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Plantar fasciitis
Plantar fasciitis Content Supplied by NHS Choices
Introduction

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Heel pain is one of the most common conditions to affect the foot. It is usually felt as an intense pain when the affected heel is used. The pain is usually worse when you get out of bed in the morning or after a long period of activity. In most cases, only one heel is affected.

After walking, the pain usually improves. However, it is common for it to be painful when you first take a step after a period of rest. The pain often worsens by the end of the day.

Most cases of heel pain are caused by damage and thickening of the plantar fascia (see below). Sometimes, the surrounding tissue and the heel bone also become inflamed (swollen).

The plantar fascia

The plantar fascia is a tough and flexible band of tissue that runs under the sole of the foot. The plantar fascia connects the heel bone with the bones of the feet, while also acting as a kind of shock absorber to the foot.

It is thought that either sudden damage or damage that occurs over many months or years can cause tiny tears, known as microtears, to develop inside the tissue of the plantar fascia. This can cause the plantar fascia to thicken, which can sometimes result in heel pain.

Plantar fasciitis is the medical term for the thickening of the plantar fascia.

How common is heel pain?

Heel pain is a very common condition. It is estimated that 1 in 10 people will have at least one episode of heel pain at some point in their life.

Two main groups of people are affected by heel pain:

  • people who regularly exercise by jogging or running
  • older adults aged 40-60

For more information see Heel pain - causes.

Outlook

The long-term outlook for most cases of heel pain is good, with four out of five cases resolving within a year. However, living with the condition for this long can be frustrating, annoying and painful.

A number of treatments can be used to relieve heel pain and speed up recovery time. For example:

  • calf stretches
  • painkilling medication, such as non-steroidal anti-inflammatory drugs (NSAIDs) and corticosteroid injections
  • good-fitting shoes that support and cushion the foot; running shoes are particularly useful
  • supportive devices, such as orthoses (rigid supports that are placed in your shoe) or strapping

For more information see Heel pain - treatment.

In around 1 in 20 people, the symptoms of heel pain will not respond to the types of treatment listed above. Surgery will be needed to release the plantar fascia. 

Symptoms of heel pain

Heel pain usually builds up gradually, getting worse over time.

Sharp pain in the heel

Heel pain is often felt as a sharp and often severe pain that occurs when you place weight on the heel. In most cases, only one heel is affected, although it is thought that a third of people have pain in both heels.

The pain is usually worst first thing in the morning, or on taking the first step after a long period of inactivity. The pain will gradually improve as you begin to use the affected heel or heels. However, by the end of the day, or after a long period of standing or walking, the pain usually gets worse again.

Some people may limp or develop an abnormal walking style as they try to avoid placing weight on the affected heel.  

Causes of heel pain

Plantar fasciitis

The most common cause of heel pain is plantar fasciitis, which accounts for four out of five cases. Plantar fasciitis is where the thick band of tissue that connects the heel bone with the rest of the foot (plantar fascia) becomes damaged and thickened.

There are thought to be two main ways that damage can occur:

  • sudden damage, such as damaging your heel when jogging, running or dancing - this usually affects younger, more physically active people
  • gradual 'wear and tear' to tissues that make up the plantar fascia - this usually affects adults aged 40 years or over

Wear and tear risk factors

Risk factors for damage caused by gradual wear and tear include:

  • being overweight or obese (very overweight with a body mass index of 30 or above)
  • having a job that requires you to spend long periods of time standing
  • wearing flat-soled shoes, such as sandals or flip-flops

Less common causes

Some less common causes of heel pain are outlined below.

Stress fracture

A stress fracture can occur if the heel bone is damaged during an injury.

Fat pad atrophy

Fat pad atrophy is where the layer of fat that lies under the heel bone, known as the fat pad, begins to waste away due to too much strain being placed on the pad. Women who wear high heels for a period of many years have an increased risk of developing fat pad atrophy.

