Many people dread getting out of bed in the morning—in particular those with plantar fasciitis, a condition characterized by stabbing pain in the heel that tends to be most intense when you take your first steps of the day.
The plantar fascia is a band of connective tissue that runs from your heel to the base of your toes. Its job is to support the arch of your foot, absorb stress, and give “spring” to your step. Too much stress, which can be caused by running, dancing, standing for long periods on your feet on a hard surface, improper shoes, obesity, and other factors, can lead to irritation and tiny tears in the plantar fascia. That damage, or degeneration, stiffens the plantar fascia and causes pain that is most often felt in the bottom of the heel.
“You see it in runners, in active young athletes, in people who work on their feet all day long, in all walks of life,” says Sean Peden, MD, a Yale Medicine orthopedic foot and ankle surgeon. “But the good news is that it’s generally self-limited, meaning it’s going to go away. It might last three to six months, but there are a lot of things, like stretching, that you can do to manage the pain in the meantime.”
Fortunately, the vast majority of patients with plantar fasciitis respond to simple treatment methods, including rest and stretching exercises. In the rare cases where surgery is required (and after up to a year of trying nonsurgical treatments with no success), Dr. Peden and his colleagues in Yale Medicine Foot & Ankle Surgery are skilled at several techniques.
What is plantar fasciitis?
The plantar fascia is designed to absorb impact we place on our feet, but too much impact or strain can damage or tear its tissue.
“The analogy I like to give is that it’s like a rope. A rope can be damaged in two ways. You can cut it, which is an immediate severing, or it can be an accumulation of fraying. That is what plantar fasciitis is like,” Dr. Peden explains. “Rather than death by one cut, it’s death by 1,000 cuts. And it’s not even a cut, but a fraying or tiny tears.”
Furthermore, the term fasciitis—which means inflammation of the fascia—is not accurate, Dr. Peden says. “It’s actually fasciosis, because when you look at the fascia microscopically in these cases, it’s not inflammation of the tissue, but tiny tears and inappropriate healing.” In an effort to heal those small tears, the plantar fascia thickens, “much like a scar on the skin,” Dr. Peden adds.
The body attempts to heal the injured tissue by mounting an inflammatory response. “That, technically, is the inflammation people talk about, meaning new blood flowing to try and heal the degenerative area,” he says.
What causes plantar fasciitis?
The main cause of plantar fasciitis, Dr. Peden says, is having tightness in your gastrocnemius, one of two major muscles in your calf. Tight calf muscles make it hard to flex your foot and bring the toes up toward your shin. This is a problem because “the tighter your calf is, the harder your foot hits the floor with each step, leading to more stress on your foot,” Dr. Peden says.
Tightness of the Achilles tendon, a tough band of tissue that connects the calf muscles to the heel bone, is also commonly associated with plantar fasciitis.
There are other factors that may contribute to plantar fasciitis:
- Repetitive impact (dancing, running, other sports)
- New or increased activity
- Very high arches
What are the symptoms of plantar fasciitis?
The most common symptom of plantar fasciitis is pain on the bottom of the foot near or on the heel. To some, it may be a stabbing sensation; to others, it may feel like pressing down on a bruise.
Often, that pain is felt most acutely when you place weight on the affected foot after getting out of bed in the morning or after a long period of sitting. That’s because most people sleep with their feet pointed downward or sit with their plantar fascia in a “relaxed” position, which causes the plantar fascia to shorten and tighten.
“If the tissue of the plantar fascia has degenerative strain on the fibers, that tightens it even more, so when you put your weight on it in the morning and stretch it out, you are standing on and stretching out partially torn tissue,” Dr. Peden explains.
The pain often subsides in about 5 to 10 minutes, but it can build up as the day goes on, especially if you are standing, running, or doing other things that exacerbate it.
How is plantar fasciitis diagnosed?
Your doctor can usually diagnose plantar fasciitis based on a physical examination and after discussing your symptoms and activities. An X-ray will be done if your doctor needs to rule out other conditions, including heel spurs (when a calcium deposit grows between the heel and arch of the foot), cysts, or stress fractures.
An X-ray, however, would not confirm plantar fasciitis—but an MRI would, Dr. Peden says. “If we are ever unsure about the diagnosis or if the patient has had it for six months and we want to confirm, an MRI may show the thickening or tearing of the plantar fascia,” he adds.
How is plantar fasciitis treated?
The first treatments for plantar fasciitis are conservative and involve simple steps like stretching your foot, calf, and Achilles tendon. Wearing supportive shoes and avoiding walking barefoot will also decrease the stress on the plantar fascia, resulting in less pain.
Cutting back or taking a break from impact activities (such as running) or changing the surface you run on to a softer one (trading pavement for track, trail, or treadmill) may also be advised. If you are overweight, losing weight will help. If wearing proper footwear is not helpful, you may want to try over-the-counter or custom orthotics.
A splint worn at night will hold your foot at a 90-degree angle and allow the plantar fascia to stretch while you sleep. Night splints come in soft, flexible materials, and a variety of styles. And if you don’t like sleeping with something on your foot, wearing the splint for a few hours while you are watching TV and have your feet up can help, Dr. Peden points out.
“I reassure patients that this is not going to be a lifelong condition. It’s not going to fully tear if you keep running or lead to problems 20 years from now if you run through it,” he says.
However, if simple treatments don’t work and the pain is limiting your lifestyle, your doctor may recommend a cortisone shot to the plantar fascia, which reduces the pain. “The shot lasts for three to six months and, often, by that time, the problem has healed itself,” Dr. Peden says.
Other options include the following physical therapy modalities:
- Dry needling—an alternative medicine technique similar to acupuncture, in which needles are inserted into the skin to relieve muscle pain.
- Joint mobilization—a manual physical therapy method used to relieve pain.
- Platelet-rich plasma injection (often called PRP)—injecting a patient’s own blood cells into his or her own injured body tissue to promote healing.
- Shockwave therapy—a nonsurgical treatment that involves sending shock waves to injured soft tissue to reduce pain and promote healing.
It should be noted that these treatments have limited evidence of effectiveness.
For the rare patient who has tried everything and gotten no relief, surgery may be an option. “Let’s say someone gets severe plantar fasciitis and it really affects their life—they get it every other year for six months and it is debilitating. For that type of patient, we might want to address the source of the problem,” Dr. Peden says.
He notes that the root cause is often an extremely tight gastrocnemius (calf muscle). For those patients, a surgery to lengthen the gastrocnemius may be able to address the problem.
What stands out about Yale Medicine’s approach to plantar fasciitis?
Yale Medicine Foot & Ankle Surgery physicians are skilled at addressing a variety of conditions that affect your ability to lead an active lifestyle. We partner with colleagues from other specialties from radiology to internal medicine to anesthesiology to ensure that every patient gets the best treatment for their particular problem.
In the case of plantar fasciitis, our surgeons are up to date on the most promising treatment options. “Previous surgical treatments for plantar fasciitis were not particularly effective, and had significant risks and downsides,” Dr. Peden says. “The newest surgical treatments go to the source of the problem—the calf—and have a high rate of success with minimal downtime or risk. But in most cases, surgery is not necessary, and having a team of experts for both surgical and nonsurgical evidence-based approaches is really what sets us apart at Yale.”