Plantar Fasciitis and Heel Spurs
Plantar fasciitis (pronounced PLAN-tar fashee-EYE-tiss) is an inflammation of the plantar fascia. "Plantar" means the bottom of the foot,
"fascia" is a type of connective tissue, and
"itis" means "inflammation". Heel spurs are soft, bendable deposits of calcium that are the result of tension and inflammation in the plantar fascia attachment to the heel. Heel spurs do not cause pain. They are only evidence (not proof) that a patient may have plantar fasciitis. The plantar fascia encapsulates muscles in the sole of the foot. It supports the arch of the foot by acting as a bowstring to connect the ball of the foot to the heel. When walking and at the moment the heel of the trailing leg begins to lift off the ground, the plantar fascia endures tension that is approximately two times body weight. This moment of maximum tension is increased and "sharpened" (it increases suddenly) if there is lack of flexibility in the calf muscles. A percentage increase in body weight causes the same percentage increase in tension in the fascia. Due to the repetitive nature of walking, plantar fasciitis may be a repetitive stress disorder (RSD) similar to tennis elbow. Both conditions benefit greatly from rest, ice, and stretching. Surgery is a last resort and may result in more harm than good in up to 50% of the patients.
We get a lot of calls from parents who have very active children who are between 8 and 13 years of age who have heel pain. The children probably just have "Severs disease" which means the combination of activity and a growing heel bone is causing pain. Rest and time are required. Ice may ease the pain. We don't know of anything you can buy that will help. Very few people under the age of 25 get plantar fasciitis.
Here are the treatments that I think are the most important:
The most successful treatments reported by our visitors are the following:
Trying to "walk through the pain" can cause a mild case to become long-term and debilitating. In my case, being gentle on my feet for several months until there was no pain and then very slowly and carefully increasing activity was the key. Since rest is the highest rated treatment, I believe many others have had a similar experience. Unfortunately many have jobs that require a lot of time on their feet which may prevent time to heal. The condition is well-known to be "cyclic" in nature. Just when you think you are getting over it, the pain often comes back in full force.
The most common complaints about doctors is that they do not seem to understand how terrible the condition can be, or that doctors make the patient feel as if they are unusual or otherwise at fault for showing up in their office with heel pain. Several have reported orthopedic surgeons find heel pain boring, difficult to treat, and unrewarding. Since heel pain is a mainstay of podiatric practices, podiatrists probably feel differently.
In 2000 and 2001 about 5,900 visitors to heelspurs.com filled out an 80 question survey. The results for the first half of the survey are available here. The data provides an extensive profile of web surfers who have heel and/or fascia pain. Although one would assume the data is biased towards chronic sufferers who are more willing to complete the survey, single-question surveys on the home page gave the same results. The following numbers are only for the first half of the survey because the percentages stated here changed very little in the second half of the data. Male sufferers weighed 12 pounds above the average American male (which is already hefty) and female sufferers weighed 30 pounds above their counterparts (compared to 1999 CDC data). More than 2 out of 3 visitors are female. Our female visitors were 2.4 times more likely to be very obese (BMI>=35) as our male visitors. These last two statements can be combined to say 6 out of 7 of our very obese visitors (n=442) were female. I do not have an explanation as to why overweight women are more likely to have heel pain than overweight men, except for different shoes or a lower center of gravity that would require more flexibility in the calf muscles. 46% had it over a year. Average age was 41. 24% said it takes less than 5 minutes of being on their feet to cause the pain to increase. 36% did not know what caused it. When sitting, 22% had no pain and 7% had severe pain. The primary type of pain (visitors could choose only one) was sharp (38%), like a stone bruise (30%), throbbing (19%), or dull (10%), but rarely tingling or numb (2%). 37% had injections. 27% who had an injection indicated the pain from the injection was "horrific", but overall, injections were rated as one of the better treatments (even if only temporary relief). Some studies indicate injections are doing significant harm by increasing the chances that the fascia will detach completely from the heel. Journal articles report it's in both feet in 15% to 35% of the cases. Our surveys indicate it's in both feet 45% of the time, but only 14% of the respondents said their feet were equally painful. Our visitors ranked podiatrists, physical therapists, and acupuncture much better than orthopedic surgeons, but orthopedic surgeons ranked as well as podiatrists when the results were restricted to patients who had been to both podiatrists and orthopedic surgeons. 8% of our visitors have had surgery. About 25% of the 267 surgeries made it worse, but 40% completed the survey less than 3 months after their surgery, so many of them are likely to improve. If surgery had made it better, they would not be visiting the web site and filling out the survey, although the same can be said for all the other treatments. About 4% of our visitors have had "devastating" cases ( here are a few examples ).
I have reveiwed the data fron the surveys in many different ways to see if any particular sub-group of patients benefitted from certain treatments more than any other subgroup. For example, what would help runners the most? Or if it's not sensitive to the touch and there is no morning heel pain, what would help that type of patient the most? This knowledge would help greatly in deciding a course of action for individual patients. However, the only important differences between any sub-groups were in the male verses female sub-groups. But the differences did not make enough sense to decide a different course of action and they were not distillable enough to mention here other than the weight issue mentioned above. But it was surprising and interesting that there were MANY differences between these two groups and almost no differences between any other subgroups.
