Natural Standard Monograph, Copyright © 2013 (www.naturalstandard.com). Commercial distribution prohibited. This monograph is intended for informational purposes only, and should not be interpreted as specific medical advice. You should consult with a qualified healthcare provider before making decisions about therapies and/or health conditions.
Calcaneal periostitis, calcaneodynia, contracture of plantar fascia, heel pain, heel spur syndrome, heel spurs, jogger's heel, painful heel syndrome, plantar fascial fibromatosis, plantar fasciosis, policeman's heel, runner's heel, subcalcaneal pain, tennis heel.
Plantar fasciitis is a common condition involving the degeneration, inflammation, and irritation of the plantar fascia in one or both feet. The plantar fascia is a thick tissue band in the bottom of the foot that connects the heel bone to the toe and forms the arch. The inflammation and degeneration may cause acute, stabbing pains in the heel. This pain is typically most noticeable with the first steps of the morning and may subside throughout the day. Pain may also occur after standing or being inactive for a long period of time.
In adults, plantar fasciitis is the most common cause of heel pain. It is estimated that this condition occurs in more than two million Americans every year. It often occurs in the middle-aged population, most commonly affecting runners, people who are overweight or pregnant, those with occupations that require long periods of standing or sitting, or those wearing inadequately supportive shoes. Having a tight Achilles tendon, which connects the calf to the heel, and other abnormalities of the lower legs and feet may also increase the risk for plantar fasciitis.
Plantar fasciitis was once thought to be caused by heel spurs, which are small calcifications in the foot. Research has found that this theory lacks evidence; however, up to one-half of patients diagnosed with plantar fasciitis may have heel spurs.
Age: Plantar fasciitis most commonly occurs in adults between the ages of 40 and 60. In the elderly, poor muscle strength, breakdown of the heel fat pad, and delayed healing, in combination with excessive flexing of the foot arches, may lead to plantar fasciitis.
Athletic activity: Plantar fasciitis is among the most common foot and ankle injuries experienced by professional athletes. Running on a regular basis and certain forms of dance (ballet and dance aerobics) may cause this condition to occur earlier in age. Increasing weight-bearing activity, duration of runs, and stress-inducing workouts may bring about plantar fasciitis. Training on hard or uneven surfaces or with inadequately supportive footwear may increase the risk of developing plantar fasciitis in athletes.
Body weight: In nonathletes, being overweight, obese, or pregnant is a risk factor for plantar fasciitis. Patients with a body mass index (BMI) greater than 30kg/m2 (kilograms per square meter)are reported to be at the greatest risk.
Diabetes: In patients with diabetes, plantar fasciitis may occur due to muscle atrophy, anatomical changes in the foot, and changes in gait.
Foot abnormalities: Flat-footedness, having too high of a foot arch, heel spurs, or a tight Achilles tendon (which connects the calf to the heel) may increase the risk for plantar fasciitis. Patients who have high or flat arches and a limited range of motion during dorsiflexion (flexing the foot upwards) may have the highest risk of the condition.
Footwear: Wearing inappropriately sized or insufficiently supportive footwear for the heel and arch may lead to the development of plantar fasciitis.
Occupation: Occupations that involve spending a long amount of time on the feet, either walking or standing, may increase the risk of developing plantar fasciitis.
The plantar fascia is a thick tissue band in the bottom of the foot that connects the heel bone to the toe and forms the arch. Normally, the plantar fascia supports the arches of the foot and acts as a shock absorber for impact upon the heel. If excess or repetitive tension, stress, or stretching in the tissue occurs, small tears may form in the collagen fibers of the tissue, causing inflammation and irritation. This may occur from any activity that would cause overuse and repetitive pulling on the tissue.
Change in activity: An increase in weight or weight-bearing activity may precipitate plantar fasciitis, along with running greater distances or for a longer duration or on uneven surfaces. Walking barefoot, on the toes, on uneven surfaces, or up stairs may exacerbate symptoms. Shoes with poor support and fit may allow for tears to form, causing inflammation.
