Plantar fasciitis is the most frequently encountered cause of plantar heel pain. For many years pain in this region has been incorrectly termed the "heel spur syndrome". It would be better termed a "plantar heel pain syndrome". While heel spurs sound ominous, they can be present and not cause any pain. The formation of a spur is a sign that too much tension has developed within the plantar fascia, and it may have partly torn from its origin at the calcaneus (heel bone). This may result in new bone formation at the site of the injury.

The term plantar fasciitis is derived in part from plantar which refers to the bottom of the foot and from fascia which is a type of dense fibrous connective tissue. The "itis" is a suffix which means inflammation. Latest studies show that in many cases of plantar fasciitis there really is no inflamation, but rather an avascularity ( loss of blood circulation ). This may be similar to what has been termed Achilles Tendinosis (rather then tendinitis). Lemont (2003) has termed it a fasciosis. It is a conceptual difference, but the pain still remains quite similar.

If your foot flattens or becomes unstable during critical times in the walking or running cycle, the attachment of the plantar fascia into your heel bone may begin to stretch and pull away from the heel bone. This will result in pain and possibly swelling. The pain is especially noticeable when you push off with your toes while walking. Since this movement stretches the already injured portion of the fascia. Without treatment the pain will usually spread around the heel. The pain is usually centered at a location just in front of the heel toward the arch. When the tearing occurs at the bone itself, a the bone may attempt to heal itself by producing new bone. This results in the development of a heel spur. Without the spur the condition is called plantar fasciitis.

The pain of this condition may cause you to try to walk on your toes, or alter your running stride and gait which will cause further damage and may cause a problem to develop in your healthy foot. Gait changes in running may also lead to ankle, knee, hip or back pain.

Related Conditions

Heel Spur:

A heel spur is a focal point of bone growth on the heel. The bone growth usually extends forward towards the toes. Heel spurs are visible on X-ray. The spur is theorized to occur when the plantar fascia tissue attaching into the calcaneus (heel bone) tears away from the bone and injures the outer layer (periosteum) of the bone. Small amounts of bleeding may occur at this site and then this area can ossify and form a heel spur. It is not the spur that causes the pain, but the continued tension and tearing of tissue at this location.

Plantar Fascia Rupture:

Tears of the plantar fascia are a less commonly found injury than either a heel spur or plantar fasciitis. They usually involve larger and more abrupt forces than the forces which allow for plantar fasciitis to develop. High speed activity develop these forces more often. The force needs to be applied to the ball of the foot. Sprinting places the foot in a position in which this could happen. Soft shoes that bend in the arch may contribute. Plantar fascia tears may also occur in baseball or softball players when sliding in to a base with the foot making contact with the base. Injections of steroid into the region of the plantar fascia may increase the likelihood of this injury.

The tear usually happens further forward than where the pain of plantar fasciitis usually occurs. It is often found 2 to 4 centimeters in front of the attachment of the plantar fascia into the calcaneus (heel bone). The patient will often recall feeling or hearing a "pop". When examined there may be pain when the toes are passively bent upwards (dorsiflexed). The usual treatment for this injury is non-weight bearing for 1 - 3 weeks in a cast and total casting for about 4 - 6 weeks. Full recovery will take 7 to 12 weeks.

Nerve Entrapment

A nerve entrapment of the first branch of the lateral plantar nerve may occur in this area and cause a "burning" pain. This is found much less often than the above discussed conditions. The portion of the lateral plantar nerve that leads to the abductor digiti minimi has been mentioned as a possibly involved nerve in some entrapment syndromes (Baxter). Other possible nerve entrapments that may contribute to pain in the heel region include the medial calcaneal nerve and tarsal tunnel nerve entrapment.

Plantar Fasciitis - Cause:

The most frequent cause is an abnormal motion of the foot called excessive pronation. Normally, while walking or during long distance running, your foot will strike the ground on the heel, then roll forward toward your toes and inward to the arch. Your arch should only dip slightly during this motion. If it lowers too much, you have what is known as excessive pronation. For more details on pronation, please see the section on biomechanics and gait.

The mechanical structure of your feet and the manner in which the different segments of your feet are linked together and joined with your legs has a major impact on their function and on the development of mechanically caused problems. Merely having "flat feet" won't take the spring out of your step, but having badly functioning feet with poor bone alignment will adversely affect the muscles, ligaments, and tendons and can create a variety of aches and pains. Excess pronation can cause the arch of your foot to stretch excessively with each step. It can also cause too much motion in segments of the foot that should be stable as you are walking or running. This "hypermobility" may cause other bones to shift and cause other mechanically induced problems.

Other factors which may contribute to plantar fasciitis and heel spurs include a sudden increase in daily activities, increase in weight (not usually a problem with runners), or a change of shoes. Dramatic increase in training intensity or duration may cause plantar fasciitis. Shoes that are too flexible in the middle of the arch or shoes that bend before the toe joints will cause an increase in tension in the plantar fascia. Make sure your shoes are not excessively worn. These shoes and other shoes that are not sufficiently controlling of pronation combined with an increase in training can lead to this condition. A change in running style, such as starting speed work, running on the ball of your foot or sudden increase in hill workouts.

Self Treatment

As with most running related injuries, an evaluation of changes in your training should be done. A decrease in workout intensity and duration is important. The most important part of self treatment for this condition is being sure that your shoes offer motion control and are optimal controlling the forces that contribute to plantar fasciitis and heel spurs. Check your running shoes to make sure that they are not excessively worn. They should bend only at the ball of the foot, where your toes attach to the foot. This is vital! Avoid any shoe that bends in the center of the arch or behind the ball of the foot. It offers insufficient support and will stress your plantar fascia. The human foot was not designed to bend here and neither should a shoe be designed to do this.

You should also be doing gentle calf stretching exercises. This will reduce stress on the plantar fascia in two ways. The first manner in which a relaxation of the tension in the calf muscles can help heel pain is that it will reduce the direct pull backwards on the heel bone (calcaneus). The second reason is a little bit more complicated, but essentially it is that a tight achilles tendon and calf muscles causes the rearfoot to move in a manner that causes over pronation as your leg and body move forward over your foot. So go ahead and gently stretch the calf muscle by doing the runner's wall leaning stretch. To strengthen the muscles in your arch toe curls or "doming" can be done. Toe curls may be done by placing a towel on a kitchen floor and then curling your toes to pull the towel towards you. This exercise may also be done without the towel against the resistance of the floor.

Icing after running can also be helpful.

Consider adding over the counter foot supports to your shoes. This should be done after you have first tried a good stability shoe, if you over pronate.

Self-Treatment Summary:

Self treatment for this problem should include:

Treatment is usually succesful for this problem. ECSWT is considered only after the above treatment has failed for 6 months. Orthotics should be tried prior to considering ECSWT (extra-corporeal shock wave therapy) or surgery. If you have hard, rigid orthotics you should try somewhat softer orthotics.