Heel Pain (Plantar Fasciitis)

CONDITION

The plantar fascia is thick, tough, fibrous tissue that spans the bottom of the foot and attaches the heel bone to the toe joints. It helps maintain the foot’s arch and is stretched with any weight bearing. Plantar fasciitis happens when the plantar fascia develops small tears and becomes irritated and painful (Figure 1).

  • The fascia most often becomes irritated where it attaches to the inner, or medial, heel bone but sometimes is injured over the arch.
  • Plantar fasciitis can happen in both children and adults but is very common in adults over age 40. It occurs in both athletes and non-athletes.
  • Plantar fasciitis is stubborn and may take months to resolve but often gets better without surgery.
  • Plantar fasciitis frequently recurs.
Figure 1.

CAUSES

The exact cause of plantar fasciitis remains unclear. Repeated, microscopic injury to tissue and chronic stress on the tissue from weight-bearing activities probably causes most plantar fasciitis, but a single injury to the plantar fascia can start the inflammatory process.

Other risk factors include:

  • excessive tightness of the calf muscles, heel tendons or tissue on the bottom of the foot
  • having a flat or high-arched foot
  • obesity
  • smoking
  • being over age 40
  • walking on hard surfaces such as concrete.

Heel spurs often result from irritation of the heel bone where the plantar fascia attaches, and are often mistakenly blamed for causing the heel pain in plantar fasciitis.

SYMPTOMS AND SIGNS

  • You will have pain over the bottom of your foot and heel, especially over the inner part of your heel bone.
  • You may sometimes notice pain over the arch in your foot.
  • Your pain will usually be worse when you first step on your foot after you get up in the morning or when you stand up and walk after a period of sitting.
  • You may notice that your pain gets better after you walk a few steps or exercise for a few minutes.
  • You will sometimes have pain with weight-bearing activities like running, jumping and standing on hard surfaces, especially for long periods of time.
  • Pain may be relieved with rest off your feet or with wearing shoes with good support.

Heel or foot swelling, redness, numbness, night pain or pain directly under the middle of the heel bone do not usually occur with plantar fasciitis and imply that something more serious may be causing your symptoms.

WHEN TO CALL YOUR DOCTOR

Call your doctor right away (day or night) if:

  • You develop significant heel pain and swelling after an injury or fall on your heel or foot.
  • You have heel redness and warmth with swelling and/or fever.
  • You develop pain in your heel that awakens you from sleep.
  • Your heel pain has become more constant and is getting progressively worse with weight-bearing activities, especially walking and running.

Call your doctor during regular office hours if:

  • You have heel or foot numbness, tingling or loss of sensation.
  • You have pain elsewhere in your foot other than over the inner part of the heel and/or arch.
  • You notice that other joints are painful and swollen.
  • You have had a recent puncture wound to the heel.
  • You have heel pain that fits the description of plantar fasciitis above (in signs and symptoms) and that does not start getting better over four weeks or does not completely go away by two months with the self-care measures listed below.

SELF-CARE AT HOME

Stretching

  • Exercises that stretch your heel tendons and the bottom of your foot should be performed daily, held for 30 seconds, and repeated three times each.
    • Calf stretch: Take the position in Figure 2. Lean forward toward the wall while keeping your back leg straight to feel the stretch in your calf muscle.
    • Heel tendon stretch: Take the position in Figure 3. Lean forward toward the wall while keeping your back knee bent until you can feel the stretch over the back of your ankle.
    • Step stretch: Stand with the ball of your injured foot on a stair or step (Figure 4). Drop your heel toward the floor while bending your knee forward until you feel a stretch over the bottom of your foot.
    • Angle board stretch: Prop one end of a small piece of plywood up on a two-foot length of two-by-four-inch board to make an “angle board.” Nail the plywood to the two-by-four. Place the setup near a wall and stop onto the board. Place your hands on the wall and, keeping the back of your knees straight, lean forward toward the wall until you feel a stretch over the bottom of your foot.
  •                    
    Figure 2. Figure 3. Figure 4.

  • Wear a night splint or sock that stretches your foot and heel while you sleep (www.thesock.com/ or www.plantarfasciitisbrace.com/). When you sleep, your foot falls into a pointed-toe (or plantar-flexed) position, which shortens the plantar fascia. The plantar fascia starts to heal in the shortened position, forming small scars. When you get up and step down on your foot, the scars will tear and the irritation will start over again. The sock or splint helps prevent this by allowing the fascia to heal in a longer position.

Strengthening

  • Exercises that help make your arch muscles stronger should be performed once daily.
    • Toe raises: Stand with your heels on a step or stair (Figure 5). Hold onto the wall or a stair railing and slowly lower your toes below the step until you feel a stretch over the front of your ankle. Then, slowly pull your toes up as high as you can using the muscles on the front of your lower leg and ankle. Repeat each raise 10 to 20 times and do two to three sets, resting briefly between sets.
    • Heel raises: Stand with the ball of your injured foot on a stair or step (Figure 6). Raise your heels by pushing up onto your toes using your calf and arch muscles. Hold a tip- toe position for one to two seconds, then lower your heels slowly below the step. Repeat each raise 10 to 20 times with each set, do two to three sets, resting briefly between sets.
    • Running the towel: Place a towel flat on a smooth floor such as linoleum, tile or wood. Start on a corner of the towel and use a curling or flexing motion of your toes to slide the towel around in a circle until you get back to the beginning of the circle. You are essentially spinning the towel in a circle using your toes and the muscles in your foot.
         
Figure 5. Figure 6.

Pain control

  • Massage your plantar fascia each evening. Wet a tennis ball and leave it in the freezer until it feels frozen. Sit down on a chair or couch, bend your knee, place the tennis ball on the floor in front of you and roll your arch and heel back and forth over the cold tennis ball for five to 10 minutes.
  • You may take ibuprofen (Advil® or Motrin®) if you can tolerate it. (See labels for dose and risks.)
  • An over-the-counter arch support or gel heel cushion can be placed in shoes to support your arch and to reduce symptoms.
  • Avoid walking barefoot and wear good-quality athletic shoes with the added cushion or support until your symptoms resolve.

Recommended activity

  • Avoid any activities that worsen your symptoms until you have minimal heel or arch pain. These may include sports or exercise that involves running and jumping.
  • Stay active with non- or low-impact exercise activities such as swimming, rowing, bicycling, or using an elliptical trainer or glider until your symptoms are minimal or resolve.
  • When you have minimal or no heel or arch pain you may gradually return to impact activities such as running.
    • Run or walk on soft surfaces such as tracks or trails.
    • Use walk-run intervals to get back to your previous level of exercise.
    • You may want to start intervals by walking for four minutes, jogging for one minute and repeating three to four times.
    • You can gradually decrease the amount of walking and increase the amount of jogging until you are jogging for your entire workout, then increase jogging time gradually.

FOR MORE INFORMATION

REFERENCES

Last reviewed: November 2009

Last revised: November 2009