Diabetes: In patients with diabetes, plantar fasciitis may occur due to muscle atrophy, anatomical changes in the foot, and changes in gait.
Foot abnormalities: Plantar fasciitis was once thought to be caused by heel spurs, small calcifications in the foot. Research has found that this theory lacks evidence; however, up to one-half of patients diagnosed with plantar fasciitis may have heel spurs. Other abnormalities of the foot, including high arches, flat feet, stiffness (limited ability to flex the foot), or a tight Achilles tendon may cause plantar fasciitis. Arthritis that causes inflammation in the tendons may also contribute to plantar fasciitis.
Normal wear and tear: The foot absorbs about 1.2 times the amount of body weight during normal walking. At running speed, the foot bears two times the runner's body weight. Over the years, normal wear and tear occurs in the Achilles tendon, plantar fascia, and heel pad. In the elderly, poor muscle strength, breakdown of the heel fat pad, and delayed healing, especially in combination with a high arch, may lead to plantar fasciitis.
Signs and Symptoms
Plantar fasciitis causes a sharp stabbing pain in the lower heel of one or both feet. The pain is often worse upon the first walking steps each morning, because the fascia ligament tightens overnight during sleep and becomes stretched when pressure is placed on it upon when getting out of bed. Pain is also more severe after standing or being seated for long periods of time or during and after weight-bearing activities.
Tenderness, swelling, and redness of the bottom of the heel and arch may occur. Stiffness in the foot may form, preventing the patient from bending or flexing the foot.
The pain may subside throughout the day while the foot gains flexibility through light activity, resulting in a dull ache, which may be improved with rest. However, it may also increase with intensification of activity and worsen by the end of the day. Walking barefoot, on the toes, on uneven surfaces, or up stairs may worsen symptoms.
Patients may adjust the way they walk or run in order to avoid knee, hip, back, and other foot pain.
Physical and subjective assessment: Assessment of pain, reported changes and limitations in lifestyle or activity, and palpation of the area are used to diagnose plantar fasciitis. Pain upon first steps in the morning is a common complaint and may help differentiate plantar fasciitis from other heel pain. It is often noted that some change in activity level occurred before the onset of pain.
The Foot Function Index, Foot Health Status Questionnaire, and Foot and Ankle Ability Measure are subjective, self-reported surveys to assess functionality and pain, which may help with diagnosis and assessment of the efficacy of treatment.
Imaging: Although imaging studies are not needed to diagnosis plantar fasciitis, X-ray or magnetic resonance imaging (MRI) may be used to rule out other causes of heel pain. Plantar fascia thickening may be observed during ultrasonography. Normal fascia is 2-4 millimeters thick, but it may increase to 5-7 millimeters in plantar fasciitis.
Plantar fasciitis may limit exercise capability and normal daily activities. Patients often limp, place the body weight on the toes, or try to avoid walking on the affected foot. Patients may adjust the way they walk or run in order to avoid knee, hip, back, and other foot pain.
Plantar fasciitis may prevent the patient from bending the foot, causing the toes to point upwards toward the shins, which may be painful. Patients may also be unable to bend the foot, resulting in decreased flexibility.
Complications may also arise from treatment selection. Corticosteroid injections and surgical procedures may cause the fascia to rupture or tear and worsen symptoms, such as pain and weakness.
Plantar fasciitis may resolve on its own, usually between six and 18 months if untreated, but often longer. According to the American Physical Therapy Association, eighty percent of patients have been reported to have resolution of symptoms in a 12-month period. Nonpharmacological and pharmacological treatments may help shorten this course, typically within six weeks of treatment.
Modifying physical activity: Resting and avoiding aggravating activity may treat and prevent the recurrence of plantar fasciitis pain. Elevating the feet and resting as much as possible when the pain is severe are important. Decreasing the amount of pressure on the heel and plantar fascia, by walking or running shorter distances, or beginning a no- or lower-impact workout (such as stationary bike riding, swimming, or deep-water running) may improve heel pain.