Black tennis shoes can often pass as dress shoes. New Balance is one of the few brands that often comes in extra wide sizes (2E and 4E) to accommodate high arches, inserts, and a heel lift. Shoe stores often do not have the wider sizes, but there are many places online you can find them (after first checking the styles out in local stores). SAS are great casual shoes, but hard to find even online.
If none of the above works the best option is the newly-approved and apparently safe ESWT treatment, but insurance may not pay for it and it can cost as high as $5000. It is much less expensive in Canada where there is competition. Some of the machines in Canada do not have FDA approval. I would not have surgery unless I was able to confirm the success rate and safety that the doctor claims. One only has to review our surgery message board to confirm that surgery should not be undertaken lightly. Depending on the patient, type of surgery, and physician, recovery from the surgery can occur in just a month or two, but it is often (if not usually) 6 months to a year.
The most frequently harmful treatments reported are the various surgeries, hard casts, deep massage, and firm heel pads. Nerve surgery ranked last out of the 46 treatments in the questionnaire because it helped only 37% and harmed 31%, but the number of responses is too small (n=16) to be statistically significant. Although having the lowest harm rate, tylenol was also the least effective (17%, n=856) presumably because it is not an anti-inflammatory like ibuprofen, Aleve, and aspirin which ranked higher at 49% helped and 3% harmed (n=1688).
"Heel pain for the average orthopedist and podiatrist ... is a real headache sort of condition. A lot of people have it, it bothers them a lot, ... the treatments that are rendered are not particularly economically enhancing to their practices ... it's a patient that takes up a lot of time in the doctor's office, and the doctor ends up giving a presciption and exercises and sometimes injections, none of which are particularly economically beneficial to him as a practitioner, and not real great resolution of the patient's problems, ... "
What is a heel spur? A heel spur on the back of the heel may be helped by some of the treatments in this document, but the heel spurs to which this page is referring are the more common type, which are located on the inside, front, and bottom of the heel (a.k.a. a "medial subcalcaneal exostosis" or "inner tubercle of the os calcis" or "medial calcaneal tubercle"). The spur is not usually, or possibly ever, solid bone. The spur is calcium that has deposited in the fascia in a process called calcification and it is bendable like cartilage. When too much tension in the plantar fascia results in heel pain, the Merck manual calls it "heel spur syndrome," or "the beginning stages of heel spur syndrome if it cannot be seen on an X-ray." The Merck Manual says plantar fasciitis is when the pain is along the length of the plantar fascia. This has the advantage of keeping the definitions of plantar fasciitis and heel spur syndrome separate, but few doctors adhere to this naming convention. Contrary to the Merck Manual, my impression is that most doctors use either name for heel pain but stick to "plantar fasciitis" when it's not in the heel.
Does it matter? So, many doctors appear to use the phrases "heel spur" and "plantar fasciitis" interchangeably. Plantar fasciitis and heel spur syndrome are "waste basket" diseases: if there is pain in the heel or bottom area of the foot and the doctor has ruled out other causes, then it may be called "plantar fasciitis" or "heel spurs." This is not a completely unfortunate situation because many of the treatments for plantar fasciitis will help many different causes of heel and arch pain.
More about heel spurs: Heel spurs probably result from tension in the plantar fascia as a result of the fascia supporting the arch or, according to some sources which I think are in error, from tension due to the abductor hallucis (a muscle attached to the big toe), and/or flexor digitorium brevis (a short muscle that helps flex the lesser toes). The fascia encapsulates these muscles and acts as their tendon attachment to the heel, but these muscles exert only a few pounds of tension compared with the 200 or more pounds of tension in the fascia created by body weight. The primary cause of many cases of plantar fasciitis and heel spurs appears to be excessive tension in the medial (inside) portion of the plantar fascia that connects the heel to the big toe, which would make it appear it's tension in the muscle of the big toe causing the spur, when it's really just body weight (with or without pronation which would further increase tension in the medial portion).
Abnormal functioning of the foot or an abnormal gait could cause excessive tension in a specific area of the heel that results in the spur. For example, pronation may cause more tension in a section of the fascia and a spur could result at that section's point of insertion into the heel.
Studies indicate that 8% to 21% of the population has heel spurs. 30% to 70% (studies seem grouped around 60%) of those with heel pain have a heel spur. The Merck Manual says a true heel spur "tends to be painful during its early development, when little or no x-ray evidence is present. As the spur enlarges, pain often diminishes ...."
Common symptoms: In agreement with most journal articles, the most frequent symptom reported in our surveys is an increase in heel pain with the first few steps in the morning (85% of our visitors). There are other conditions that can cause this, but plantar fasciitis (heel spurs) is the most common. 82% of our visitors indicated that the pain is 24 hours/day or when walking or standing. Over 70% indicated that it hurts when pressed with a finger. 58% indicated the pain increases after walking less than 100 yards. The pain is usually in the heel area, but visitors frequently report that it "moves around" for no apparent reason. It may also be over the entire bottom area of the foot.
