Plantar Fasciitis and Heel Spurs
Plantar heel pain syndrome in runners and athletes
by Stephen M. Pribut, D.P.M.
Plantar fasciitis occurs often in runners and other athletes. Plantar fasciitis is the most frequent cause of plantar (bottom of the foot) heel pain. For many years pain in this region has been incorrectly termed the "heel spur syndrome". It is better termed the "plantar heel pain syndrome" since a heel spur is not always found at this location. While a "heel spur" sounds ominous often the spur is present and does not cause any pain. The formation of a spur is a sign that too much tension has developed within the plantar fascia, partially tearing from its origin at the calcaneus (heel bone). The result is new bone formation at the site of the injury. The new bone which grows is an attempt by the body to stabilize and reinforce this area in response to the stresses and strains placed upon it.
More big words are in store for those of you looking for the proper medical terminology. Chronic plantar fasciitis is now often termed plantar fasciosis. The new term is used to indicate degenerative changes in the plantar fascia and an absence of microscopic signs of inflammation. Pain, along the course of the plantar fascia is correctly termed a plantar fasciopathy. The most common heel problem, seems to be caused by a painful partial tearing or avulsion of the plantar fascia which happens most often at the portion of the fascia attached to the medial calcaneal tuberosity. As we've stated, this tearing can sometimes result in a heel spur forming (from the injured bone attempting to heal itself). The heel spur itself, as we have mentioned, is not the cause of the pain. The injured soft tissue is the cause of the pain. Tenderness is usually found right at this location on the medial plantar calcaneus. The term in common use "plantar fasciitis" is derived in part from plantar which refers to the bottom of the foot and from fascia which is a type of dense fibrous connective tissue. The "itis" is a suffix which means inflammation. Latest studies show that in many cases of plantar fasciitis there really is no inflamation, but rather an avascularity (loss of blood circulation). This may be similar to what has been termed Achilles Tendinosis (rather then tendinitis). Lemont (2003) termed this condition a fasciosis. It is a conceptual difference, but the pain still remains quite similar. The origin of the plantar fascia is actually relatively complicated and is called an enthesis. At the origin, where the fascia inserts into the bone, there are found several types of cartilage. This area can possibly be affected by various disease processes resulting in an enthesitis or enthesopathy.
Plantar fasciitis is the most common cause of heel pain.
If your foot flattens or becomes unstable during critical times in the walking or running cycle, the attachment of the plantar fascia into your heel bone may begin to stretch and pull away from the heel bone. This will result in pain and possibly swelling. The pain is especially noticeable when you push off with your toes while walking. Since this movement stretches the already injured portion of the fascia. Without treatment the pain will usually spread around the heel. The pain is usually centered at a location just in front of the heel toward the arch. When the tearing occurs at the bone itself, a the bone may attempt to heal itself by producing new bone. This results in the development of a heel spur. Without the spur the condition is called plantar fasciitis.
The pain of this condition may cause you to try to walk on your toes, or alter your running stride and gait which will cause further damage and may cause a problem to develop in your healthy foot. Gait changes caused by pain while running may also lead to ankle, knee, hip or back pain.
A heel spur is a focal point of bone growth on the heel. The bone growth usually extends forward towards the toes. Heel spurs are visible on X-ray. The spur is theorized to occur when the plantar fascia tissue attaching into the calcaneus (heel bone) tears away from the bone and injures the outer layer (periosteum) of the bone. Small amounts of bleeding may occur at this site and then this area can ossify and form a heel spur. It is not the spur that causes the pain, but the continued tension and tearing of tissue at this location.
Plantar Fascia Rupture:
Tears of the plantar fascia are a less commonly found injury than either a heel spur or plantar fasciitis. They usually involve larger and more abrupt forces than the forces which allow for plantar fasciitis to develop. High speed activity develop these forces more often. The force needs to be applied to the ball of the foot. Sprinting places the foot in a position in which this could happen. Soft shoes that bend in the arch may contribute. Plantar fascia tears may also occur in baseball or softball players when sliding in to a base with the foot making contact with the base. Injections of steroid into the region of the plantar fascia may increase the likelihood of this injury.
The tear usually happens further forward than where the pain of plantar fasciitis usually occurs. It is often found 2 to 4 centimeters in front of the attachment of the plantar fascia into the calcaneus (heel bone). The patient will often recall feeling or hearing a "pop". When examined there may be pain when the toes are passively bent upwards (dorsiflexed). The usual treatment for this injury is non-weight bearing for 1 - 3 weeks in a cast and total casting for about 4 - 6 weeks. Full recovery will take 7 to 12 weeks.