Ice: Ice packs may be applied to the area for 15-20 minutes twice daily, or more often during or after days of increased activity. Daily ice massage, in which water is frozen in a paper cup and rubbed over the heel in a circular motion for 5-10 minutes, may help reduce the inflammation and pain associated with plantar fasciitis.
Weight loss: Obesity has been found to be a risk factor for plantar fasciitis. Weight loss may benefit overweight or obese patients with plantar fasciitis.
Orthotics: Adding orthotics (customized arch supports) and heel cups (felt pads for the heel) to the footwear may provide cushioning, improve symptoms of plantar fasciitis, and reduce stress and tension on the area. Heel cups are reportedly less effective in patients with plantar fasciitis. Orthotics may or may not contain magnets. In a randomized control trial, magnetic insoles displayed a lack of benefit vs. placebo insoles in pain relief. To maintain adequate cushioning and support, runners should change worn-out footwear every 250-500 miles or every six months.
Motion control shoes: Motion control or stability shoes are rigid, stable, and durable shoes that limit movement of the foot. They provide extra support on the arch and the rear of the foot for runners who experience overpronation (excess flexion of the plantar fasciitis). According to a 2002 study by May et al. in Current Sports Medicine Reports, more than 80% of patients with plantar fasciitis symptoms experience overpronation.
Stretching: Stretching the plantar fascia, calf muscles, and Achilles tendons may decrease pain. Rolling the foot over a tennis ball or a can may be effective at stretching the plantar fascia. Massage before walking in the morning may also improve symptoms. Stretching three times daily may help resolve plantar fasciitis, but it may cause an increase in pain for the first 3-4 weeks.
Splints and boots: Night splints, fitted to the calf and foot, worn for 1-3 months, lengthen the Achilles tendon and plantar fascia overnight to maintain flexibility of the area and allow healing in a fully extended position. In one study, 11 of 14 patients with plantar fasciitis for greater than one year who were resistant to other treatments experienced complete resolution in four months when combining night splints with nonsteroidal anti-inflammatory drugs (NSAIDs), heel cups, and stretching exercises. Poorly fitted splints, the bulkiness of the device, and patient discomfort may limit effectiveness.
A short leg cast, or cast boot, worn full-time for 3-6 weeks, may also reduce inflammation by stretching the surrounding muscles and keeping them in a neutral position. It allows the heel to rest and reduces strain on the heel during the day and night. In one study, a boot was used along with stretching exercises, resulting in 88% of patients experiencing improved symptoms vs. 72% of patients who used stretching alone.
Physical therapy: Physical therapy may be effective to strengthen and stretch the muscles of the lower leg to stabilize the plantar fascia and Achilles tendon. A physical therapist may assist in teaching the patient stretching exercises and taping techniques to reduce stress on the heel. Taping may prevent excess flexing of the foot while decreasing the amount of arch flattening during activity.
Extracorporeal shock wave therapy: For runners with chronic plantar fasciitis, sound waves directed to the area of pain may stimulate healing during extracorporeal shock wave therapy. This is reserved for patients who have not responded to other therapy, and it may cause swelling, tingling, bruising, and other pain. It has not been proven to be consistently successful, especially for nonathletes, and it requires more high-quality evaluation. Two shock wave machines have been approved by the U.S. Food and Drug Administration (FDA) for plantar fasciitis and tennis elbow treatment.
Pharmacological treatments: Pharmacological treatments, such as nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Advil® or Motrin®) and naproxen sodium (Aleve®), may be used for 2-4 weeks to reduce swelling and pain.
Corticosteroid injections may be painful, but they may also reduce pain and inflammation for longer periods of time (between one and six months). Injections, or dry needling, into painful and sensitive parts of muscle with local anaesthetics, botulinum toxin A, and saline, as well as corticosteroids, have limited evidence of effectiveness. These injections may damage the heel pad, cause the plantar fascia to weaken or even rupture or tear, or cause infection, and they may result in poor recovery afterwards.
Iontophoresis, which uses electric current to assist in the absorption of corticosteroid solution through the skin, is a less painful route and may provide 2-4 weeks of pain relief. More evidence is needed to confirm if iontophoresis as an effective treatment.