Simple tests: If applying tape as shown in this document immediately reduces pain, it is good evidence that tension in the fascia is the cause of the pain. If placing a firm heel pad or 1" of carefully folded paper under the heel (or stretching the calf muscles) immediately relieves the pain, then it's an indication that lack of flexibility in the calf muscles is the underlying cause of excessive tension in the plantar fascia. If only a soft heel pad helps then it may still be plantar fasciitis, but it could also be a stress fracture or not enough tissue cushioning under the heels (heel pad atrophy). The following actions may also reduce pain and thereby provide evidence that tension in the plantar fascia is the cause of the pain: 1) pressing the toes down while walking (which transfers tension from the fascia to tendons and muscles in the calf), 2) pointing the foot inward toward the other foot while walking, and 3) walking on the outside edges of the feet. If 2 minutes of compression with the palm of your hand or anti-inflammatory medication helps then it is a sign that inflammation is a cause of the pain.
Advanced Tests: Bone scans ($$) often show increased blood flow where the fascia attaches to the heel (one source says 60% of those with heel pain), especially if the pain is severe. A journal article theorized that repetitive pulling on the tubercle (spur) from the fascia causes a small stress fracture (Graham). A positive bone scan can indicate a stress fracture, infection, or a surgery wound. If a bone scan is negative, a stress fracture is unlikely, indicating another cause such as nerve involvement or plantar fasciitis. If a bone scan indicates a "hot spot" and there is no sign of infection and there was a specific incidence of injury or an increase in activity on a hard surface (e.g., running on pavement without shoes), then a stress fracture is likely and rest and a cast are indicated. One source says pain only in the morning is not usually caused by a stress fracture or nerve entrapment. Another source says squeezing the sides of the heel (anteriorly, medial to lateral) very strongly to put pressure on the heel bone (to slightly deform it) should not hurt and if it does, it is a symptom of stress fracture or osteomyelitis (infection). A nerve study (which is painful if the method of inserting needles into muscle tissue is used) by a neurologist can help rule out nerve problems. Blood tests can look for the possibility of arthritis but cannot prove that arthritis is not present. MRI ($$) may be used to help confirm plantar fasciitis, but another source says MRI is not very useful for this. Another questionable source says MRI is the standard for finding bone fracture or infection. Ultrasound can be used as a diagnostic tool to detect an increase in the thickness of the fascia. In one study ultrasound indicated the fascia was twice as thick in heel pain patients (5.2 mm) as controls (2.6 mm). An MRI report had similar results (6.7 mm verses 3.3 mm). MRI can detect rupture.
David S. Wander, DPM, FACFAS writes:
I use MRI when a patient is not responding to conservative care to rule out a stress fracture of the calcaneus and/or a partial tear of the plantar fascia. A radiologist specializing in musculoskeletal MRI may be very beneificial in determining whether a partial (or complete) tear of the plantar fascia or a stress/occult fracture of the calcaneus exists. Critics feel that MRI's are not necessary, since a patient that is not responding to conservative care can simply be placed in a cast, and the treatment for a partial tear or stress fracture would be the same anyway. However, if I am considering sending a patient for an aggressive physical therapy treatment, or if the patient is considering EPF or another fascia release surgery, I want to be sure that there is no pre-existing tear of the fascia or stress/occult fracture present.
Patient History / Characterisitics: If a patient has heel or plantar pain and is also female, overweight, above the age of 30, and just started step aerobics after years at a desk job, you can be pretty sure she has plantar fasciitis. 87% of our visitors are above the age of 30. 74% are overweight. 72% are female. 43% have a job that requires more than 6 hours a day of standing or walking. If heel pain began concurrently with a change or increase in activity, or an increase in weight, then it can be considered more evidence of plantar fasciitis (heel spurs). A study reports heel pain patients have, on average, thinner heel pads. Several studies point out that heel pain is more common in those who have heel spurs. If the patient is "overpronating" (inside ankle bone rolls downward too much when walking), the doctor can identify it while watching the patient stand without shoes or during walking. I've read overpronation causes thicker skin under the middle of the ball of the foot and a lack of normal thickness under the ball of the foot at base of big toe. Over-pronation is usually caused by flat feet. 21% of our 299 visitors who indicated they "over-pronate" also indicated pain along the medial (inside) arch. Only 13% of the 2356 non-over-pronators indicated pain along the medial arch.
The 1st picture below is raw data and the second picture is a graphical interpretation of where visitors indicated pain. Visitors were allowed to choose up to 3 of the oval areas.
Heel pain is probably the 2nd most common foot complaint (toenail problems are No.1). One source says 2 million cases are reported in the U.S. each year. Another souce estimates 6.5 million. Doctors report that 2% to 10% of their patients have it for more than a year. This estimate may be low: visitors to this web site report discontinuing doctor visits because there was nothing else the doctor could do or because the patient refused injections or surgery. Out of the 1st 2,655 responses to the survey, 46% had had heel pain for over a year. The pain can range from mild to debilitating. In some cases, patients report having to quit work and crawl to get around the house. If there is little success after 9 to 12 months of proper conservative treatment, patients are often advised to have surgery. A podiatrist emailed to say that the presence of a bone spur increases the chances that surgey is required. Surgery fails 2% to 35% of the time, depending on which journal article is quoted. Some doctors may have a failure rate greater than 50%. A failed surgery can ruin the patient's ability to walk for at least a year. Some surgeries reported as "successful" by the doctor may decrease a patient's ability to walk for up to a year. Those who delay seeing a doctor, have heel spurs in both feet, or are overweight are more likely to have the condition for a long time. It is important for the patient to be active in their treatment.