Bursitis

Bursitis is inflammation of one or more bursa, which are small fluid-filled sacs under the skin that are usually found over the joints and between tendons and bones. Bursitis can develop anywhere inside the human body, not just in the foot.

Tarsal tunnel syndrome

The nerves in the sole of your foot pass through a small tunnel on the inside of the ankle joint (tarsal tunnel). If a cyst forms or there is damage or poor foot function, the nerves can become compressed (squashed). Nerve compression can cause pain anywhere along the nerve, including beneath your heel.

Sever's disease

Sever's disease is a common cause of heel pain in children. It is the result of the muscles and tendons of the hamstrings and calves stretching and tightening in response to growth spurts.

The stretching of the calf muscle pulls on the Achilles tendon. This pulls on the growing area of bone at the back of the heel (growth plate), causing pain in the heel. The pain is further aggravated by activities such as football and gymnastics. The pain is often at the side of the heel, but it can also be felt under the heel.

Calf and hamstring stretches and, if necessary, heel pads are usually effective treatments for Sever's disease.

Diagnosing heel pain

Your GP or podiatrist (a healthcare professional who specialises in foot care) should be able to make a confident diagnosis of the cause of your heel pain by:

  • asking you about your symptoms and medical history
  • physically examining your heel and foot

Further testing is only usually required if you have additional symptoms that suggest that the cause of your pain is not inflammation of the tissue inside your heel (plantar fasciitis). For example:

  • numbness or a tingling sensation in your foot - this could be a sign of nerve damage in your feet and legs (peripheral neuropathy)
  • the affected foot feels hot and you have a high temperature (fever) of 38ºC (100.4ºF) or above - these could be signs of a bone infection
  • you also have stiffness and swelling in your heel - these could be signs of arthritis

Possible further tests could include:

Treating heel pain

Your treatment plan

Treatment for heel pain usually involves trying a combination of techniques, such as painkillers and exercise, to relieve pain and speed up your recovery time.

Surgery is usually regarded as a 'treatment of last resort' if your symptoms fail to improve after 12 months. Only 1 in 20 people will need surgery.

Rest

Rest the affected foot whenever possible by avoiding standing for long periods of time or walking long distances. However, it is important to regularly exercise your feet and calves with stretching exercises. See below for more information.

Pain relief

Non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, are a type of painkilling medication that are usually effective in helping to relieve pain.

Some people also find that applying an ice pack to the affected heel for 5 to 10 minutes can help to relieve pain and inflammation. Ice packs are available from larger pharmacies and supermarkets.

Do not apply the ice pack directly to the skin because this can damage it. Instead, wrap the ice pack in a towel. If you do not have an ice pack, use a packet of frozen vegetables.

Exercise

Regular exercises designed to stretch both your calf muscles and your plantar fascia (band of tissue that runs under the sole of the foot) should help relieve pain and improve flexibility in the affected foot.

A number of stretching exercises are described below. It is usually recommended that you do the exercises on both legs, even if only one of your heels is affected by pain. This will improve your balance and stability, as well as helping to relieve heel pain.

Towel stretches

Keep a long towel beside your bed. Before you get out of bed in the morning, loop the towel around your foot and use the towel to pull your toes towards your body while keeping your knees straight. Repeat three times for each of your feet.

Wall stretches

Place both of your hands on a wall at shoulder height with one of your feet in front of the other. The front foot should be 30cm (12 inches) away from the wall. With your front knee bent and your back knee straight, lean towards the wall until you feel a tightening in the calf muscles in your back leg. Then relax. Repeat this procedure 10 times, then switch legs and repeat the cycle. It is recommended that you carry out wall stretches twice a day.

Stair stretches

Stand on your stairs facing upstairs while using your banister for support. Your feet should be slightly apart and your heels should be hanging off the back of the stair. Lower your heels until you feel a tightening in your calves. Hold this position for around 40 seconds, then raise your heels back to normal. Repeat this procedure six times, at least twice a day.