A nerve entrapment of the first branch of the lateral plantar nerve may occur in this area and cause a "burning" pain. This is found much less often than the above discussed conditions. The portion of the lateral plantar nerve that leads to the abductor digiti minimi has been mentioned as a possibly involved nerve in some entrapment syndromes (Baxter). Other possible nerve entrapments that may contribute to pain in the heel region include the medial calcaneal nerve and tarsal tunnel nerve entrapment.
Plantar Fasciitis - Cause:
The most frequent cause is an abnormal motion of the foot called excessive pronation. Normally, while walking or during long distance running, your foot will strike the ground on the heel, then roll forward toward your toes and inward to the arch. Your arch should only dip slightly during this motion. If it lowers too much, you have what is known as excessive pronation. For more details on pronation, please see the section on biomechanics and gait. Clinically not only those with low arches, but those with high arches can sometimes have plantar fasciitis.
The mechanical structure of your feet and the manner in which the different segments of your feet are linked together and joined with your legs has a major impact on their function and on the development of mechanically caused problems. Merely having "flat feet" won't take the spring out of your step, but having badly functioning feet with poor bone alignment will adversely affect the muscles, ligaments, and tendons and can create a variety of aches and pains. Excess pronation can cause the arch of your foot to stretch excessively with each step. It can also cause too much motion in segments of the foot that should be stable as you are walking or running. This "hypermobility" may cause other bones to shift and cause other mechanically induced problems.
Other factors which may contribute to plantar fasciitis and heel spurs include a sudden increase in daily activities, increase in weight (not usually a problem with runners), or a change of shoes. Dramatic increase in training intensity or duration may cause plantar fasciitis. Shoes that are too flexible in the middle of the arch or shoes that bend before the toe joints will cause an increase in tension in the plantar fascia. Even though you may have run in shoes that are flexible before, now that you have developed plantar fasciitis, make certain that your shoe is stable and does not bend in the midfoot. Check and be certain that your shoes are not excessively worn. Shoes that do not sufficiently control excessive pronation combined with an increase in training can lead to this condition. A change in running style or parameters, such as starting speed work, running on the ball of your foot or sudden increase in hill workouts may lead to problems. All changes should be gradual and not abrupt. Gait changes such as altering your foot strike, switching shoe style, running barefoot or in minimalist shoes should all be made gradually and not abruptly. The "terrible too's" of too much, too soon, too often with too little rest also applies to "too many changes with too little adaptation". Make your changes gradually and allow your muscles, bones, and other body structures to adapt to the alterations you may be attempting.
First check your shoes for too much midfoot flexibility and check your training for changes. A detailed evaluation of changes in your training is necessary. You should start with what is called "relative rest" which means a decrease in workout intensity, duration of session and decrease in the number of sessions per week. The most important part of self treatment for this condition is being sure that your shoes offer sufficient stability and are optimal in controlling the forces that contribute to plantar fasciitis and heel spurs. Check your running shoes to make sure that they are not excessively worn. They should bend only at the ball of the foot, where your toes attach to the foot. This is vital! Avoid any shoe that bends in the center of the arch or behind the ball of the foot. It offers insufficient support and will stress your plantar fascia. The human foot was not designed to bend here and neither should a shoe be designed to do this.
You should also be doing gentle calf stretching exercises. This will reduce stress on the plantar fascia in two ways. The first manner in which a relaxation of the tension in the calf muscles can help heel pain is that it will reduce the direct pull backwards on the heel bone (calcaneus). The second reason is a little bit more complicated, but essentially it is that a tight achilles tendon and calf muscles causes the rearfoot to move in a manner that causes over pronation as your leg and body move forward over your foot. So go ahead and gently stretch the calf muscle by doing the runner's wall leaning stretch. To strengthen the muscles in your arch toe curls or "doming" can be done. Toe curls may be done by placing a towel on a kitchen floor and then curling your toes to pull the towel towards you. This exercise may also be done without the towel against the resistance of the floor.
Strengthen the foot's "intrinsic" muscles by performing "toe curls". The toe curls can be done for 15 to 20 seconds twice daily.
Icing after running can also be helpful. But long term use of ice only serves to mask the pain. Ice used in chronic conditions can quite possibly slow healing by decreasing the blood flow to the injured area.
Consider adding over the counter foot supports to your shoes. This should be done after you have first tried a good stability shoe, if you over pronate.
Self treatment for this problem should include:
- Temporary decrease in training
- Gentle Stretching of calf muscles. Wall stretches - 10 seconds each side. Repeat ten times. Do two sets of 10 reps each day.
