The plantar fascia is a large combined ligament/tendinous structure that runs along the majority of the bottom of the foot. It attaches to the heel bone (calcaneus) and the base of the toes (ball of the foot). The plantar fascia helps support the bottom and arch of the foot. The plantar fascia tissue can become irritated and ultimately degenerated if it is repeatedly stretched. ( If stress happens over a long period of time, the heel bone responds by laying down more bone where the plantar fascia attaches to the heel, thus creating a heel spur). It is commonly believed that this spur points downward and that stepping on it is like stepping on a tack since pain is noted in this portion of the heel. The spur actually runs along the bottom of the foot, pointing toward the toes. Typically, the heel spur itself does not cause pain, but reflects a painful plantar fascia which is already aggravated.

Pain in the heel is actually due to one of two conditions. First, you may truly have inflammation in the ligament and surrounding tissue. As you step down, the irritated tissue pushes against the bones causing pain. The second and more common cause is the chronic condition called Plantar Fasciosis (old name, fasciitis) where the tissue is no longer inflamed but has been damaged and areas of it are degenerative or contain unhealthy tissue. Current opinion suggests that the unhealthy tissue has restricted blood vessel supply and may contain a chemical irritant, which is the source of the pain.

What causes undue stress on the plantar fascia?

• Weakness of the muscles in the foot
• Foot structure - an arch that is either too high or too low (e.g. flat feet)
• Tight calf and hamstrings muscles - causes a tug of war over the ankle and foot joints. Note - prolonged periods in high heels or using heel lifts in shoes can cause tight calf muscles.
• Tightness of the plantar fascia itself (e.g. A person may be born with tightness)
• Heavy use - either an occupation that requires long hours of standing, heavy lifting or active sports that require a lot of leg and foot movement, or being overweight

Heel pain is usually due to a combination of several causes listed above. Therefore it takes a combination of exercises, control of overuse by bracig and other treatments to affect a solution. An experienced doctor or therapist can evaluate you to determine what your problem areas are and what treatment is appropriate.

Most people with plantar fasciitis/fasciosis have their greatest pain in the morning when taking their first steps out of bed. This is due to the fact that most people sleep with their feet pointing down, allowing the calf muscles and plantar fascia to tighten up during the night. The sensitive tissue stiffens with hours of relative inactivity. When you step out of bed, you are suddenly stretching your calf muscles and the bottom of your foot. This causes a sharp pull at the attachment of the stiff plantar fascia, which in turn causes pain. When your body warms up, the plantar fascia become more flexible, thus less pull is created, and the pain decreases or goes away. Doing some simple warm-up and stretching exercises such as ankle circles and pulling your toes up toward your knee prior to getting up can greatly decrease the amount of pain you experience. If the pain is severe and other methods have not helped, a splint can be worn at night that keeps the foot from pointing down so the muscles do not lose flexibility while you sleep. Most people do not require a splint but some can benefit from its use.

Other people have the opposite problem where walking or standing for long periods of time causes swelling to occur at the heel region. It is necessary to use ice and elevate the foot to help control and decrease the swelling and irritation, which in turn decreases the pain. Caution must be used when applying ice because it can cause serious frostbite burns and nerve damage if not used correctly. If possible, apply ice to the painful area several times a day to help control pain and inflammation. It is especially important to apply ice after a strenuous day of work or exercise.

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Even with the correct exercises, some people have abnormal foot mechanics that continue to place too much stress on the tissues. These problems can be present for several years before causing pain but will continue to cause discomfort if not corrected. Prescription orthotics (custom molded inserts that fit into your shoes) may be required to correct these structural problems

Plantar fascia pain is not usually caused in one day, and unfortunately it cannot be eliminated in one day. Healing is a slow process that can take months to a year or more. Exercises and stretching must be performed on a daily basis. Be aware that the problem can reoccur if you stop the exercises and the tightness or weakness returns.

Night Splints

Studies have shown that a low load sustained stretch helps to increase a muscle's length. By wearing the night splint during sleep hours, a prolonged passive stretch to the calf, Achilles tendon and the plantar fascia can occur and has been helpful in some cases.

Surgical Care Unfortunately, there are some cases in which treatment does not help and surgical intervention is required. There are multiple techniques, some better than others, so research should be done to check out your options. We have found that surgical success is better if surgery focuses on only removing the unhealthy tissue and preserving the rest of the plantar fascia. It is our observation that the old surgical technique of releasing the entire fascia leaves the painful tissue behind and weakens the foot and arch and can lead to continuing problems or even harm.

Please note that there are many conditions other than plantar fasciitis that can cause heel pain. If you suspect that you have plantar fasciitis/fascosis it is important that you be evaluated by a orthopedic surgeon to determine the true source of your heel pain. Once diagnosed, a licensed Physical Therapist can then evaluate your condition and determine an appropriate program of treatment tailored to your specific needs.