"Oh, My Aching Feet!"

Ouch! Those first steps after getting out of bed can be miserable for people with plantar fasciitis. According to Harvard Women's Health Watch (April 2007), this common foot problem affects more than two million Americans each year. Classic symptoms include pain at the heel with initial weight-bearing while getting out of bed, or upon standing up after prolonged sitting.

What is plantar fasciitis?

The plantar fascia consists of fibrous bands of tissue on the bottom of the foot, extending from the calcaneus (the large bone of the heel) to the proximal phalanx of the toes. During normal gait, this tissue withstands up to three times the individual's body weight and takes the majority of the stress applied to the foot (Donatelli, The Biomechanics of the Foot and Ankle, 1990). Inflammation at the plantar fascia origin (the medial calcaneal tuberosity) results from overstretching or micro-tearing, causing a deep-bruised feeling or sharp pain.

However, a more recent study suggests that plantar fasciitis may not result from inflammation, but instead from a degenerative process where the plantar fascia thickens. The chronic stress on this thickened tissue may cause pain from irritated nerve fibers, or compression of blood vessels causing ischemic pain (Dubin, 2007).

Radiographic studies often reveal a heel spur, which is a bony growth of the medial calcaneal tuberosity, caused by the constant pulling of the fascia on the bony origin. Despite the painful sounding name, the heel spur is often a result of plantar fasciitis, not the cause of the pain and symptoms (Dubin, 2007).

What causes plantar fasciitis?

Common causes of plantar fasciitis include extended walking and standing for long periods of time, as well as repetitive trauma from running or high-impact exercise. Plantar fasciitis is responsible for 25% of the diagnosed foot injuries in runners (Landorf, 2006). Those who have a flat-foot (pronated) posture and those who are obese are more likely to experience symptoms. Also, due to the decrease in elasticity of these tissues, older adults are at greater risk for problems.

Another factor is footwear. Those who wear high-heeled shoes at work, and then wear low-heel shoes or no shoes at home may have greater difficulty. Although fashionable, high heels cause consistent tightness of the Achilles tendon and plantar fascia. Also, some shoes and sandals have flat or negative heels, which create increased tensile forces on the plantar fascia. Research does demonstrate that women suffer from plantar fasciitis more than men – maybe it is the shoes (Harvard Women's Health Watch, 2007).

What treatments are available for plantar fasciitis?

After proper clinical diagnosis, there are several techniques to treat plantar fasciitis. For more serious and debilitating symptoms, rehabilitation with modalities such as ultrasound, electrical stimulations, and iontophoresis (electrical stimulation with a corticoid steroid) may be helpful to relieve pain (Donatelli, The Biomechanics of the Foot and Ankle, 1990). Aggressive soft tissue mobilization/massage may also improve tissue flexibility and tolerance to stress on the plantar fascia. Home remedies include ice/cold packs and over-the-counter nonsteroidal anti-inflammatories.

Clinicians often recommend custom foot orthoses or off-the-shelf shoe inserts. Anecdotal evidence may support the benefits; however, a recent study suggests that commonly prescribed customized and prefabricated orthoses produce only small short-term benefits for people with plantar fasciitis compared with a sham device. These devices were not shown to provide long-term benefits, and overall, both custom and prefabricated inserts performed similarly (Landorf, 2006).

More aggressive treatments include corticosteroid injections and surgery. Injections may assist with decreasing acute pain and inflammation; however, repeated injections can cause the tissue to break down, leading to a risk of plantar fascia rupture. Surgery should be considered the last resort. Approximately 5% of individuals with chronic plantar fasciitis undergo a fasciotomy, where the fascia is released from the calcaneus, thus decreasing stress on those tissues (Harvard Women's Health Watch, 2007).

However, the most common method of treating plantar fasciitis involves stretching. Typical stretching protocols include gastroc-soleus, or Achilles tendon stretches, and plantar fascia stretches. Recently, researchers at the University of Rochester Department of Physical Therapy found that specific stretching to the plantar fascia provide tremendous patient satisfaction, including decreased pain and increased function (DiGiovanni, 2006).

Performing stretches may be accomplished several ways, but the best time to stretch is before taking the first steps after sleeping or prolonged sitting. Simple ways to accomplish stretching (before weight bearing) includes the following:

Note: Do not stretch into feeling pain, you should only feel a slight pulling sensation.

Despite being one of the most common foot injuries, plantar fasciitis typically resolves within a year (DiGiovanni, 2006). Maintaining proper body weight will help decrease symptoms, but because walking or other forms of weight-bearing exercise may exacerbate the condition, exercises such as swimming and cycling may have to be substituted. Runners should also consider cross-training with the above exercises to rest their plantar fasciitis and control symptoms.

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