- Check shoes for flexion stability. Avoid and replace any shoe that bends before the ball of the foot. Put your flip flops in the closet and forget about them for a very long time.
- Try wearing shoes that offer more anti-pronation control
- Perform 20 seconds of "toe curls"three times daily to strengthen your intrinsic foot muscles.
- Ice 15 minutes, 10 minute break repeat 1 - 2 times each day
- Consider rolling your foot over frozen water bottle ( or using frozen peas rather than ice)
- Carefully examine your training regimen (if you've been keeping a running diary - check it for possible training errors).
- Do not go barefoot in your house or at any other time for 6 weeks. Also, no slippers, flip flops, open back shoes, sandals that are open in the back without attaching your heel to them.
- Try over the counter orthotics
- Visit a sports podiatrist
- Consider custom orthotics
Treatment is usually succesful for this problem. ECSWT is considered only after the above treatment has failed for 6 months. Orthotics should be tried prior to considering either ECSWT (extra-corporeal shock wave therapy) or surgery. If you have hard, rigid orthotics softer orthotics are often helpful. An accomodation indentation at the medial calcaneal tuberosity, the site of the origin of the plantar fascia and of many heel spurs can be helpful.
Shoe Pushup Test
The “shoe pushup test” should be done to check where the shoe bends. Hold the heel of the shoe in one hand and then press up underneath the forefoot. The shoe should bend at the ball of the shoe, where the metatarsals would be. Next press under the part of the shoe where the metatarsal heads would be. The shoe should not bend under moderate pressure before this area. If it does you should change to a shoe that meets this criterion.
An alternative to the "shoe pushup test" is the shoe pushdown test. Press the shoe at a 45 degree or greater angle onto a countertop as seen below. The shoe should bend at the ball of the shoe. It should not bend before this point further back on the shoe.
In the images below the shoe on the left demonstrates a shoe that flexes at the correct part of the sole. The shoe in the image on the right flexes too far back on the foot. Varying areas of flexion that are too far proximal (back towards the heel) often line up with the tender part of the foot. Make sure your shoe bends at the ball of the foot.
Office Treatment of Plantar Fasciitis
Plantar fasciitis is usually controlled with conservative treatment. Following control of the pain and inflammation an orthotic (a custom made shoe insert) will be used to stabilize your foot and prevent a recurrence. Over 98% of the time heel spurs and plantar fasciitis can be controlled by this treatment and surgery can be avoided. The orthotic prevents excess pronation and prevents lengthening of the plantar fascia and continued tearing of the fascia. Usually a slight heel lift and a firm shank in the shoe will also help to reduce the severity of this problem.
The office visit will be used for careful examination and review to distinguish plantar fasciitis and plantar heel pain syndrome from other problems, many of which are outlined below. It is important to distinguish between a stress reaction of the calcaneus and plantar fasciitis. A feature of many calcaneal stress fractures is pain on lateral and medial compression of the calcaneus.
Sometimes physical therapy modalities are helpful. The most frequently used modalities include ultrasound (high frequency sound vibrations that create a deep heat and reduce inflammation) and galvanic electrical stimulation ( a carefully applied intermittent muscular stimulation to the heel and calf that helps reduce pain and relax muscle spasm, which is a contributing factor to the pain). This treatment has been found most effective when given twice a week. Repeated taping and padding is sometimes used. The felt pads that will be strapped to your feet will compress after a few days and must be reapplied. While wearing them they should be kept dry, but may be removed the night before your next appointment.
Resistant cases of heel pain caused by plantar fasciitis, heel spurs or cases of stress fracture of the calcaneus often need to be placed in a removable below knee cast boot.
It is important to be aware of how your foot feels over this time period. If your foot is still uncomfortable without the strapping, but was more comfortable while wearing it, that is an indication that the treatment should help. Remember, what took many months or years to develop can not be eliminated in just a few days.
With failure of the above treatment "shock wave" therapy can be used. It has only been used for resistant heel pain which has been present for more than 6 months and not responded to orthotics, physical therapy, casting, and other therapeutic measures. In my personal experience I have not found it necessary to recommend this often, since the current therapies work so well. I'd have one strong recommendation for those who have had orthotics that have not worked and have tried all the advice recommended above. That recommendation is to replace that thin, flat heeled very hard orthotic that you've been prescribed with a more flexible and somewhat softer orthotic that has a significantly deeper heel cup. In my practice I often use laminated leather orthotics with a deep heel cup. The material is non-compressible but still yielding and offers significant shock attenuation. The device may also be adjusted to decrease direct pressure on the most painful part of the heel and this can easily be done in the office rather than by sending it back to the laboratory.