36% of our visitors indicated that they did not know what caused their plantar fasciitis or heel spurs. Visitors indicated the following causes: 15% walking, 12% running, 10% changing activity, 5% sudden injury, and 4% changing shoe. Only 7% indicated being overweight had caused it eventhough 74% are overweight for their height from either fat or muscle (BMI>=25) and 16% fall into the "severely obese" (BMI>=35) category.
Probably the number one cause of plantar fasciitis is lack of flexibility in the calf muscles. A journal article reports that people with inflexible calf muscles are 23 times more likely to get it. Since most people do not know if their calf muscles are inflexible compared to the rest of the population, this helps explain why the cause is a mystery to most people.
A long-term inactive lifestyle makes it more likely that a sudden increase or change in activity will result in plantar fasciitis, because the fascia or its attachment to the heel is unconditioned for the extra stress. Years at a desk job can lead to a lack of flexibility in the calf muscles (a.k.a. "ankle equinus"), which places more strain on the fascia because the front of the foot is forced into the ground which strains the fascia. People who spend too much time on their feet, such as nurses, mail carriers, and teachers, may get it. Standing or walking for many hours without well-cushioned shoes on hard surfaces such as concrete or tile floors can also cause it. Changing from a house with carpet to one with hardwood floors may cause it. Canadian insurance investigators seeking support for a health claim have called me about 10 times asking if I could provide a reference that says these kind of jobs can cause it. Finally, a journal article reported that worker's who spend the majority of time on their feet are 3.6 times more likely to get it. See "Risk Factors for Plantar Fasciitis: A Matched Case-Control Study" J Bone Joint Surg Am. 2003 Jul;85-A(7):1338.
Results: Individuals with 0° of dorsiflexion had an odds ratio of 23.3 (95% confidence interval, 4.3 to 124.4) when compared with the referent group of individuals who had >10° of ankle dorsiflexion. Individuals who had a body-mass index of >30 kg/m 2 had an odds ratio of 5.6 (95% confidence interval, 1.9 to 16.6) when compared with the referent group of individuals who had a body-mass index of 25 kg/m 2 . Individuals who reported that they spent the majority of their workday on their feet had an odds ratio of 3.6 (95% confidence interval, 1.3 to 10.1) when compared with the referent group of those who did not.
Being mildly or severely overweight, or experiencing a rapid increase in weight, can cause or exacerbate plantar fasciitis.
Engaging in certain sports (especially on a hard surface) can make plantar fasciitis more likely to develop. Aerobics (particularly step aerobics), stair climbing, volleyball, and excessive running are some examples. Hiking, basketball, or lunging forward in a singles' game of tennis (about 10 have emailed me) can also lead to plantar fasciitis. Pushing a car is an ideal way to injure the fascia because of the sudden increase in unusual activity, the steep angle of the foot bending back, and the strength that is necessary. Squatting, especially while lifting something heavy, can be similarly dangerous (all the weight is on the front of the feet which pulls the fascia away from the heels). Three visitors have emailed me who appear to have acquired heel pain by operating a delivery vehicle where they have to make a high step many times a day to get in the vehicle. This is an ideal way to get it because all the weight is on the ball of the foot for that one long hard step. Everyone who has plantar fasciitis and is required to climb stairs of some sort should step on their heels rather than the balls of their feet. Pushing a lawnmower in the spring after an inactive winter is another way. These activities put a large amount of tension on the fascia when the ball of the foot (instead of the heel) pushes on the ground. A sudden tearing of the fascia away from the heel bone can occur, usually as a result of a sudden run or lunge forward. Several visitors to this web site have emailed to say they heard or felt a popping when this happened. Three or four have emailed to say it happened while playing tennis. Here is an example email about tennis: "Hi scott, yesterday while playing tennis I heard a snap located within my right arch." Here's an example from soccer: "During a soccer game I went to jump up to head a ball. As I was jumping, as I was lifting off on my left foot, I heard a really loud snap/pop noise -- everyone around me heard it. Then I felt alot of pain and numbness at the bottom of my left foot. It is now 5 days later and it is still VERY sore and discoloured (dark purple) at the bottom of the foot, and I cannot walk on it (on crutches)". It is a painful experience, but the ultimate result is similar to having surgery that detaches the fascia. This sudden separation of the fascia from the heel bone can be the beginning of recovery if the person has a history of heel pain -- or it can be the beginning of serious problems. I recommend icing immediately and 3 times a day for week, the Pinnacle arch support, rest, and tape. All of these are very important. No heat. The arch can fall resulting in a flat foot and, as in PF release surgery, the cuboid bone on the top outside edge of the arch may start hurting from the lowered position of the arch.