Chair stretches

Sit on a chair with your knees bent at right angles so that your feet are pointing in opposite directions. Lift the affected foot upwards while keeping the heel on the floor. You should then feel your calf muscles and Achilles tendon (band of tissue that connects the heel bone to the calf muscle) tighten. Hold this position for several seconds, then relax. Repeat this procedure 10 times, five or six times a day.

Dynamic stretches

While seated, roll the arch of your foot (the curved bottom part of the foot between your toes and your heel) over a round object, such as a rolling pin, tennis ball or drink can (some people find that using a chilled can from their fridge has the added benefit of helping to relieve pain). Move your foot and ankle in all directions over the object. Continue the exercise for several minutes and repeat the exercise twice a day.

Shoe wear

Depending on your usual choice of footwear, your GP or podiatrist (a healthcare professional who specialises in foot care) may advise you to change your footwear. Avoid wearing flat-soled shoes as these will provide no support to your heel and could make pain worse.

Ideally, you should be wearing shoes that provide good support to the arches of your feet while cushioning your heels, such as laced-up sport shoes.

For women, wearing high heels and, for men, wearing high-heeled boots or brogues can provide short- to moderate-term relief of pain, as they help reduce the pressure on the heel. But these types of footwear may not be suitable in the long-term, as they can lead to further episodes of heel pain. Your GP or podiatrist should be able to advise you.

Orthoses

Orthoses are in-soles that fit inside your shoe to support your foot and assist the healing of your heel. You can buy orthoses off the shelf at larger pharmacies or sports shops, or your podiatrist should be able to recommend a supplier.

If your pain keeps reoccurring, does not respond to simple treatment measures, or you have an abnormal foot shape or structure, custom-made orthoses are available. They are specifically made to fit the shape of your feet.

However, there is currently no evidence that the custom-made orthoses are more effective than those bought off the shelf.

Strapping and splinting

An alternative to using orthoses is to have your heel strapped with sports strapping (zinc oxide) tape. The strapping will help to relieve pressure on your heel.

Your GP or podiatrist should be able to teach you how to apply the straps yourself.

Night splints can also be useful in some cases. Most people sleep with their toes pointing down, which means that the tissue inside the heel is squeezed together.

Night splints, which look like a type of boot, are designed to keep the toes and feet pointing up during sleep. This will stretch both the Achilles tendon and your plantar fascia while you sleep, which should help speed up your recovery time.

Night splints are usually only available from specialist shops and online retailers. Again, your podiatrist should be able to recommend a supplier.

Corticosteroid injections

If none of the treatments above help to relieve your pain symptoms, your GP may recommend that you have an injection of corticosteroids.

Corticosteroids are a type of medication that have a powerful anti-inflammatory effect. They have to be used sparingly because overuse can cause serious side effects, such as weight gain and high blood pressure (hypertension).

As a result of this, it is not usually recommended that more than three corticosteroid injections are given within a year in any part of the body.

Before having a corticosteroids injection, a local anaesthetic (painkilling medication) may be used to numb your foot so that the injection is not painful.

Surgery

If all the treatments listed above and corticosteroid injections do not relieve your heel pain, your GP may refer you to either:

  • an orthopaedic surgeon - a surgeon who specialises in surgery that involves the bones, muscles and joints
  • a podiatric surgeon - a podiatrist who specialises in foot surgery

Surgery is sometimes recommended for professional athletes and other sportspeople whose heel pain is negatively affecting their career.

Plantar release surgery

The most widely used type of surgery for heel pain is known as plantar release surgery. This is when the surgeon cuts the fascia to release it from the heel bone. This should reduce tension in your plantar fascia, which in turn should reduce inflammation and relieve your pain symptoms.

