Joel D. Stewart, MD
One of the most common complaints for which I see patients is heel pain due to plantar fasciitis. Sometimes people call this heel spurs, but it’s not usually the bone that hurts. The plantar fascia is a thick band of connective tissue that runs underneath your foot and connects behind your heel bone to your toes. We all have them, but middle-aged folk, runners, overweight people and people with poorly supportive shoes tend to have problems with their plantar fascia more than others. We tend not to adequately stretch our hamstrings and plantar fascia as we age. We get little microtears in them and they get irritated and inflamed. We don’t pay attention, stop, rest and listen to our bodies, but keep on pushing. All at once, we have a problem that can become chronic.
This inflammation of the plantar fascia can be extremely painful, especially and characteristically, when you first get out of bed in the morning and taking your first steps across the floor to the bathroom or to make coffee. The stabbing and jabbing pain you feel makes you think you have a spike or hot piece of glass in your heel. After walking for a few painful minutes, the stiff plantar fascia tends to stretch out a bit and the pain eases somewhat, making walking easier.
Early on, patients tend to forget about the morning pain and go on about their business. Eventually, the morning pain morphs into more pain as the patient sits for a while or stands for longer periods. Their discomfort becomes so severe and lingering that they eventually Google/WebMD their symptoms and seek medical attention. That’s where I come into the picture.
During an office visit with me, I do a thorough physical exam and ask the patient lots of questions about their pain, when they have it, when it’s worse and what seems to help it feel better. I will order x-rays to rule out bone spurs or stress fractures. Surprising, many people who do have heel spurs don’t have heel pain, but those with plantar fasciitis have horrible heel pain.
Once we make the diagnosis of plantar fasciitis, I typically recommend a comprehensive regimen of stretching, activity modification, physical therapy, icing and non-steroidal anti-inflammatories, like naproxen or ibuprofen. I can also prescribe a night splint to keep their foot in a flexed position and orthotics for their shoes. When I say stretching, I mean like deep stretching 20-30 times a day, to really see long-lasting relief and results. Patients who dedicate themselves to doing this will typically be rewarded with the payoff of relief and the end of treatment. I recommend that they continue stretching for life.
Some patients don’t see such great results and continue having pain. Their next treatment option can be formal therapy, immobilization or injected steroids. These shots into the plantar fascia are painful and I don’t recommend giving them too often because they can actually weaken the tissue and cause it to rupture or thin the padding under the heel if too much medication is injected over time. However, an injection here and there can provide significant relief and help bring down inflammation enough to make headway in one’s stretching and PT program.
If the injected steroid doesn’t work, I might suggest next trying Platelet Rich Plasma (PRP). This is a blend of healing constituents from your own blood, that we withdraw in the office, spin down in a centrifuge, and reinject into the painful area of your heel. You may have heard of the treatment, as it is used on many famous athletes in the pro sports world with great results. Thankfully, about 90% of patients see resolution of their symptoms with conservative treatments.
In only the rarest of cases is surgery every recommended for plantar fasciitis, and only when the patient has no success with any of the other possible treatments. In that surgery, which is typically done as an outpatient surgery, the plantar fascia will either be partially or fully released from the heel bone and allow it to heal. This will require crutches and boot for some time. Other options include the Achilles tendon to be lengthened if needed. For those who must have surgery, it is successful 70-90% of the time in providing pain relief and restoration of function.