Shoes can play a major role in the development of plantar fasciitis (heel spurs). Bad shoes are those who do not have arch support or cushion, or the toe portion does not bend back easily. Buying a new pair of boots that do not bend back easily at the base of the toes is a great way to get plantar fasciitis. The heels on boots help counteract the harm done by the soles being stiff (more on this later), but often not enough. Simply changing the kind of shoes worn may cause plantar fasciitis. For instance, switching from a shoe with a heel to a flatter shoe can cause it because calf muscles get accustomed to the extra heel height and lose their flexibility.
It has often been written that people with flat feet or high arches are more likely than others to get plantar fasciitis (heel spurs). 30% of our visitors claim they have high arches and 19% claim they have flat feet. But I do not know if this is significantly different from the rest of the population. Flat feet often pronate, which places more strain on the inside ("medial") portion of the fascia. Some pronation is normal; the foot is said to over-pronate when the inside ankle bone "rolls" down and inward as the foot passes under the torso during normal walking or running. Arch support and/or a medial wedge (called a "post" when placed beneath an orthotic) under the forefoot and rear of the foot will prevent over-pronation. Underpronation ("supination") is common in those with a high arch and also can be a contributing factor. Other biomechanical abnormalities, such as one leg being 1/2" longer than the other, may also cause plantar fasciitis (heel spurs). Rigid orthotics can also easily make heel pain worse if they are not designed perfectly or if a break-in period for your feet is not allowed (i.e. 30 minutes a day for the first week, 45 minutes a day the second week, etc.). The high arch can place tension on the fascia, causing it to pull away from the heel.
Injury or irritation of the fascia often causes inflammation that may not be obvious. Inflammation in the heel places more pressure on tissue and nerves in the area, causing more pain. One source suggests a "vicious cycle" in which injury leads to scar tissue, which leads to more injury, and so on. Destruction of blood vessels in the area may slow future healing. Another source claims that fascia scar tissue can adhere to other tissue in the area, inflicting more pain (and damage) when the fascia is under stress. The greatest amount of stress in the fascia occurs immediately before and during when the heel raises off the ground. Scar tissue is not as flexible and strong as the original tissue; applying ice immediately after injury helps to minimize the amount of scar tissue. The fascia also can become thicker (from a normal of 3 mm up to 15 mm) with more injury, putting more pressure on the nerves.
Weak foot muscles that control the toes and ball of the foot may contribute to plantar fasciitis, because these muscles promote better functioning of the foot. Limited dorsiflexion of the great toe may also be a cause: it increases the effective length of the foot in the same manner as a shoe that is inflexible under the ball. An "artificially elongated" foot such as this requires the foot to bend back farther for a given stride. In the absence of great flexibility in the calf muscles, an "elongated" foot will create more tension in the fascia.
A lower center of gravity as can be caused by pregnancy, equipment belts, large thighs and hips (this may explain why overweight women are 6 times more likely than overweight men to get it) can contribute to it because more flexibility in the calf muscles is required when the center of gravity is lower. The reasons for this are discussed later. The only place that a lower center of gravity is mentioned as a cause is here at heelspurs.com. I met an engineer who had heel pain and who had a "squat" look. It looked like his hands came further down below the waist than normal. I mentioned this and my low center of gravity theory to him. He said a lower-back vertebra was removed years ago. I theorized that his calf muscle flexibilty would have become very good over the years as a result of the lowered center of gravity. He allowed me to check his calf muscle flexibility and it appeared to be the greatest amount of flexibility I've seen (out of about 50 people). The observation that weight plays more of a role in women than in men is also only mentioned here at heelspurs.com (to my knowledge).
Sciatic nerve problems (sciatica) usually cause pain in the buttocks and back of the upper thighs, but the pain may also appear very low in the back where the pinching of the nerve begins and in the heel area where the nerve ends.
We did some research after a visitor emailed to say the antibiotic ofloxacin (a fluoroquinolone or quinolone) had caused her plantar fasciitis. These compounds are known to cause serious problems in tendons (especially the Achilles tendon) and therefore could easily be a cause of plantar fasciitis. Plantar fasciitis and Achilles tendonitis are often caused by tight calf muscles and activities that increase tension in the calf muscles. The plantar fascia itself at the heel could be considered a tendon. Fasciae envelope and invest muscle and are given the new name "tendon" as they come together at the ends of muscle and connect to bone. Patients are 4 times more like to get tendon rupture when taking a quinolone antibiotic. They are 28 times more likely for it to happen if they are > 60 years old and taking specifically ofloxacin. Anyone taking a quinolone and beginning an aggressive stretching program for plantar fasciitis should be very concerned about getting achilles tendonitis or rupture if not making their plantar fasciitis much worse. Stretching the calf muscles is very unusual behavior for the general population. Maybe only 1 in 20 people do it at the level that is generally recommended for plantar fasciitis. Night splints make the situation even worse. All this applies even more to those who are active in a job or sport that uses the calf muscles (especially men > 30) in sudden bursts of running, jumping, or doing squats. Ciprofloxacin and norfloxacin are similar compounds which are also implicated. If these pills weaken the plantar fascia tissue, they may not only cause the condition or make it worse, but they may also decrease the pain by letting the tissue tear and thereby release tension as in plantar fascia release surgery. Dr Z in our message board reported that he had two PF patients get better after taking one of these pills. Email me at firstname.lastname@example.org if you have taken one of these pills and have also had heel pain before or after take it and if you think it made any difference to your heel pain.
