Expert advice on how to diagnose and treat one of the most common causes of foot pain.
Medically reviewed by Dr Roger Henderson and words by Annie Hayes
Plagued by plantar fasciitis pain? The most common cause of pain on the bottom of the heel, plantar fasciitis makes up 15 per cent of foot conditions that require professional care among adults, and left unchecked it can seriously interfere with your quality of life.
Your plantar fascia – a band of tissue that runs from your heel to your toes – experiences plenty of wear and tear as a result of your daily activities, which makes this type of heel pain extremely common. But how do you treat this painful condition and are there steps you can take to prevent it?
We spoke to Mr Suresh Chandrashekar, consultant foot and ankle surgeon at London Sports Orthopaedics and London Bridge Hospital (part of HCA Healthcare UK), and Tony Gavin, podiatrist and founder of OSGO Healthcare, about plantar fasciitis causes, symptoms and treatment options:
What is plantar fasciitis?
Plantar fasciitis is a condition that occurs when the plantar fascia – the band of thick tissue that runs beneath the foot – becomes irritated and inflamed. This happens when the tissue has been overloaded, says Gavin, typically due to excessive exercise, walking, standing, wearing inappropriate footwear or weight gain.
While plantar fasciitis is a type of heel pain, not all heel pain is caused by plantar fasciitis. The condition usually develops gradually over time.
Plantar fasciitis symptoms
Plantar fasciitis usually affects only one foot, but it can affect both feet at the same time. ‘The severity of this condition can range from mild discomfort to constant severe pain, and regular limping and a super-sensitive heel,’ says Mr Chandrashekar.
Periods of pain can last anywhere between a few months to more than a year in severe cases. Common plantar fasciitis symptoms include:
- Pain in the bottom of your foot towards the inside point of your heel – it may be sharp or feel more like burning or aching.
- Pain putting your foot flat on the ground, especially first thing in the morning when you get out of bed or after long periods of sitting down.
- A limp – you may also walk on the ball of your foot.
- Difficulty climbing stairs due to the heel feeling very stiff.
- Aching in the heel after continuous periods of standing or walking. You may also start putting more pressure on the outside border of your foot.
- You may also notice wear on the outside of the soles of your shoes.
How does plantar fasciitis pain start?
The pain associated with plantar fasciitis often comes on the following day after strenuous activity.
‘We commonly hear patients tell us stories such as, “A few months ago I was out on a city tour, which was not really strenuous – the next day I felt like someone had kicked me on my heel. I felt a deep bruise, and started limping”,’ says Mr Chandrashekar. ‘This is usually related to the fact that the plantar fascia attachment to the heel was not accustomed to the activity that was undertaken prior to the onset of the symptoms.’
Stretching the plantar fascia can lead to inflammation, causing the area to become sensitive to pressure.
In short, the plantar fascia was not prepared to accommodate the amount of stretching that would occur. This undue stress can lead to inflammation, and the area becomes sensitive and painful to pressure and loads that it was otherwise previously fine with, Mr Chandrashekar continues. ‘This tends to spiral down and lead to increasing symptoms over the course of the following few weeks or months,’ he says.
Plantar fasciitis risk factors
Plantar fasciitis can affect people of any age, although it’s most prevalent in middle-aged obese females and young male athletes, according to a review published in the Journal of Research in Medical Sciences.
‘The scientific literature estimates that around seven to 10 per cent of the population may at some stage suffer some degree of plantar fasciitis,’ says Mr Chandrashekar. ‘However, this figure seems like an underestimation – the tip of the iceberg.’ Plantar fasciitis risk factors include:
- Being overweight or obese, especially if the weight gain has been rapid.
- Structural foot problems like flat feet, high arches or tight Achilles tendons.
- Wearing ill-fitting shoes, or those with thin soles or no support.
- Participating in long-distance running (e.g. training for a marathon).
- Other forms of repetitive physical activity, such as sports.
- A job that requires a lot of walking or standing on hard surfaces.
- Being pregnant (especially in the late stages of pregnancy).
- Being between 40 and 70 years of age.
Even if you are fit and healthy, you can still experience plantar fasciitis. Unfortunately, a fitness routine does not make you immune. This is especially true if you have other structural foot problems or injuries. ‘Plantar fasciitis often arises in patients who have pre-existing issues with their lower limb musculature, including calf tightness, mechanical alignment problems or arch abnormalities,’ says Mr Chandrashekar.
Plantar fasciitis diagnosis
To diagnoses plantar fasciitis your doctor will perform a physical exam, checking your foot for tenderness, redness and swelling. They will also note the location of the pain as you flex your foot and point your toe. Usually, this will be enough information to make a diagnosis of plantar fasciitis.