Surgery: About five percent of people may require surgery as a last-line therapy if other treatments fail. Partial fasciotomy, in which the plantar fascia is detached from the heel bone to release the tight tissue, is used if conventional therapy fails after 6-12 months of multiple treatments. There are multiple complications that may result from surgery including flattening of the arch and rupture of the fascia. In one trial, satisfaction with the results of surgery was limited, with 33% of patients reporting forefoot and midfoot pain during long-term follow up.
Unclear or conflicting scientific evidence:
Magnet therapy: There is conflicting evidence regarding the beneficial use of magnets in shoe insoles in patients with heel pain. Cushioned insoles with bipolar magnets, worn daily for 4-8 weeks, have been used. In a clinical trial examining treatment of plantar fasciitis with magnets, a lack of significant between-group differences was found for every outcome variable studied. More research is needed before a conclusion may be made.
People with implantable medical devices, such as heart pacemakers, defibrillators, insulin pumps, hepatic artery infusion pumps, or other electrical devices, should avoid exposure to magnets, as magnets may affect the functioning of some equipment. Some experts discourage the use of static magnets or electromagnetic field therapy during pregnancy or in people with myasthenia gravis or bleeding disorders, and they suggest that magnets may cause dizziness, nausea, or prolong poor wound healing or bleeding. Use of magnets may interact with various medications. A healthcare practitioner should be consulted before using magnets.
Physical therapy: Physical therapy may be effective to strengthen and stretch the muscles of the lower leg to stabilize the plantar fascia and Achilles tendon. A physical therapist may assist in teaching the patient stretching exercises and taping techniques to reduce stress on the heel. Taping may prevent excess flexing and stretching of the foot while decreasing the amount of arch flattening during activity. Additional research is needed in this area.
There is evidence that low-intensity laser irradiation, a widespread but controversial physical therapy technique, is not an effective treatment of plantar fasciitis when compared with sham laser treatment. Other therapies, such as extracorporeal shockwave treatment, have been studied, but low-quality study design limits conclusions.
Not all physical therapy programs are suited for everyone, and patients should discuss their medical history with a qualified healthcare professional before beginning any treatments. Based on the available literature, physical therapy appears generally safe when practiced by a qualified physical therapist. However, complications are possible.
Traditional or theoretical uses lacking sufficient evidence:
Acupuncture: The practice of acupuncture originated in China 5,000 years ago. Aside from needles, other methods of stimulation are also considered forms of acupuncture. These include use of heat from moxibustion (the burning of herbs placed on acupuncture targets) and the placement of herbal pastes on specific points. Adequate evidence is not available to make conclusions for or against the use of acupuncture for plantar fasciitis. Anecdotal reports suggest some effectiveness. When combined with electrical stimulation therapy weekly for 3-6 weeks, mean overall pain scores were reduced. More high-quality research is needed.
Adverse effects due to improper sterilization and disposing of needles may lead to infection or cross-transmission of HIV, hepatitis, and other infectious diseases. Mild side effects, including bleeding or bruising at needle sites, fainting, and nausea, may also occur. Complications, including bent or broken needles, typically occur due to improper technique or poor-quality needles.
Bowen therapy: Bowen therapy is a technique that involves gentle but precise soft tissue manipulation. It was originally developed in the 1960s by Thomas Bowen, based on his sense of what types of bodywork would be effective for good health, rather than on any particular scientific theory or finding. Bowen therapists use their thumbs or fingers to make subtle rolling maneuvers over soft tissues. Bowen therapy aims to trigger a response from the body, rather than to physically alter the body.
Short-term benefits are said to include a sense of relaxation. Longer-term effects may include better overall well-being or improvements in disease states. During a Bowen session, practitioners occasionally leave the treatment room, with the aim of allowing the patient's body to purportedly "absorb messages" that have been transmitted by the practitioner via bodywork. Many Bowen practitioners see this approach as being complementary to other medical treatments, such as prescription drugs or surgery, rather than as a replacement for other treatments. There is a lack of clinical evidence for Bowen therapy's use in plantar fasciitis.