Plantar fasciitis (heel spurs) is the most common cause of heel pain. Most of the treatments described in this document are not dangerous to implement and will help many cases of heel pain, regardless of the cause. From another web site: "The sciatic nerve ends in the heel and if the nerve is pinched in the lower back or sacroiliac area, often the pain (called referred pain) is felt in the heel." Tight hamstrings may contribute to sciatic nerve problems. Most of the treatments for plantar fasciitis will not help sciatica. If arthritic back pain is present and pain is present in both feet, the problem could be a form of arthritis (see the nutritional supplement section). Many of the treatments for arthritis in the heel are the same as for plantar fasciitis. Heel pain can also be attributed to tendonitis (rest, ice, anti-inflammatories, and 200 mg a day vit B6); damage to the long plantar ligament (pain should be deeper and not sensitive to touch -- should be treated identically to PF, but the PF release surgery may make it worse), and stress fracture (bone damage -- more common in flat feet -- needs rest, cast, and soft heel pad). Tarsal tunnel syndrome (the foot's version of carpal tunnel syndrome): The tarsal tunnel is formed by ligament and bone through which tendons and nerves pass. It is located at the 7-o'clock position relative to the inside ankle bone (beneath and slightly behind the inside ankle bone) - halfway between the inside ankle bone and the bottom of the back of the heel. Pain results in this area and/or in the bottom and/or heel area of the foot when there's inflammation in the tendons. The inflammation places pressure on the nerves that are trapped in the tunnel. The heel and bottom of the foot can be affected because the trapped nerves provide sensation to these areas. The pain may be a dull type in the tunnel area or a numbing and/or tingling sensation in the bottom or heel of the foot. Tapping the tarsal tunnel may produce tingling on the bottom of the foot - this is called Tinel's sign. But tapping too hard will produce a tingling in anybody. Diagnosis is often not easy. 200 mg/day of B6 will reduce synovial fluid build up in the tunnel. It is often caused by ignoring the pain and walking too much. I've met several people with this condition, and they all seemed to have a kind of hyper personality that caused them to walk too much, too quickly and in an obsessive way while ignoring the pain. According to some, surgery usually fails to help. Hyperpronation may cause it.
Other causes of heel pain are the loss of resilient tissue in the heel pad (more common in the elderly -- needs soft heel pad), and heel bursitis. Heel bursitis is sometimes a result of plantar fasciitis but more often it's caused by thin heel pad. Treatment is the same with an emphasis on pills for inflammation and using a soft heel cushion, and manganese and vitamin B6 may be helpful. Bursitis surgery may help, but beware of injections. A rupture of the plantar fascia can occur (it breaks completely away from the heel) Immobilization in a non-weight-bearing cast for 4 to 6 weeks may be needed, or an intelligent and aggressive use of tape. Thrombophlebitis of the subcalcaneal plexus sometimes causes heel pain as does Reiter's Syndrome, ankylosing spondylitis, psoriatic arthropathy, Sever's disease (quick growth of the heel bone combined with activity causing pain in ages 9 to 14 although another source says ages 6 to 10) -- some treatments are the same as those for PF), sacral radiculopathy, nerve entrapment of the first lateral branch of the posterior tibialis nerves or lateral plantar nerve, necrotizing fasciitis, and even AIDS. Tibialis posterior tendonitis can also cause heel pain. Someone emailed to say "plantar fasciitis is also commonly found with fibromyalgia patients and polymyalgia rheumatica." Peroneal tendon dysfunction and Lupus are also possible causes.
A study reported that 50% of its sample of 411 plantar fasciitis (heel spurs) patients were on their feet most of the day. If the amount of time on the feet cannot be decreased, lower weight, more cushion in the shoes (especially for hard floors), shoes or inserts with arch support, and/or taping may help the most. The best treatment is to spend less time on the feet. Heel pads and stretching may not be necessary. People conditioned to long periods of time on their feet during their teens and 20's may be less likely to get plantar fasciitis than those who start careers in their 30's and 40's that require a lot of time on their feet. It may be that the ability able to endure lengthy periods of time on the feet requires years of conditioning ligaments, fascia, and tendons. Thick rubber floor mats have long been a foot-saver to those who have to stand for long periods on hard surfaces.
Being overweight (from either fat or muscle - your feet don't know the difference) is a contributing factor and major cause of plantar fasciitis (heel spurs), especially in U.S. women. One journal article reports those who are obese (BMI>30) are 5.6 times more likely to get it than those who are not overweight (BMI<25). According to our surveys of 5,900 people, overweight women are 6 times more likely than overweight men to get heel pain. Underweight and healthy-weight women are 2.4 times as likely as Underweight and healthy-weight men to have heel pain. If extra weight deposits at a lower position on a woman's body than it does on a man, then it would lower the center of gravity and require more flexibility in the calf muscles as discussed below. The CDC reported in the Oct 4, 2000 issue of JAMA that in 1999, U.S. men and women self-reported that they weigh an average of 187 and 151 pounds respectively. Men and women visiting this web site report they weigh an average of 198 and 181 pounds respectively (n=2486). The averages for U.S. women and men is already above what is considered healthy by the World Health Organization and other medical authorities. To discover that women with heel pain average 20% more in weight than the already heavy average American woman is impressive. Almost half of the women who visit heelspurs.com are medically classified as "obese" which is about 22% above what is considered healthy (BMI>30). Due to the incidence of heart disease, stroke, diabetes, and cancer in those who weigh this much, the average woman with heel pain will die at a considerably younger age than others.
