and offer quick pain relief.  However, there may be long-term side effects including plantar fascia rupture and heel fat pad atrophy, which causes chronic pain when walking with pressure on heels.  These complications require difficult and complex treatment. Steroid injections are thus not recommended for plantar fasciitis except in cases of severe symptoms and failure to respond to other treatment methods.  Meanwhile, the injections should be performed under ultrasound guidance by medical experts to ensure proper placement of the needle and reduce risk of such complications. 

Operative treatment is the alternative when all other treatment methods have proved ineffective, which is rare.

The plantar fasciotomy involves cutting part of the plantar fascia ligament on the inner side to release the tension on the heel. Surgery may also be considered to remove heel spurs or bumps of extra bone growth or to correct the abnormal foot structures that may cause plantar fasciitis such as high arches. 

Compiled by Sqn. Ldr. Dr. Pongpol Petchkum, Orthopaedic surgeon - Foot & Ankle 

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