Plantar fasciitis

What plantar fasciitis is

The plantar fascia is a broad, fibrous sheet that begins on the underside of the heel bone and fans forward to attach near the base of the toes. It is not a muscle and does not contract. It works as a tie beam, holding the arch together so the foot can behave like a rigid lever at push off. Each time the toes bend upward during a step, the fascia is drawn tight and the arch rises, transmitting considerable tension through the small area where the fascia meets the heel bone. Plantar fasciitis is what happens when that attachment point is repeatedly overloaded.

Despite the ending of the name, which implies inflammation, the tissue changes seen in long standing cases are largely degenerative: the collagen becomes disorganized and thickened near its origin. That is why treatment is usually directed at load and tissue quality rather than inflammation alone. Contributing factors are mechanical. A tight calf or Achilles tendon limits how far the ankle can bend and forces the forefoot to compensate, increasing tension in the fascia. Sudden increases in walking or running volume, prolonged standing on hard surfaces, unsupportive footwear, high or flattened arches, and increased body weight all raise the load the tissue absorbs. Heel spurs are frequently seen on X-rays here, but are generally understood to be a consequence of traction rather than the source of pain.

Symptoms that often bring people in

• Sharp pain under the heel with the first steps out of bed, easing as you keep moving.
• A return of the pain after sitting, or toward the end of a long day on your feet.
• Tenderness at a specific point on the inner side of the underside of the heel.
• Pain that increases after exercise rather than during it.
• A pulling along the arch, and discomfort walking barefoot on hard floors.

How it is evaluated

The diagnosis is usually made clinically. The pattern of first step pain is characteristic, and examination looks for tenderness precisely where the fascia attaches to the heel, tests whether pain increases when the toes are pulled upward to put the fascia on tension, and measures how far the ankle bends with the knee straight and bent, which reveals calf tightness. Part of the assessment is excluding other causes of heel pain treated differently: a stress fracture of the heel bone, thinning of the fat pad, irritation of a nerve near the fascia, Achilles problems, and pain referred from the lower back. Imaging is not always required; X-rays help exclude bone problems, while ultrasound or MRI can show thickening of the fascia.

Treatment options in general terms

The great majority of cases are managed without surgery, with the emphasis on reducing tension in the tissue and improving the mechanics that raised it.

• Stretching programs. Calf and plantar fascia stretching are the cornerstone of care, generally guided by a physician or therapist.
• Footwear and orthoses. Supportive shoes, heel cushioning and arch supports that reduce strain at the attachment.
• Activity adjustment. Temporarily changing the volume or surface of walking and running while symptoms settle.
• Night splints. Devices worn during sleep to keep the fascia and calf from tightening overnight.
• Shockwave therapy and injections. Extracorporeal shockwave therapy may be discussed for persistent cases; corticosteroid injection and platelet rich plasma are used selectively.

Surgery is uncommon and reserved for pain that persists despite thorough non-surgical treatment.

• Calf lengthening procedures. Releasing a tight calf muscle to reduce the tension it transmits to the fascia.
• Partial plantar fascia release. Dividing part of the fascia at its origin, through a small incision or endoscopically.

What to expect when you consult Dr. Wolfson

Dr. Wolfson, MD, FRCSC, FACS, treats heel pain by first confirming that the fascia is genuinely the source, since several conditions produce pain in the same region and respond to different treatment. A consultation includes examination of the foot, ankle and calf, and an explanation of the mechanical factors loading the tissue in your case.

This page provides general information about plantar fasciitis and is not medical advice. It is not a substitute for examination, imaging and diagnosis by a qualified physician. Every case is different and requires individual evaluation. If you have severe pain, an obvious deformity, loss of function, fever, or an injury from a significant accident, seek medical care promptly.

Contact Dr. Wolfson if you would like to setup an appointment. If you are a new patient, please book all in-person appointments with Dr. Wolfson via telephone.

If you live outside of the San Francisco Bay Area, you can request a complimentary phone consultation with Dr. Wolfson to assess your case. Please call or e-mail us to set up your complimentary consultation.

Call: (415) 221-4400

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