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Sun 2 Sep 2007 12:00 AM

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Easing the pain of plantar fasciitis

To relieve heel pain, simple therapies may be all you need.

Getting out of bed in the morning marks the beginning of a new day, but it can be an excruciating start for people with plantar fasciitis, one of the most common causes of heel pain in adults. Plantar fasciitis affects more than two million people each year in the United States, and the majority of them are women.

The main symptom is intense pain that feels like a deep bruise on the bottom of the foot, just in front of the heel. It's usually at its worst first thing in the morning and when one gets up after sitting for a long time. The pain may go away as one walks around, but it's likely to return at the end of the day if a person spends a considerable part of it on their feet.

About 50% of people with plantar fasciitis will also have a heel spur.

The cause of the pain is inflammation of the plantar fascia, a band of tendon-like tissue that extends along the bottom of the foot (the plantar surface) from the heel bone to the ball of the foot, where it fans out to attach to the toe bones. When pressure or strain damage or overstretch the plantar fascia, swelling, tearing, or bruising can occur.

Plantar fasciitis results mainly from high-impact activities, such as running and jumping, but it can also occur after prolonged periods of standing. It's more common in people who are obese or flat-footed and also in older people, because the plantar fascia loses its elasticity with age, making it more vulnerable to injury.

Diagnosing plantar fasciitis

A clinician will ask patients to describe the symptoms and say when they started and what makes them worse. She or he will examine the foot and confirm the diagnosis by eliciting pain while pressing on a specific area of the heel or when flexing the foot upward, which stretches the fascia. Sometimes magnetic resonance imaging (MRI) is ordered to rule out other possible causes of heel pain, such as a stress fracture.

About 50% of people with plantar fasciitis will also have a heel spur - a bony projection arising from the heel bone (calcaneus) that is visible on an x-ray. Some physicians believe that heel spurs develop when the plantar fascia pulls away from the heel from overuse, poor support, weight gain, or flattening of the arches. The heel spurs themselves don't cause pain, but the plantar fascia or other tissues around the spur may become inflamed and start to hurt.

Treating plantar fasciitis

Most plantar fasciitis improves with home-based treatments - usually within weeks, although it can take several months. It may be sufficient to avoid activities that put excessive strain on the heel - jumping or running, for example - for two weeks. Patients must be careful not to stop exercising entirely, because inactivity can cause the plantar fascia to stiffen and then become painful again when you start to move around. Instead of jogging or aerobics, substitute bicycling or swimming. Also, patients should perform exercises specifically recommended for treating plantar fasciitis. Although data on effectiveness are limited, many people have found one or more of the following approaches to be helpful:

Reduce pain and inflammation.Application of ice to the bottom of the foot near the heel for 20 minutes, several times a day. A nonsteroidal anti-inflammatory drug, such as aspirin, ibuprofen, or naproxen, can also help relieve pain and inflammation. These drugs can have serious side effects, however. Patients can also wear a splint at night that is designed to hold the foot upright and flexed back slightly while sleeping, stretching the plantar fascia to relieve morning pain. Findings on the effectiveness of these splints are conflicting, however.

Protect the heel.Putting orthotic devices into shoes can help decrease any impact on the heel and reduce the chance of further inflammation. Various heel cushions and cups are available in most drugstores; there's some evidence that silicone inserts are more effective than felt pads or rubber heel cups. A cutout heel pad can help reduce pressure on a heel spur. If off-the-shelf orthoses don't do the trick, patients may be able to custom-order them. Whatever cushioning device is used, it must be placed in every pair of shoes the patient wears.

Support the foot.The time to recovery and the chance of reinjury are affected by the kind of footwear used. Athletic shoes are a good choice, because most have cushioned soles and internal arch support. If patients stand or walk on hard surfaces a lot, they should wear cushion-soled or crepe-soled shoes. Leaving the foot unsupported is likely to worsen symptoms, so going barefoot or wearing slippers must be avoided. When patients get out of bed in the morning, they should step into a supportive shoe.
Stretch the foot.There is evidence that a gentle plantar fascia-stretching exercise can restore flexibility and reduce pain. In a study of 66 patients with chronic plantar fasciitis, researchers at the University of Rochester found that two years after learning the exercise, 92% of participants diagnosed with plantar fasciitis reported total or near-total satisfaction with their recovery, and 94% reported decreased pain (Journal of Bone and Joint Surgery, August 2006). A randomized trial by the same research group showed that stretching the plantar fascia reduced pain and improved function more effectively than stretching the Achilles' tendon. (People with certain connective tissue disorders, such as Ehlers-Danlos syndrome, should avoid stretching exercises.)

Other treatments

The main symptom is intense pain that feels like a deep bruise on the bottom of the foot.

If pain doesn't respond to these home-based measures, clinicians may suggest a steroid injection. Steroids reduce inflammation and pain and can speed healing in the short term, but repeated injections can cause the heel pad to atrophy and raise the risk of a ruptured plantar fascia. Another risk of injection is that it may encourage overuse of the temporarily painless foot before the plantar fascia is completely healed. Patients shouldn't suddenly boost activity levels because the heel feels better after an injection.

Some clinicians recommend extracorporeal shock wave therapy (ESWT), which supposedly triggers the body's healing response by directing high-energy sound waves at the painful part of the plantar fascia. This procedure can be painful at first, with some temporary bruising or swelling. It may cost more than $1000 and is not always covered by insurance. In any case, there is no proof that ESWT relieves pain any better than a placebo, or sham treatment.

Up to 5% of people with plantar fasciitis have persistent symptoms that require surgery. Fasciotomy involves cutting part of the fascia and disconnecting it from the heel bone to release tension in the tissue.

Sometimes, this procedure is performed endoscopically, using instruments inserted through small incisions. Heel spurs that can be felt through the skin of the heel pad may require surgery.

Some foot care specialists use a form of cryosurgery to treat plantar fasciitis. In this technique, a handheld probe is pressed against the painful area of the heel to freeze the nerves affected by the inflamed plantar fascia. Unfortunately, the relief may be temporary, and the pain may shift to elsewhere in the foot. This technique is still regarded as experimental for plantar fasciitis, and insurers are unlikely to pay for it.

Preventing heel pain

There are several things one can do to avoid getting plantar fasciitis or prevent it from returning. If patients are overweight, they should lose weight. One should also warm up before working out or participating in sports by doing the stretching exercises described above. Choose shoes that support your arch and cushion the heel. If a patient is already prone to plantar fasciitis, they might also consider exercises to stretch the Achilles' tendon and the calf muscles as well as those that stretch the plantar fascia.

This article is provided courtesy of Harvard Medical International. © 2007 President and Fellows of Harvard College.

Diagnosing plantar fasciitisThe clinician will press the toes back with one hand, to make the fascia taut, and try to elicit pain with the thumb of the other hand. Pain is usually localised to a point in front of the heel, but there also may be other tender points along the fascia.

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