Bowen therapy is generally believed to be safe in most people. However, its safety has not been thoroughly studied. Bowen therapy should not be used for severe conditions or in place of more proven treatments. Use cautiously in patients with cancer or in those who are undergoing surgery.
Bromelain: Bromelain, found in pineapple plants, may help treat inflammation and tissue injury, due to its possible anti-inflammatory properties when taken on an empty stomach. Daily doses of 500-2,000 milligrams of bromelain have been used. More evidence is needed in order to determine the effectiveness of this treatment for plantar fasciitis.
In theory, bromelain may increase the risk of bleeding. Caution is advised in people who have bleeding disorders or in those who are taking drugs that increase the risk of bleeding. Dosing adjustments may be necessary. Bromelain should be used with caution in people with stomach ulcers, active bleeding, or a history of bleeding; in those taking medications that thin the blood; or prior to some dental or surgical procedures. Bromelain may increase the heart rate at higher doses and should be used cautiously in people with heart disease. Some experts warn against bromelain use by people with liver or kidney disease, although there is limited scientific information in these areas. Bromelain may cause abnormal uterine bleeding or heavy or prolonged menstruation. Bromelain should be avoided during pregnancy or breastfeeding, as little safety information is available.
Extracorporeal shock wave therapy: For runners with chronic plantar fasciitis, sound waves directed to the area of pain may stimulate healing during extracorporeal shock wave therapy. This is reserved for patients who have not responded to other therapy, and it may cause swelling, tingling, bruising, and additional pain. It has not been proven to be consistently successful in treatment and requires more high-quality evaluation. Two shock wave machines have been approved by the U.S. Food and Drug Administration (FDA) for plantar fasciitis and tennis elbow treatment.
Fish oil: Fish oil may act as an anti-inflammatory agent, which in theory may improve symptoms of plantar fasciitis. Doses of fish oil range from one to 10 grams daily, and 2-6 months of use may be required before effects are evident. Until human studies are performed, it cannot be determined if this is a safe and effective treatment for plantar fasciitis.
The U.S. Food and Drug Administration (FDA) classifies intake of up to three grams of omega-3 fatty acids from fish daily as Generally Regarded as Safe (GRAS). Caution may be warranted, however, in diabetic patients, due to potential increases in blood sugar levels; in patients at risk of bleeding; and in those with high levels of low-density lipoprotein (LDL). It is not known if omega-3 fatty acid supplementation in women during pregnancy or breastfeeding is beneficial to infants. It has been suggested that high intake of omega-3 fatty acids, particularly DHA, during pregnancy may increase birthweight and gestational length. However, higher doses may not be advisable due to the potential risk of bleeding. Fatty acids are added to some infant formulas.
Glucosamine: Use of glucosamine may allow for reduced doses of nonsteroidal anti-inflammatory agents. Glucosamine may improve symptoms and provide nutrients to accelerate the healing process. Three doses of 500 milligrams of glucosamine sulfate daily have been used. Until higher-quality studies are performed, it cannot be determined if this is a safe and effective treatment for plantar fasciitis.
Avoid if allergic or hypersensitive to shellfish or iodine. Some reports suggest a link between glucosamine and chondroitin products and asthma. Use caution with diabetes or a history of bleeding disorders. Avoid if pregnant or breastfeeding.
Massage: Massage is often suggested as part of a treatment plan for chronic pain, anxiety, sports injuries, and repetitive strain disorders. Cross-friction massage may help reduce symptoms if completed before the first walking steps after a long period of little movement. Using a tennis ball or a can to massage and roll under the foot may also help strengthen and loosen the tightened fascia. More research is warranted in this area.
Avoid with bleeding disorders or low platelet counts, or if on blood-thinning medications (such as heparin or warfarin (Coumadin®)). Areas should not be massaged where there are fractures, weakened bones from osteoporosis or cancer, open or healing skin wounds, skin infections, recent surgery, or blood clots. Use cautiously in those with history of physical abuse or who are pregnant or breastfeeding. Massage should not cause pain to the client.