On occasion, your doctor may order an x-ray, MRI scan or ultrasound to check that nothing else is causing your heel pain, such as a bone fracture. ‘An ultrasound scan is a more reliable investigation, both for confirming the diagnosis and for planning potential management,’ says Mr Chandrashekar.
Plantar fasciitis treatment
There are different ways to treat plantar fasciitis, starting with simple home stretches all the way up to surgical treatments. However, most patients find their symptoms improve within 10 months of following home remedies, such as:
- Rest and recuperation
If you suspect your plantar fasciitis is caused by over-exertion, decrease (or avoid entirely) any activities that makes the pain worse. This is especially true if the activity involves hard surfaces, such as running on a pavement or treadmill. ‘If your heel pain is due to sudden unaccustomed increased loading or a spike in your gym, running or sport schedule, gait analysis and gait re-training can be very useful,’ says Mr Chandrashekar.
Muscle tightness in the feet and calves can make the plantar fasciitis more painful. Calf stretches, performed facing a wall with staggered legs, are especially useful. Performing three minutes at a time, three times a day or five 20-second intervals, twice daily, both have the same effect, according to research published by the Methodist Sports Medicine Centre in Indiana.
Other targeted plantar fascia stretching exercises may be helpful. You could also try repeatedly flexing the foot and pointing the toes with a resistance band, picking up a marble with the toes, or rolling the arch of your foot using a golf ball or designated foam roller boll. Standing on the edge of a step with your heels off the edge and lifting your body up and down in a controlled motion will also stretch the plantar fascia.
- Night splints
Most people sleep with their feet pointed down, relaxing the plantar fascia and resulting in heel pain the following morning. Night splints keep your foot flexed, passively stretching the plantar fascia and calf while you sleep. They may take some getting used to, but night splints are very effective and don’t have to be used forever. Between one and three months is usually recommended.
- Ice the area
You could ice your plantar fascia by filling a plastic bag with ice and resting your foot on it. Alternatively, roll your foot over a frozen water bottle for 20 minutes. Try doing this three or four times each day.
- Anti-inflammatory meds
Non-steroidal anti-inflammatory drugs (NSAIDs) such as high-dose aspirin and ibuprofen can help to relieve pain and reduce inflammation associated with plantar fasciitis. However, you shouldn’t you shouldn’t take over-the-counter medication for long-term pain relief without seeing your doctor first.
- Physical therapy
A physical therapist can provide an exercise programme that focuses on stretching your calf muscles, plantar fascia and Achilles tendon, and also strengthening your leg muscles to stabilise your heel. This is often combined with massage techniques and medication to decrease inflammation.
- Supportive shoes and inserts
Shoes with thick soles and extra cushioning can ease the pain of plantar fasciitis. You could also try shoe inserts, which offer extra support to the arch – taking pressure off the plantar fascia and distributing it more evenly around the foot. Specialist compression socks can help to decrease swelling and increase arch support, too.
The best shoes for plantar fasciitis
You don’t necessarily have to buy specialist shoes to treat plantar fasciitis pain. Just be sure to look for shoes with the following characteristics:
- Shoes that support your natural arches.
- Footwear with a sturdy base.
- A firm but flexible midsole.
- Cushioning in the forefoot.
- Shoes with moderate heels.
Plantar fasciitis medical treatments
Usually, plantar fasciitis can be treated and managed successfully with home treatments. ‘Most people can recover from plantar fasciitis with rest, using ice on the painful area, stretches and taking nonsteroidal anti-inflammatory drugs to relieve pain and reduce inflammation,’ says Gavin.
However, there are some cases where the pain may persist, despite following all of the above advice. If this occurs, your doctor may recommend further treatment, such as:
🔹 Shockwave therapy
This involves applying pulsed energy waves to the heel for a few minutes three or four times per week. It breaks down injured tissues or painful inflamed tissues and that helps stimulate better healing, says Mr Chandrashekar, leading to a 70 to 80 per cent improvement in symptoms.
🔹 Cortisone injections
Cortisone is a powerful anti-inflammatory steroid. Using an ultrasound device to help determine the best location on the heel, it is injected directly into the plantar fascia. Multiple injections can cause the plantar fascia to rupture, so your doctor will limit the amount you have.
🔹 Plantar fascia release
This is a type of surgery, and is only performed when pain is severe or lasts more than 12 months. During the procedure, the plantar fascia is partially cut to release it from the heel bone and reduce tension.
🔹 Gastrocnemius recession
This involves surgically lengthening one of the two muscles that make up the calf. As with any surgery, there can be complications, so this option is only considered after all nonsurgical measures.