The primary method of determining "what is overweight" is the the "Body-Mass Index" or "BMI". The BMI is weight in kilograms divided by height in meters squared, with no shoes or clothes on. Usually, BMI between 20 and 25 is considered healthy for men and women, but some sources use between approximately 21 and 26 for men and between 19 and 25 for women. Another important caveat to the BMI is that it is shifted higher for those who have lots of muscle mass because muscle is more dense than fat. The National Institutes of Health and the World Health Organization (WHO) define overweight as a BMI of 25 or greater and obesity as a BMI of 30 or greater. Epidemiological studies show that about 55% of the U.S. adult population is overweight and 22% is obese (JAMA article using 1988-1994 NHANES III data 12 which contradicts a 1994 JAMA article which said it was 33% 1994:272:205-211). An October 4, 2000 an article in JAMA by the CDC 20 using 1999 telephone survey results of U.S. citizens, which may be the closest study for comparison to our survey, indicated about 19% of men and 19% of women are obese. 40% of the visitors to this web site are obese based on their self-reported height and weight (n=2486).
The numbers beside each curve in the chart below indicate the BMI.
Plantar fasciitis (heel spurs) can begin with pregnancy because of the increase in weight and carrying the baby after pregnancy.
One source claims roughly 40% of the incidence of obesity is caused by genetics and the remaining 60% is believed to be due to the environment14 but another source claims obesity would be very rare if only 10% of our calories were from fat27 as was common in paleolithic times and in modern countries where cancer is, by comparison, non-existent. But the past 2 decades have seen a dramatic increase in the pecentage of obese people in the U.S. 12 despite the decrease in fat consumption from 1980 to 1990. 16 Replacing fat with sugar in the diet may be the cause. Sugar raises blood glucose quickly which insulin turns to fat and the sugar victim is hungry again a short time later, whereas fat satisfies hunger for a longer period of time. Our paleolithic ancestors consumed less sugar and fructose in an entire day as is found in half a 16 ounce soda. They were also extremely active because it was before the advent of agriculture. Diet and activity changes are believed to be the cause of the continuing increase in American obesity. Obesity is the 2nd leading cause of preventable deaths in the U.S.12.
More statistics about weight and heel pain. A study reports 27% of its 411 plantar fasciitis patients weighed more than 200 pounds compared to 5% of the controls and that 77% were "overweight" 19. Our surveys gave similar results with 35% over 200 pounds and 74% overweight. Another study reports 23% of "overweight" women had plantar fasciitis (heel spurs) compared to 8% of the controls18. The median weight for U.S. adults aged 20 years and older is 160 pounds (BMI=25.5): 176 pounds 5'9" for men and 145 pounds 5'4" for women (NHANES III data 12), although U.S. body weight has been on the rise since this 1988-1994 data. The median weight for our visitors responding during the year 2000 is 182 pounds (BMI=28.5): 195 for men (BMI=27.3) and 177 for women (BMI=29.4) (71% of the responses were from women). The median height for our men is 2 inches above that reported by NHANES III men and our women are 1 inch above the NHANES women. The average weight of our visitors is 186 pounds (BMI=29.5): 199 pounds for men (BMI=28, n=721) and 181 pounds for women (BMI=30.1, n=1798). Shorter, simpler surveys confirmed the data.
Approximately 10% of running injuries involve heel pain. 7% of our female visitors and 25% of our male visitors said it was caused by running. Long strides and hills increase damage to the fascia because of the increase in the angle that the foot has to bend back. Stretching the calf muscles before and after running will help. Ice after running is just as important. Sports that require running on grassy fields have been said to not result in heel spurs, so running on a hard surface could be a major cause. Another source says sand and soft terrain can cause it. Stiff shoes can cause plantar fasciitis and Achilles tendonitis in runners. It is usually necessary to decrease the amount of running until the pain is gone. Swimming is a good alternative activity. "Deep water running" is used by injured runners; they wear a flotation device and exaggerate the swinging of their arms while "running" without letting their feet touch. Bicycling is good but will cause too much tension in the fascia when the ball of the foot pushes too hard on the pedals. I pedal with my heels instead of balls of my feet and I have used tape to protect the fascia. When pushing on the ball of the foot, tension is transferred in the fascia from the ball all the way to where it attaches to the heel and also through the heel bone to the Achilles tendon. If all the weight is on the heel, there is no tension in the fascia. But if pushing on the heel causes pain, I wouldn't do it. Running shoes have raised heels to help prevent plantar fasciitis (heel spurs) and Achilles tendonitis. Taping is sometimes used by runners to relieve pain, but it is difficult to apply tape correctly (especially when the forces are so great as in running) and it may cause Achilles tendonitis or severe skin irritation. Shoes should bend under the ball of the foot, not in the middle. Firm heel pads help prevent and relieve Achilles tendonitis and plantar fasciitis if there is a lack of flexibility in the calf muscles. A straight last is supposed to be used for flat feet and a curved last for high arches. The windlass mechanism is the tightening of the fascia when the toes bend back. When the fascia tightens it pulls the forefoot back towards the heel causing the effective length of the foot to shorten and the arch to increase. It makes the foot more rigid and stable and enables the first ray to become the point from which to push off.
