Heel pain and plantar fasciitis

What plantar fasciitis is

The plantar fascia is a thick band of tissue that runs from the heel bone to the base of the toes and holds up the arch. In plantar fasciitis it becomes painful where it attaches to the heel. It is one of the most common reasons people see a foot and ankle specialist, and it is most common between the ages of 40 and 60.^[1]

Things that raise the risk include long hours on your feet, running and other repetitive impact, higher body weight, a very flat or very high arch, and a tight calf.^[1]

The typical pattern

The classic symptom is a sharp or aching pain at the inner part of the bottom of the heel, worst with the first steps out of bed. It often eases after a few minutes of walking, then returns after long periods of standing or after getting up from a chair.^[1,2]

When heel pain is something else

Heel pain has many possible causes, and where it hurts is the first clue. Pain that steadily worsens after an increase in running can be a stress fracture of the heel bone. Burning, tingling or numbness points to an irritated nerve. A deep, bruise-like ache in the center of the heel can come from the fat pad, and pain at the back of the heel usually comes from the Achilles tendon.^[2] Most heel pain is mechanical, but arthritic, infectious and other causes need to be kept in mind too.^[5]

If your heel pain comes with burning or numbness, or hasn’t responded to usual care, a nerve may be involved.

How we evaluate it

Your history and a hands-on examination are usually enough to make the diagnosis: exactly where it hurts, when it is worst, how tight the calf is, and how your foot is shaped and loads. X-rays at the practice help rule out a stress fracture or arthritis, and ultrasound can show a thickened plantar fascia when the picture is unclear.^[1]

Treatment at the practice

Care is stepped: simple measures first, then more if you need it. Improvement is often slow, so each step gets a fair trial.

• Stretching and strengthening. Stretching the plantar fascia and the calf, with advice on footwear and activity, is the foundation of treatment.^[3] A simple heel-raise strengthening program has also helped people recover faster in the first few months.^[6]
• Shoes, heel cushions and orthotics. Supportive shoes and inserts reduce the load on the heel. Orthoses reduced pain more than sham inserts in trials, and custom and prefabricated orthoses performed similarly, so we match the insert to the problem rather than defaulting to the most expensive option.^[7] See custom orthotics.
• Shockwave therapy. In a large meta-analysis, shockwave was the treatment that improved pain in the medium and long term, and in head-to-head trials it outperformed corticosteroid injections at three and six months.^[4,8] We offer it in the office; see shockwave therapy (ESWT).
• Injections. A corticosteroid injection can ease pain for a few weeks, but the benefit is short-lived and repeat injections carry risks.^[9] Platelet-rich plasma (PRP) outperformed corticosteroid for pain at three months and beyond in pooled trials, though the studies were small and of mixed quality.^[10] See regenerative medicine.
• Night splints, rest from what aggravates it and anti-inflammatory medicine help many people, especially early on.^[1]

Minimally invasive options: Tenex and TenJet

If heel pain has lasted six months or more despite this care, the American College of Foot and Ankle Surgeons says surgery can be considered.^[11] Before a traditional release, we offer two minimally invasive procedures that remove the damaged part of the plantar fascia through a cut of about 5 mm, guided by ultrasound, under local anesthetic: Tenex, which uses ultrasonic energy, and TenJet, which uses a fine, high-pressure jet of saline. Both devices are FDA-cleared.^[12,13,14]

• In a Mayo Clinic series of 58 procedures, average pain fell from 6.8 to 0.7 out of 10, and 91% of treated feet were rated satisfied an average of 6.6 years later, with no complications.^[15]
• In a prospective study of 67 patients, 94% were satisfied at one year.^[16]
• A walking boot is typically worn for one to two weeks afterward.^[12]

The studies so far are case series rather than randomized trials, TenJet’s published results come from other tendons, and some insurers don’t yet cover the procedure, so we check your benefits first.^[17,18] Our article on Tenex and TenJet goes through the evidence in detail.

If it doesn’t get better

Surgery is generally reserved for people who still have pain after about a year of thorough non-surgical treatment.^[1] The two operations used most often are a partial release of the plantar fascia and lengthening of the calf muscle, which reduces the pull on the heel.

When to seek care

Book an evaluation if heel pain lasts more than a few weeks despite rest, stretching and better shoes, or if it is getting worse.