Polarity therapy: Polarity integrates the three principles and five chakras, or energy centers within the body, of Ayurvedic (traditional Indian) medicine and draws from ancient Hermetic philosophy. Polarity therapy is thought to remove energy blockages and strengthen energy fields. Touch with the hands is used with the intention of influencing flow of body energy. Polarity treatment may also involve exercise and lifestyle changes. Energy-based body work and education are used to promote energetic and cleansing principles of eating and increased self-awareness. Polarity yoga is said to balance the human energy field. Dietary changes (believed to purify or build health), counseling, yoga, craniosacral therapy, and other body work techniques may be employed by the practitioner. Research in polarity therapy is in its infancy. There are anecdotal reports of improvements in pain, anxiety, stress, and side effects from surgery, chemotherapy, or radiation therapy (including nausea, hair loss, neuropathy or nerve pain, radiation burns, or hardening or scarring of tissue in mastectomy patients), but more studies are required before making a conclusion regarding effectiveness.
According to the available literature, serious adverse effects have not been reported in association with polarity therapy.
Vitamin C: Vitamin C is necessary for connective tissue repair and may help strengthen fibrous tissue in plantar fasciitis. Doses of 1-3 grams daily have been used for tissue repair until the problem has resolved. More evidence is needed in order to determine its effectiveness specifically for the treatment for plantar fasciitis.
High doses of vitamin C have been associated with multiple adverse effects. These include kidney stones, severe diarrhea, nausea, and gastritis. Rarely, flushing, faintness, dizziness, and fatigue have been noted. Large doses may precipitate hemolysis (red blood cell destruction) in patients with glucose 6-phosphate dehydrogenase deficiency. High doses of vitamin C are to be avoided in people with conditions aggravated by acid loading, such as cirrhosis, gout, renal tubular acidosis, or paroxysmal nocturnal hemoglobinuria.
Zinc: Zinc may increase tissue strength due to its theoretical benefit in tissue repair and regeneration. A dose of 15-30 milligrams of zinc daily has been used. There is a lack of evidence for zinc's direct effect on plantar fasciitis.
Zinc is generally considered safe when taken at the recommended dosages. Avoid zinc chloride, as studies have not been done on its safety or effectiveness. While zinc appears safe during pregnancy in amounts lower than the established upper intake level, caution should be used, because studies cannot rule out the possibility of harm to the fetus.
Modification of activities: Avoiding aggravating activities is the best way to prevent recurrence of plantar fasciitis. Altering workouts to a no- or lower-impact exercise (such as stationary bike riding, swimming, or deep-water running) may also prevent recurrence. Decreasing the distance, frequency, or duration of running or activities that strain the heel may help avoid occurrence of heel pain. Long periods of standing or exercising on uneven and hard surfaces should be avoided.
Supportive footwear: Plantar fasciitis may be prevented by wearing supportive footwear and replacing worn footwear when necessary. Appropriate arch support, cushioning, and shoe fitting are important and may be achieved with shoe inserts. Runners are advised to change worn-out sneakers every 250-500 miles or every six months. Walking barefoot on hard surfaces should be avoided.
Stretching: Maintaining flexibility in the calf muscle and Achilles tendon by stretching may help prevent plantar fasciitis.
Body weight: Obesity has been found to be a risk factor for plantar fasciitis. Maintaining appropriate weight or weight loss in certain populations may help prevent this condition.
This information has been edited and peer-reviewed by contributors to the Natural Standard Research Collaboration (www.naturalstandard.com).
Natural Standard developed the above evidence-based information based on a thorough systematic review of the available scientific articles. For comprehensive information about alternative and complementary therapies on the professional level, go to www.naturalstandard.com. Selected references are listed below.
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Copyright © 2013 Natural Standard (www.naturalstandard.com)
The information in this monograph is intended for informational purposes only, and is meant to help users better understand health concerns. Information is based on review of scientific research data, historical practice patterns, and clinical experience. This information should not be interpreted as specific medical advice. Users should consult with a qualified healthcare provider for specific questions regarding therapies, diagnosis and/or health conditions, prior to making therapeutic decisions.
March 22, 2017