After recovery from plantar fasciitis, if you have taken a break from running check out Dr. Pribut's return to running schedule.
Questions & Answers on Heel Spurs and Heel Pain:
Milwaukee, WI: How do you get rid of heel spurs that aren't responding to the stretching exercises prescribed by my doctor?
Dr. Pribut: Orthotics are often used for treatment of plantar fasciitis and heel spurs. But let's look at some background first.
Factors which may contribute to plantar fasciitis and heel spurs include a sudden increase in daily activities, increase in weight, or a change of shoes or allowing your current shoes to wear excessively. Shoes that are too flexible in the middle of the arch or shoes that bend before the toe joints will cause an increase in tension in the plantar fascia. Make sure your shoes are not excessively worn and that they do not bend in the "middle of the arch".
Just to emphasize what you can do at home to treat this: Check your shoes to make sure they offer sufficient support and motion control. They should bend only at the ball of the foot, where your toes attach to the foot. This is very important. Avoid any shoe that bends in the center of the arch or behind the ball of the foot. It offers insufficient support and will stress your plantar fascia. The human foot was not designed to bend here and neither should a shoe be designed to do this.
You may also strengthen the muscles in your arch by performing toe curls or "doming". Toe curls may be done by placing a towel on a kitchen floor and then curling your toes to pull the towel towards you. This exercise may also be done without the towel against the resistance of the floor.
Plantar fasciitis is usually controlled with conservative treatment. Besides surgery and cortisone injections, physical therapy modalities such as electrical stimulation and ultrasound can be used. Often the foot will be taped to limit pronation. Following control of the pain and inflammation an orthotic (a custom made shoe insert) can be used to control over-pronation.
The orthotic has a very high percentage of long term success. If the orthotic has failed for 6 months (and make sure you have also tried a softer orthotic, if a hard plastic one fails) surgery or ESWT (shock wave therapy) can be considered. The protocol for this therapy requires 6 months of failed treatment. I believe that the orthotics and physical therapy work quite well. This currently very expensive therapy should not be needed very often.
Other recently attempted treatments include PRP (platelet rich plasma) and prolotherapy. At this time evidence based research is sketchy at best.
Fort Worth, TX: What is the best shoe for plantar fasciitis?
Dr. Pribut: The best shoe for plantar fasciitis will vary from one person to the next. I do recommend as described above that the shoe have flexion stability, torsional stability, and a stable and solid heel counter. It should not bend in the middle. It shouldn't torque about the long axis of the shoe, and the heel should have a solid counter. The first two criterion are key. The images demonstrate the flexion stability required. For additional information on what could be for you the best shoes for plantar fasciitis see Dr. Pribut's Running Shoe Llist and also read how to select a running shoe.
Oxford, MI: On my run this afternoon, I felt a pop and sudden knife-like pain on the bottom of my heel. Now I can hardly stand let alone walk. Is this plantar fasciitis? What else could it be?
Dr. Pribut: Plantar fasciitis usually comes on slowly. A sensation of a "pop on the bottom of your heel" is something else. It began abruptly and suddenly with something feeling as if it had torn or popped. It seems to be a tear or avulsion of the plantar fascia from its attachment on the heel bone (calcaneus). But I can't tell exactly where the injured part is without an examination. It is possible that pop and pain are a bit further forward and then it could be a partial tear of your plantar fascia. If this is the case, you will likely need to use a cast or a removable Pneumatic Walking Cast Boot.
Calcaneal Stress Fracture:
Calcaneal stress fractures usually are painful in a slightly different location than Plantar Fasciitis. The maximum tenderness is over the body of the calcaneus. Pain is elicited when the calcaneus is pressed on its medial and lateral sides. The tenderness usually continues in a line from the bottom of the bone up the side to the back of the body of the bone.
Insertional Achilles Tendonitis:
This condition is usually painful at the back of the heel. Tenderness is found somewhere at the back of the heel either directly behind or more often somewhat posterior-lateral (outside back part of bone) or posterior-medial (inside back part of calcaneus). Occasionally the tenderness continues to the undersurface of the calcaneus and can overlap and coexist with plantar fasciitis.
Calcaneal apophysitis occurs more often in boys than girls and most often between the ages of about 8 - 12 years old. The pain may occur either at the posterior or plantar portion of the calcaneus. While classically described as being located on the back of the heel, it probably occurs clinically plantarly 40% of the time. See additional information on Calcaneal apophysitis (Sever's disease)
Xray examination often reveals an apparent fragmentation of the growth plate. Growth is not impaired by this condition. Treatment is similar to that for plantar fasciitis. Decrease activity. Initially a heel lift is used, which often fails to relieve the pain. Custom orthoses and gentle calf stretching is usually quite effective in treating this condition and allowing a reasonably rapid return to sports.