There are two ways that the surgery can be performed:

  • open surgery - the section of the plantar fascia is released by making a cut into your heel
  • endoscopic/minimal incision surgery - a smaller incision is made and special instruments are inserted through the incision to gain access to the plantar fascia

Endoscopic/minimal incision surgery has a quicker recovery time so you will be able to walk normally much sooner (almost immediately) compared with two to three weeks for open surgery.

A practical disadvantage of endoscopic surgery is that it requires both a specially trained surgical team and specialised equipment, so you may have to wait longer for treatment than if you choose open surgery.

Endoscopic surgery also carries a higher risk of damaging nearby nerves, which could result in symptoms such as numbness, tingling or some loss of movement in the foot.

You should discuss the pros and cons of both approaches with your surgical team.

The results of both surgical techniques have been mixed. As a result, they are rarely performed.

As with all surgery, plantar release carries the risk of causing complications, such as:

  • infection after surgery
  • nerve damage
  • symptoms getting worse after surgery - although this is rare

Extracorporeal shockwave therapy (EST)

A new type of non-invasive treatment (does not involve making any cuts in your body) is known as extracorporeal shockwave therapy (EST).

EST involves using a device to deliver high-energy sound waves into your heel. These waves can sometimes cause pain, so a local anaesthetic may be used to numb your heel.

It has been claimed that EST works in two ways:

  • the sound waves have a 'numbing' effect on the nerves that transmit signals of pain to the brain
  • the sound waves help stimulate and speed up the healing process

Neither claim has yet been definitely proven.

In 2009, the National Institute of Health and Clinical Excellence (NICE) issued guidance about EST.

NICE reported that it believed the procedure was safe, but there were uncertainties about how effective EST was in the treatment of pain. Some studies had reported that EST was superior to both traditional surgery and non-surgical treatments, while other studies found that EST was no better than placebo (sham treatment).

If you are considering EST, it is important that you understand the real uncertainties that surround EST. It is possible that EST works well for some people but has no effect on others.  

Preventing heel pain

While it is not possible to prevent all cases of heel pain, the following advice may help you avoid further episodes.

Maintain a healthy weight

Being overweight or obese means that you are placing your feet, and in particular your heels, under a level of pressure that they were never designed to support. This increases the risk of damaging your heel and other parts of your feet.

If you are overweight or obese, you should lose weight and maintain a healthy weight by combining regular exercise with a calorie-controlled diet.

See the Health A-Z topic about Obesity - treatment for more information and advice.

Choose appropriate footwear

It is important to always wear footwear that is appropriate for your environment and your day-to-day activities.

Wearing high heels when out on a date or socialising with friends is unlikely to be harmful. But wearing high heels throughout a working week, when your job involves a lot of walking or standing, may damage your feet.

Ideally you should wear laced-up shoes with a low to moderate heel (but not shoes with no heels at all), that support and cushion your arches and heels.

Avoid walking barefoot on hard ground, especially on holiday. Many cases of heel pain occur when a person protects their feet for 50 weeks of the year, then suddenly tries to walk barefoot when they are on holiday. Their feet are not used to the extra pressure, which results in heel pain.

If you regularly jog, run or do other physical activity that places additional strain on your feet, it is important to replace your trainers or sports shoes regularly. Most sportswear experts recommend that you replace trainers or sports shoes once you have travelled more than 500 miles in them.

See the Live Well sections about Tips for new runners and Choosing sports shoes for more information and advice.

For an active jogger who can run a mile in 10 minutes and jogs around 30 minutes a day five days a week, this would equate to changing their trainers every eight to nine months. More active athletes would need to chance their shoes more frequently.

See what the doctor sees with Map of Medicine

The Map of Medicine is used by doctors throughout the NHS to determine the best treatment options for their patients. NHS Choices offers everyone in England exclusive and free access to this cutting-edge internet resource, which lets you see exactly what your doctor sees.

The information in the Map has been approved by the UK's leading clinical experts, is based on the best available clinical evidence, and is continually updated. To take advantage of this unique resource go to:

Map of Medicine: Plantar fasciitis.

 
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