Heel pain is a common condition in people of all ages and at a variety of activity levels. Usually, "heel pain syndrome" involves an inflammation or irritation of the plantar fascia (Figure). The plantar fascia is the ligament (tissue connecting two bones) under the foot that supports the arch. It originates from the calcaneous (heel bone), spans the arch, and inserts into the toes. Most commonly, an overuse injury involving the arch causes the plantar fascia to become inflamed with tiny tears where it attaches to the heel bone. The overuse injury can be caused by increased standing, change in activity level (i.e., new or more vigorous exercise program), increased body weight, poorly supportive shoewear, or injury to the foot. A tight Achilles tendon (the tissue that connects the calf muscle to the heel bone) puts stress on the plantar fascia and is often associated with heel pain. Typically, the initial symptoms involve pain under the heel during the first few steps in the morning or after sitting for a long time. As the symptoms progress, pain can be present with every step and can become constant.

In most people, plantar fasciitis goes away spontaneously or with rest. However, healing takes a long time. A research study showed that healing time averages eight months.1

Nonoperative treatment
The initial steps in treating plantar fasciitis include participating in a heel cord stretching program (see "Taking Care of Heel Pain"), wearing supportive shoes, and avoiding going barefoot. Often, taking a nonsteroidal anti-inflammatory medication (such as aspirin or ibuprofen) is helpful. Using over-the-counter or custom-fitted arch supports relieves some stress on the arch and allows the plantar fascia to heal quicker. Heel lifts or pads can cushion the heel.

Other helpful treatments include wearing a night splint or fiberglass cast. A night splint positions the foot at a 90° angle to the leg (like when standing), which prevents it from pointing downward. This treatment, which is applied when you rest or sleep, improves symptoms in most people.3 Even when all other nonoperative treatments have failed, a walking fiberglass cast sometimes rests the plantar fascia enough to allow it to heal properly. Usually, the cast is worn at all times for three weeks.

An injection of steroids (a strong anti-inflammatory medication) into the heel relieves symptoms in about one third of people. However, this treatment is not appropriate for everyone and cannot be administered often. Frequent injection carries some risk of weakening and rupturing the plantar fascia.

Physical therapy tools such as ultrasound, iontophoresis, and phonophoresis help about half the people treated. New high-impulse ultrasound technology shows some promise in people who do not get better with other types of nonoperative treatment; these tools will be used more in the future.

Operative treatment
If your symptoms do not improve with nonoperative treatment and they continue for more than six months to one year, you may need surgery. Surgery is usually performed on an outpatient basis (i.e., you spend less than 24 hours in the hospital). The doctor makes a three-inch incision that exposes the inner and middle segments of the plantar fascia near the heel bone. Next, he or she lengthens the plantar fascia. The doctor also may release the plantar nerve from tissues that put pressure on it if it is irritiated.

Postoperative treatment
After surgery, you wear a special shoe and begin walking as tolerated. By six weeks, you usually can wear your own shoes. You have maximum improvement by around three months. Seventy-five percent of people significantly improve with surgical treatment.

Heel pain takes time to get better, and you must wear supportive shoes, participate in special exercises, and use other treatments. Fortunately, most people with plantar fasciitis get completely well without surgery.

Leland C. McCluskey, M.D.
Columbus, Georgia

Further reading
1. Wolgin M, Cook C, Graham C, Mauldin D. Conservative treatment of plantar heel pain: long-term follow-up. Foot Ankle Int. 1994;15(3):97-102.
2. Gill L, Kiebzak G. Outcome of nonsurgical treatment for plantar fasciitis. Foot Ankle Int. 1996;17(9):527-532.
3. Wapner KL, Sharkey PF. The use of night splints for treatment of recalcitrant plantar fasciitis. Foot Ankle. 1991;12(3):135-137.