There are many diagnoses within the differential of heel pain; however, plantar fasciitis is the most common cause of heel pain for which professional care is sought. Approximately 10% of the United
States population experiences bouts of heel pain, which results in 1 million visits per year to medical professionals for treatment of plantar fasciitis. The annual cost of treatments for plantar
fasciitis is estimated to be between $192 and $376 million dollars. The etiology of this condition is multifactorial, and the condition can occur traumatically; however, most cases are from overuse
Plantar fasciitis is the most common cause of heel pain, accounting for around four out of five cases. Plantar fasciitis is when the thick band of tissue that connects the heel bone with the rest of
the foot (the plantar fascia) becomes damaged and thickened. Damage to the plantar fascia is thought to occur following sudden damage, for example, damaging your heel while jogging, running or
dancing; this type of damage usually affects younger people who are physically active, gradual wear and tear of the tissues that make up the plantar fascia - this usually affects adults who are 40
years of age or over. You are at an increased risk of gradual wear and tear damaging your plantar fasciitis if you are overweight or obese, if you have a body mass index (BMI) of 30 or over, you are
considered to be obese, have a job that involves spending long periods of time standing, wear flat-soled shoes, such as sandals or flip flops. Less common causes of heel pain are a stress fracture. A
stress fracture can occur if your heel bone is damaged during an injury. Fat pad atrophy. Fat pad atrophy is where the layer of fat that lies under the heel bone, known as the fat pad, starts to
waste away due to too much strain being placed on the pad. Women who wear high-heeled shoes for many years have an increased risk of developing fat pad atrophy. Bursitis. Bursitis is inflammation of
one or more bursa (small fluid-filled sacs under the skin, usually found over the joints and between tendons and bones). It's possible to develop bursitis anywhere inside the body, not just in the
foot. Tarsal tunnel syndrome. The nerves in the sole of your foot pass through a small tunnel on the inside of the ankle joint, known as the tarsal tunnel. If a cyst forms or the tunnel is damaged,
the nerves can become compressed (squashed). This can cause pain anywhere along the nerve, including beneath your heel. Sever's disease. Sever's disease is a common cause of heel pain in children.
It's caused by the muscles and tendons of the hamstrings and calves stretching and tightening in response to growth spurts. The stretching of the calf muscle pulls on the Achilles tendon. This pulls
on the growing area of bone at the back of the heel (growth plate), causing pain in the heel. The pain is further aggravated by activities such as football and gymnastics. The pain often develops at
the side of the heel, but can also be felt under the heel. Calf and hamstring stretches and, if necessary, heel pads are usually effective treatments for Sever's disease. Bone spurs. Bone spurs are
an excess growth of bone that forms on a normal bone. Bone spurs can develop on the heel (a heel spur) and are more common in people with heel pain. However, they can also occur in people without
heel pain. A heel spur does not cause heel pain.
The main symptom of plantar fasciitis is heel pain when you walk. You may also feel pain when you stand and possibly even when you are resting. This pain typically occurs first thing in the morning
after you get out of bed, when your foot is placed flat on the floor. The pain occurs because you are stretching the plantar fascia. The pain usually lessens with more walking, but you may have it
again after periods of rest. You may feel no pain when you are sleeping because the position of your feet during rest allows the fascia to shorten and relax.
If you see a doctor for heel pain, he or she will first ask questions about where you feel the pain. If plantar fasciitis is suspected, the doctor will ask about what activities you've been doing
that might be putting you at risk. The doctor will also examine your foot by pressing on it or asking you to flex it to see if that makes the pain worse. If something else might be causing the pain,
like a heel spur or a bone fracture, the doctor may order an X-ray to take a look at the bones of your feet. In rare cases, if heel pain doesn't respond to regular treatments, the doctor also might
order an MRI scan of your foot. The good news about plantar fasciitis is that it usually goes away after a few months if you do a few simple things like stretching exercises and cutting back on
activities that might have caused the problem. Taking over-the-counter medicines can help with pain. It's rare that people need surgery for plantar fasciitis. Doctors only do surgery as a last resort
if nothing else eases the pain.
Non Surgical Treatment
More than 90% of patients with plantar fasciitis will improve within 10 months of starting simple treatment methods. Rest. Decreasing or even stopping the activities that make the pain worse is the
first step in reducing the pain. You may need to stop athletic activities where your feet pound on hard surfaces (for example, running or step aerobics). Ice. Rolling your foot over a cold water
bottle or ice for 20 minutes is effective. This can be done 3 to 4 times a day. Nonsteroidal anti-inflammatory medication. Drugs such as ibuprofen or naproxen reduce pain and inflammation. Using the
medication for more than 1 month should be reviewed with your primary care doctor. Exercise. Plantar fasciitis is aggravated by tight muscles in your feet and calves. Stretching your calves and
plantar fascia is the most effective way to relieve the pain that comes with this condition. Cortisone injections. Cortisone, a type of steroid, is a powerful anti-inflammatory medication. It can be
injected into the plantar fascia to reduce inflammation and pain. Your doctor may limit your injections. Multiple steroid injections can cause the plantar fascia to rupture (tear), which can lead to
a flat foot and chronic pain. Soft heel pads can provide extra support. Supportive shoes and orthotics. Shoes with thick soles and extra cushioning can reduce pain with standing and walking. As you
step and your heel strikes the ground, a significant amount of tension is placed on the fascia, which causes microtrauma (tiny tears in the tissue). A cushioned shoe or insert reduces this tension
and the microtrauma that occurs with every step. Soft silicone heel pads are inexpensive and work by elevating and cushioning your heel. Pre-made or custom orthotics (shoe inserts) are also helpful.
Night splints. Most people sleep with their feet pointed down. This relaxes the plantar fascia and is one of the reasons for morning heel pain. A night splint stretches the plantar fascia while you
sleep. Although it can be difficult to sleep with, a night splint is very effective and does not have to be used once the pain is gone. Physical therapy. Your doctor may suggest that you work with a
physical therapist on an exercise program that focuses on stretching your calf muscles and plantar fascia. In addition to exercises like the ones mentioned above, a physical therapy program may
involve specialized ice treatments, massage, and medication to decrease inflammation around the plantar fascia. Extracorporeal shockwave therapy (ESWT). During this procedure, high-energy shockwave
impulses stimulate the healing process in damaged plantar fascia tissue. ESWT has not shown consistent results and, therefore, is not commonly performed. ESWT is noninvasive-it does not require a
surgical incision. Because of the minimal risk involved, ESWT is sometimes tried before surgery is considered.
The most common surgical procedure for plantar fasciitis is plantar fascia release. It involves surgical removal of a part from the plantar fascia ligament which will relieve the inflammation and
reduce the tension. Plantar fascia release is either an open surgery or endoscopic surgery (insertion of special surgical instruments through small incisions). While both methods are performed under
local anesthesia the open procedure may take more time to recover. Other surgical procedures can be used as well but they are rarely an option. Complications of plantar fasciitis surgery are rare but
they are not impossible. All types of plantar fasciitis surgery pose a risk of infection, nerve damage, and anesthesia related complications including systemic toxicity, and persistence or worsening
of heel pain.