Peroneus longus tendinitis (tendinopathy) occurs in the middle of the foot. Sometimes it is mistaken for plantar fasciitis. Read the article that covers problems in the "Zone of Confusion". And yes, tendinitis is spelled two ways, but should really be called a tendinopathy.
Sciatica/Lumbar Radiculopathy/Lower Back Nerve Compression or Disc Origin
A neurological examination can assist in this diagnosis. A thorough local examination though will usually demonstrate no local tenderness. If there is no local tenderness, a more proximal origin of the pain should be suspected. Check patellar and ankle reflexes.
HLA B27/Asymmetrical Arthropathies
Keep in mind the other symptoms or the presence of other disorders to possibly be the cause of the heel pain. Seronegative arthropathies such as IBS, Reiter's disease, Psoriatic Arthritis, Ankylosing Spondylitis, and other conditions may cause heel pain.
Difficult to treat. Evaluate other symptoms.
Additional conditions that Plantar fasciitis and heel spurs must be distinguished from:
- Lateral Plantar Nerve, 1st branch entrapment
- Calcaneal Stress Fracture
- Tarsal Tunnel Syndrome
- Plantar Fascia Tear, Partial tear, or Rupture
- Sciatica, Discogenic Pain, Other back disorder
- Achilles Tendonitis
- Rheumatoid Arthritis
- Other Arthritis as above (Seronegative or Other Associated HLA B27 arthritis, such as with IBS, Ankylosing spondylitis, Psoriatic Arthritis, arthralgia or Reiter's Syndrome)
- Neoplasm, Calcaneal bone cyst
- Infection, Osteomyelitis
Anatomical Considerations: Location, Location, Location
Pain below the calcaneus
- Plantar fasciitis
- Plantar fascia rupture
- Plantar fascia avulsion from calcaneus (or muscular avulsion of intrinsic muscle)
- Fat pad dysplasia/atrophy
- Tarsal tunnel syndrome
- Bone cyst
- Discogenic pain
Pain in the midfoot
- Tendonitis of the peroneus brevis
- Tendonitis of the peroneus longus
- Tendonitis of the flexor digitorum longus
- Tendonitis of the flexor hallucis longus
- Tendonitis of the tibialis posterior
- Discogenic Pain
Pain at the back of the heel
- Achilles tendonitis
- Retroachilles bursitis
- Retrocalcaneal bursitis
Baxter DE, Pfeffer GB: Treatment of Chronic Heel Pain by Surgical Release of the First Branch of the Lateral Plantar Nerve: Clin Orthop. 279:229-235, 1992.
Kibler WB, Goldberg C, Chandler TJ: functional biomechanical deficits in running athletes with plantar fascitis. Am J Sports Med 19:66-71, 1991.
Lemont, H, et. al.: Plantar Fasciitis: A degenerative process. JAPMA 93:234, 2003.
Lynch DM, Goforth WP, Martin JE, Odom RD, Preece CK, Kotter MW: Conservative Treatment of Plantar Fasciitis A Prospective Study. J Am Pod Med Assoc. 88:375-379, 1998.
Pribut SM, "Current Approaches to the Management of Plantar Heel Pain Syndrome" J Am Podiatr Med Assoc, January 1, 2007; 97(1): 68 - 74.
Tanz SS: Heel pain. Clin Orthop 28:169, 1963.
Warren BL: Plantar Fasciitis in Runners: Treatment and Prevention. Sports Med. 10:338-345, 1990.
Scherer PR: Heel Spur Syndrome. Pathomechanics and Nonsurgical Treatment. J Am Pod Med Assn. 81:68-72, 1991.
About Dr. Pribut: Dr. Pribut is a member of the Advisory Board of Runner's World magazine. He is a past president of the American Academy of Podiatric Sports Medicine (AAPSM). He served as chair of the AAPSM Athletic Shoe Committee for 5 years and has served on the Education Committee, the Research Committee, the Public Relations Committee and the Annual Meeting Committee. He is a co-Editor of the current AAPSM Student's Manual. Dr. Pribut is a past president of the District of Columbia Podiatric Medical Association, serving in that post for 4 years. Dr. Pribut currently is a member of the American Podiatric Medical Association's Clinical Practice Advisory Committee. Dr. Pribut is a Clinical Assistant Professor of Surgery at the George Washington University Medical Center.
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