Plantar fasciitis

What is plantar fasciitis?

Plantar fasciitis is a common condition causing pain on the bottom of your foot, around your heel and arch. It happens when the plantar fascia, a thick band of tissue running from your heel bone to your toes that supports your foot's arch, becomes irritated from repeated strain. Around 1 in 10 people develop it at some point.

What are the symptoms of plantar fasciitis?

The main symptom is pain on the bottom of your foot, most often around your heel but sometimes in the arch. It's more likely to be plantar fasciitis if:

• the pain is much worse with your first steps after sleeping or resting, then gradually eases as you start moving
• it gets worse again after standing, walking or running for a long time, or towards the end of the day
• it's painful to stretch the sole of your foot, for example when raising your toes off the floor or walking up stairs
• the underside of your heel feels tender, usually in one particular spot, when pressed
• you have some stiffness or swelling around your heel, and possibly a tight Achilles tendon or calf.

Symptoms can build up gradually over time, or, less often, start suddenly after a burst of intense activity. The pain itself can range from a dull, constant ache to a sharp or stabbing sensation, and how bad it feels can vary quite a bit from day to day.

What are the causes of plantar fasciitis and who is at risk?

Plantar fasciitis happens when the plantar fascia is strained, overstretched or overused, though it's not always clear why this happens in a given case. Things that can contribute include:

• a sudden increase in how much you're walking or running, or standing for long periods you're not used to
• exercising on hard surfaces, or without warming up or stretching first
• tightness in your calf muscles or reduced flexibility at your ankle
• having high-arched or flat feet, which are both less able to absorb the stress of walking normally
• wearing shoes with poor cushioning or arch support, or walking barefoot on hard floors
• being overweight, or having gained weight quickly
• having diabetes.

You're also more likely to develop plantar fasciitis if you're aged 40 to 60, and it's somewhat more common in women than men.

Are there different types of plantar fasciitis?

Plantar fasciitis isn't divided into separate types, but it can present in two different ways. Symptoms often build up gradually, causing a longer-lasting ache that might make you shorten your stride or shift your weight towards the front of your foot. Less often, it starts suddenly after a bout of intense activity, with sharp pain on your first steps that eases as you keep moving.

It's also worth knowing that plantar fasciitis is a different thing from a heel spur, a small area of extra bone that can form near where the plantar fascia attaches to the heel. Heel spurs can develop as a result of the same stress that causes plantar fasciitis, but around 3 in 10 people have one without any heel pain at all, and the spur itself isn't considered the cause of the pain.

How is plantar fasciitis diagnosed?

Plantar fasciitis is usually diagnosed from your symptoms and a physical examination, without needing any scans. Your doctor or physiotherapist will likely ask about your activity levels and any recent changes to your routine, examine your foot for a tender spot under the heel, and check your ankle flexibility and foot shape.

Imaging is only usually needed if your history or examination suggests something else might be going on, such as a stress fracture, arthritis, or a trapped nerve. If imaging is used, this is usually an ultrasound scan, which can show thickening and swelling of the plantar fascia. An X-ray or MRI scan may be used instead in some cases.

How is plantar fasciitis treated?

Self-care

Most people improve substantially with simple measures over several weeks to a few months, though it can take up to around 18 months to resolve fully in some cases.

• Rest from the activities that bring on the pain: Such as prolonged standing, walking or running, while staying active through lower-impact options like swimming, cycling or aqua jogging
• Ice: Wrap an ice pack, or a bag of frozen peas, in a damp towel and apply for up to 15–20 minutes several times a day, or after activity. Avoid this on skin with reduced sensation or poor circulation, and check the skin every few minutes
• A short course of painkillers: Paracetamol or anti-inflammatory painkillers such as ibuprofen, taken with food
• Stretching the sole of your foot, your calf and your Achilles tendon daily: Simple options include leaning against a wall with your affected leg straight behind you and heel on the floor to stretch your calf, or sitting down and gently pulling your toes back towards your shin, holding each stretch for around 30 seconds to a minute
• Rolling the sole of your foot over a golf ball: Or a chilled bottle for a few minutes a couple of times a day
• Wearing shoes with cushioned heels and good arch support: Use insoles or heel pads if needed, and avoid walking barefoot, in flip-flops, high heels or tight, pointy shoes.
• Losing weight if you're overweight: And keeping any long-term conditions such as diabetes well controlled.

Non-surgical treatment

If self-care hasn't helped enough, a physiotherapist can guide you through a tailored stretching and strengthening programme, and a podiatrist can advise on shoe inserts (orthotics), taping, or night splints, which stop the plantar fascia tightening while you sleep.

Other options sometimes offered include extracorporeal shockwave therapy, which uses sound waves to stimulate healing, and less commonly dry needling or platelet-rich plasma injections.

Surgery

Surgery is rarely needed and is generally considered a last resort, since the large majority of people improve without it, and surgery isn't guaranteed to relieve symptoms.

The two main procedures are lengthening the calf muscle to reduce tension on the plantar fascia (gastrocnemius recession), or making small cuts in the plantar fascia itself to release tension (plantar fascia release).

Both carry a small risk of nerve damage, and releasing too much of the fascia can occasionally lead to a flattened foot.

When should I see a doctor?

See a GP if:

• your foot pain is severe or is stopping you doing your normal activities
• it's getting worse or keeps coming back
• it hasn't improved after about 2 weeks of self-care
• you notice any tingling or loss of feeling in your foot
• you have diabetes, since foot problems can be more serious if you do.