It is beneficial during doctor visits for the patient to provide a brief, itemized, typed list of their history, symptoms, the success of the various treatments they've tried, and any questions. It should be less than a page long to ensure that the doctor will read it. It allows the patient and the doctor to concentrate on important points. It can also make sure the patient does not forget anything. To see the list I gave the last doctor I saw view History of Scott's Foot Pain. An excellent and uncommon doctor will routinely hand out documents telling patients more about their specific health condition. When changing doctors, it's important to get complete copies of all blood work reports, X-ray, bone scan report, MRI, nerve studies, etc from the previous doctor. In our surveys, podiatrists (59% "effectiveness" ranking) and physical therapists (53%) rank much better than orthopedic surgeons (38%) at helping patients with plantar fasciitis and heel pain, but neither ranked nearly as well as heelspurs.com (88%). Patients who had seen bother podiatrists and orthopedic surgeons ranked them about the same. Our visitors have seen medical professionals in the following percentages: podiatrist 38%, physical therapist 17%, orthopedic surgeon 14%, chiropractor 9%, acupuncture 4%, other 28%.
Patients who rely solely on the brief remarks spoken by their doctors are at a great disadvantage compared to those who become more knowledgeable about their specific health condition. Ideally, doctors would hand out informative brochures as soon as a firm diagnosis has been made. However, doctors who do so may lose business because the most successful treatments for many conditions do not require future doctor visits. Well-informed patients can be a doctor's worst nightmare as evidenced by the saying "Doctors make the worst patients." Doctors may not be aware of the most successful and basic conservative treatments available for plantar fasciitis: stretching, arch support, rest, ice, massage, and heel pads. Doctors may recommend specific, inexpensive over-the-counter inserts that have a good arch support. Others immediately prescribe $300-$500 orthotics made in their office that health insurance often doesn't cover. Patients are often left with the choice of purchasing the orthotics or seeing a new doctor. Below is an email that is typical of the ones I get concerning doctor visits.
Hello- I have been recently diagnosed with plantar fasciitis- after suffering with incredible pain for several months I finally went to a podiatrist, he told me the ONLY thing that would help me is to purchase $300 inserts for my shoes that he custom makes. My insurance does not cover these, and I don't have the money now, I asked if there were stretches that would help or putting ice or massage, he said no the only thing that would help me is the inserts.
Humans are the only mammals that locomote primarily by walking on two legs. This could help explain why foot, knee, hip, and back pains are common. Mammal legs, paws, hooves, etc. were originally designed to support 1/4 of the mammal's body weight rather than 1/2. But if our environment, lifestyle, and weight were similar to our hunter-gatherer ancestors, our feet would probably be strong and durable enough to prevent the need for orthotics and other inserts.
Shoes that do not bend under the ball of the foot as easily as toes are effectively increasing the length of the foot. As explained above, this increases tension in the plantar fascia (and Achilles Tendon as mentioned below).
If women gain weight in their thighs and hips and men gain weight in their chest and belly, then a woman's lowered center of gravity could help explain why heavy women are 6 times more likely than heavy men to get heel pain. The combination of women's shoes and being overweight could have a combined negative effect that exceeds some threshold above which there is a cascade of additional injury to the plantar fascia (which would make my center-of-gravity explanation unnecessary).
Heel lifts help the foot tip over, so that they reduce tension in the fascia in those that have limited flexibility in the calf muscles. But I view them as a temporary emergency aide. A dependency on them can result if the calf muscles lose their flexibility from not being stretched as they normally would with each step. Switching from high heels to barefeet at the end of the day can similarly be very harmful.
The Achilles tendon and plantar fascia are two links in a chain that extends from the ball of the foot to the back of the knee. Extra tension in the plantar fascia due to walking or running (but not just for standing) means there is also extra tension in the Achilles tendon.
OSHA requires steel-toe shoes in many work environments that do not bend in the very front very well. Having to wear stiff steel-toe shoes can be cruel to someone with heel pain, but sufferers cannot say anything to their employer if they wish to continue working in areas that require the steel-toe shoes. It is ironic that in order to protect toes, OSHA may be decreasing the ability of some sufferers to walk.
|Introduction||Symptoms||Spurs or Fasciitis?||The Prognosis|
|Causes of Fasciitis||Causes Heel Pain||Body Weight||Time on Feet|
|Running||Doctor Visits||List of Treatments||Arch Support|
|Stretching||Muscle Strength||Decrease Activity||Ice & Heat|
|Massage||Taping||Inflammation||Vitamins & Arthritis|
|ESWT, Lithotripsy||Other & Psychological||Tension in Fascia||Diabetes, Heart, Cancer|