Plantar fasciitis heel and foot pain

Answer provided by Jorgeana Lass, Pharmacist in AXA PPP healthcare's Health at Hand team.

Heel pain can be an intense pain and if it is felt in one or both heels, builds up gradually and gets worse over time, it is likely to be caused by plantar fasciitis. Plantar fasciitis is where the tissue that runs from the heel to the ball of the foot (the plantar fascia) becomes thickened and inflamed.

Heel pain is often severe and occurs when placing weight on the heel. It's usually worse first thing in the morning, or when you first take a step after a period of being inactive. Walking can improve the pain, but it often gets worse again after walking or standing for a long time.

What are the causes of heel pain?

Plantar fasciitis is the most common cause of heel pain, accounting for around four out of five cases.

Plantar fasciitis usually affects people who run and jog regularly, or overweight people, aged between 40 and 60, who spend a lot of time on their feet.

The plantar fascia is a piece of tissue that starts at the Achilles tendon. It attaches to the ball of the foot and runs forward through the arch to just below the base of the toes. It pulls the heel bone forwards, while the Achilles tendon pulls it back, to maintain your foot arch.

As we mobilise, our feet support the equivalent of 20 times our body weight, assisted by the plantar fascia which acts as a soft cushioning pad or shock-absorber.

Sudden damage, or damage that occurs over many months or years, can cause tiny tears inside the tissue of the plantar fascia. This can cause the it to thicken, resulting in heel pain. The surrounding tissue and heel bone can also sometimes become inflamed.

If the pain persists longer than three weeks, see your GP or another suitably qualified healthcare professional, such as a podiatrist.

This is necessary as there are many types of heel pain, each with their own different cause and form of treatment. While plantar fasciitis is the most common cause of heel pain, others might include:

• Arthritis in the ankle or heel
• Nerve irritation in or around the heel
• Atrophy – a weakness or thinning of the heel pad
• Injury of the heel pad or heel bones
• Prolonged standing or working on hard surfaces
• Flat (pronated) or high arched (supinated) feet place additional stress on the heel and plantar fascia
• Tight calf muscles and stress on the Achilles tendon can cause ankle stiffness and place further tension on the plantar fascia.

How can you prevent heel pain?

There are many simple ways to prevent plantar fasciitis. You could:

• Try to wear supportive, cushioned footwear where possible
• Minimise the time you spend standing on hard surfaces
• Use insoles or orthoses if you have flat feet, or arch supports if you have highly arched feet
• Regularly stretch your calf muscles to reduce stress on the heel
• Early treatment can prevent the problem deteriorating or recurring.

What are the treatments for heel pain?

Heel pain is a common condition and in most cases will diminish following some routine self-care measures.

Here are some simple steps you can take to reduce the heel pain caused by plantar fasciitis:

• Avoid wearing ill-fitting or uncomfortable shoes
• Wear shoes with good heel cushioning and effective arch support
• Wear a raised heel (no more than 6-10mm higher than normal)
• Avoid walking or exercising on hard ground
• Exercise and stretch. Rest regularly and try not to walk or run too fast
• Rest
• Apply ice packs
• Deep heat therapy
• Steroid injections
• Orthotic supports
• Weight loss, if necessary
• In some cases, padding and strapping can be applied to alter the direction of the stretch to alleviate symptoms in the short-term.

In rare cases, these treatments for plantar fasciitis won’t work. If this happens, you could undertake the following:

• Injections. Injecting a type of steroid medication into the tender area can provide temporary pain relief. Multiple injections aren't recommended because they can weaken your plantar fascia and possibly cause it to rupture. More recently, platelet-rich plasma has been used, under ultrasound guidance, to provide pain relief with less risk of tissue rupture. Note that this approach is classed as unproven treatment and not recommended under the NICE guidelines[1].
• Surgery. The plantar fascia is cut partially or completely to reduce the stress on the heel. The incision is usually 3-5cms in length on the inside of your heel. Surgery can also involve cutting through or removing nerves if they are damaged and are contributing to your pain.
  You may feel a sense of numbness or some tingling around the heel after the operation. This is known as paraesthesia and should not last long. After the procedure, you will need to wear specialised heel cushions or moulded insoles, both of which support healing. It can take up to six weeks or longer for the wound to heal and for the foot to bear weight bear comfortably.
• Extracorporeal Shockwave Therapy (EST). This is where soundwaves are beamed into the surface of the foot. The shockwaves cause microscopic damage to the plantar fascia, which stimulates healing, and can make the nerves less sensitive to pain. Three treatments are usually given, one or two weeks apart. There is limited information on effectiveness on this.

Evidence suggests that the most effective long term solution is correction of foot posture through the use of insole supports and appropriate foot stretching and strengthening regimes.

Answered by our Health at Hand team.

References

1. Setayesh K, Villarreal A, Gottschalk A, Tokish JM, Choate WS. Treatment of muscle injuries with platelet-rich plasma: a review of the literature. Rev Musculoskelet Med. (2018) 11:635–42.

2. Interventional procedure overview of autologous blood injection for tendinopathy - National Institute for Health and Clinical Excellence (NICE).

Further reading

Heel Pain – NHS Factsheet

Taking care of your feet - AXA PPP healthcare

Why not to wear high heels to work - AXA PPP healthcare