Plantar fasciitis develops over a long period of time and usually starts with several episodes of discomfort that are infrequent at first but increase in duration and intensity with time. The location is commonly in the bottom of the heel but can extend into the midfoot and arch area with time. Although damage occurs with activity, it generally is more painful after rest. A good example of this is when you get up after sleeping or after driving more than 20 minutes. This has a fancy term, Post Kinetic Dyskinesia, that is used to describe the pain that presents after rest. Your connective tissue loses flexibility when at rest and then lets you know how much damage was created while you were active.
What Causes this Heel Pain?
Damage to the plantar fascia can be a combination of four causes. You have no control over the most common reason which is your biomechanics or the way the foot works. This is most likely a result of the genes your parents or grandparents gave you. We will examine the mechanics and the way you stand to better evaluate this. Other significant contributors are the number of steps you do each day, your body mass, and the tightness of your Achilles tendon. The Achilles tendon is the largest and strongest of all the tendons in the body. When it shortens, the heel lifts off the ground earlier than it should and extra force is placed on the arch and plantar fascia.
Stretching the Achilles tendon complex has a significant effect on the plantar fascia. This is perhaps the easiest and largest contribution that you can address to help your symptoms. Although body mass is a factor, it is not something we will change immediately. Weight generally decreases as activity increases after plantar fasciitis is controlled. Minor contributions involve shoe selection.
You may be surprised that we encourage normal or increased activity while we treat you. Not all shoes are created equal and we will discuss what is helpful in a shoe to improve your foot mechanics. Most of my patients tell me that they have “good shoes.” I will get 9 different answers to the question “What is a good shoe?” from 10 different people – and expensive is not the right answer.
What is the Plantar Fascia?
The plantar fascia is a very strong thick band that starts at the bottom of the calcaneus (heel bone) and passes under the arch and expands to attach to all the toes. If you pull your toes upward the plantar fascia becomes very prominent in the arch area and is easily felt. The plantar fascia is not easily damaged and it takes an incredible amount of repetitive force before it will let you know that it is angry. Although you may pinpoint the start of your symptoms, starting several weeks or months ago, it actually takes years before there is enough damage to set off the inflammation alarm. Walking will produce 2 to 4 times your body weight coming down on your foot for every step you take. There are 1,000–1,100 steps per mile. I will let you do the math and see how body mass and the number of steps you do each day are part of the equation that create plantar fasciitis.
A very poor nickname for plantar fasciitis is “Heel Spurs.” The weakest link in the plantar fascia is the attachment to the calcaneus. As damage increases in this area, the bone will try to heal over the micro tears in and around the plantar fascia producing the well-known “heel spur”. The buildup of bone take years, if not decades, to form. The spur has no relation to the plantar fascia pain and is secondary to the soft tissue damage -like smoke is secondary to a fire (not the real problem). So if the typical plantar fascia pain has been present for six months to one year and the spur has been present for five years – the spur does not cause the pain. It is very common to have plantar fascia pain in one foot and find “heel spurs” on both feet. It is also very common to have plantar fascia symptoms without any bone development. (Disclaimer – This is not true for the spur formation that develops in the back of the heel where the Achilles attaches. You can learn more about Insertional Achilles tendinitis and “Pump Bump” by clicking on these links.)
Plantar Fasciitis can be treated in multiple ways and has a significant success rate with nonsurgical treatment. Treatment options may involve a simple stretching program and shoe selection or more aggressive splinting, orthotics, and medications. If your symptoms are minor an over-the-counter (non custom) insert may be helpful. Beware of soft flimsy inserts made out of foam– they offer very little change. Double Beware of the over-the-counter inserts that you see advertised on TV from the “Not so Good Foot Store.”
I will admit that these inserts are a great way to lose weight—because your wallet will be much lighter when you leave the store. These are over-the-counter inserts for custom orthotic prices.
A stretching brace can be very helpful but is not as good as a stretching program you can do. The stretching brace must extend above the knee to have any influence. If your knee bends while wearing a stretching splint there is little to no effect. Both the Achilles tendon and the plantar fascia are very strong “ropes” and the larger guy always wins in a tug of war. By stretching or relaxing the Achiles tendon and its muscle there is less pulling on the Plantar fascia.
The pain can be significant if plantar fasciitis becomes a chronic problem. This can make you walk differently creating additional issues. To avoid this heel pain people commonly walk on the front of the foot to keep the heel off the ground. This will produce pain in the forefoot with the most common location underneath the second toe. Walking with the heel off the ground will further shorten the Achilles tendon which will damage the plantar fascia more. Walking on a very soft sandal or flip-flop may feel better or different at first but typically you don’t do a lot of steps in this type of footwear. If you did your typical amount of walking while wearing flip flops the problem would get much worse. Flip flops and sandals do nothing for your biomechanics and will aggravate a very tight Achilles tendon. You may experience temporary relief when wearing a high heel shoe. This will alleviate the tightness in the Achilles tendon for a short amount of time, but the Achilles tendon will tighten to this position and cause new pain.
Whatever you do, don’t simply accept foot pain! Jeffrie C. Leibovitz, D.P.M. and his team are here with real solutions that address not only the symptoms but also the fundamental causes of plantar fasciitis. To schedule an appointment with us, please fill out our contact form online, or call our office in Indianapolis, IN at 317-545-0505.