What Is Plantar Fasciitis? 
Plantar Fasciitis is a painful condition that affects the connective tissue that attaches to the base of your heel and foot. The Plantar Fascia is a thick band of connective tissue that extends from your heel bone to your toes. The Plantar Fascia has three bands: Medial, Central and Lateral. It functions to support and protect the foot (1). Plantar Fasciitis is one of the most common causes of heel pain and is estimated to affect two million people annually in the United States (2). The prevalence is lowest in those aged 18-44 and highest in those aged 45-64 years of age. It can affect both sedentary and athletic individuals alike.
What Are the Symptoms of Plantar Fasciitis?
Plantar Fasciitis develops in stages. It typically begins with slight discomfort in your heel or arch. The mild intermittent pain can progress to constant and debilitating nightmare. The most common symptoms include:
- Heel Pain (typically one sided: left or right)
- Arch Pain
- Morning Pain: That first step out of bed can take your breath away. It typically gets better as the day progresses
- Achilles Tendon Tenderness and Pain
- Tight Calves
- Difficulty Walking Due to Pain
Risk Factors for Plantar Fasciitis
Risk factors for Plantar Fasciitis can be grouped into three major categories: anatomical, mechanical, and environmental (3).
Anatomical Factors
Obesity
Flat Feet
Very high arched feet
Shortened Achilles Tendon
Mechanical Factors
Overpronation ( inward rotation)
Limited ankle movement
Weak foot muscles
Environmental Factors
Leg length asymmetry
Deconditioning
Prolonged standing
Poor footwear
Poor biomechanics
Is Plantar Fasciitis a Simple Case of Inflammation?
No. The term Plantar Fasciitis is misleading as the “itis” would lead the reader so suspect an inflammatory process. For example, Bursitis is the inflammation a Bursa which can be a painful condition. A Bursa is fluid filled sac that promotes frictionless sliding of tendons, muscles, and ligaments over boney areas in the body. There are many in the foot and ankle.
Plantar Fasciitis is NOT a simple inflammation of the Plantar Fascia. Rather it is a chronic degeneration and micro tearing of the Plantar Fascia (4).
Treatment Options for Plantar Fasciitis
Treatment options depend upon the severity of the condition and resources available in your community. When appropriate conservative care should always be first line of treatment.
Conservative Care
Rest, safe anti-inflammatory medications such as Turmeric and Fish oil, stretching, elevation, appropriate shoes, night splint, orthotics, physical therapy are examples of conservative, first line treatment options.
Steroid Injections
Steroids are often recommended when conservative care fails to provide significant benefit. Steroids are powerful anti-inflammatory agents but are also known to cause tissue damage including cartilage damage and tendon rupture (5).
Surgery
When conservative care and steroids have failed many patients are referred for surgery. The most common surgery is Partial Plantar Fasciotomy that involves cutting a portion of the Plantar Fascia. Intuitively this makes little sense as the underlying problem is degeneration and micro tearing. Cutting a portion of the diseased Plantar Fascia out will not address the underlying degeneration of Fascia. Rather it will weaken an already compromised structure which can give rise to pain and dysfunction.
PRP
Platlet rich plasma is powerful treatment option as it is rich in growth factors that can increase blood flow and decrease inflammation. It is a simple process where blood is extracted from your arm, processed to concentrate the platelets and then injected into the area of damage within the Plantar Fascia. Ultrasound is required to ensure proper placement of the PRP. Blind injections are below the standard of care of the the Centeno-Schultz Clinic and should be avoided. In multiple studies PRP has been not only effective in the treatment of Plantar Fasciitis but is also superior to steroids (6).
Not All Heel Pain is Plantar Fasciitis
Not all heel pain is from Plantar Fasciitis. Establishing a correct diagnosis is critical so that an appropriate treatment plan can be developed. This is the cornerstone at the Centeno-Schultz Clinic. The wrong diagnosis and prescribed treatments can lead to harmful outcomes as illustrated in a current clinic patient.
Meet PR
PR is a 65 year old Real Estate professional who presented to the clinic with a 5 year history of heel pain that was progressive in nature localized on both heels, left greater than right. The pain was burning in character and often times awakened her at night. Onset was not associated with any trauma. Treatment to date had included rest, NSAID’s, stretching and massage. She has been given the diagnosis of Plantar Fasciitis. Her Plantar Fasciitis was so bad that she could not walk at times. This complicated her job and her ability to care for her elderly mother. My discussion with PR included these questions:
How was the diagnosis of Plantar Fasciitis made? The doctor simply told me that is what I had.
What imaging studies were performed? None
Was an ultrasound examination performed confirming the diagnosis of Plantar Fasciitis? No
Was a thorough examination performed including examination of your low back and nerves? No
What were the treatment recommendations? Surgery in 2 weeks and walking boot for 30 days thereafter.
PR disclosed that she had a longstanding history of low back pain and an episode of severe left Sciatica last year. Her examination revealed tenderness in her low back, limited movement and decreased sensation and strength in her left toes. X-ray of her low back demonstrated severe disc injury characterized by reduced height of the lowest disc. Ultrasound of her heel and Plantar Fascia was normal. Surgery would not have helped her. PR did not have Plantar Fasciitis but rather an irritated nerve in her low back due to her disc injury. PR underwent a diagnostic injeciton of numbing medicaiton and low dose steroid. Shortly thereafter all her debiliating heel pain was gone. She had tears of joy. Later this month she will return for a Platelet Epidural injection.
To learn more about PRP injections as an alternative to back surgery and epidural steroid injections please click on the video below.
Other Causes of Heel Pain
As illustrated above not all heel pain arises from Plantar Fasciitis. Other causes of heel pain include:
Tibial nerve entrapment or compression (Tarsal Tunnel Syndrome)
Neuropathy from underlying medical conditions such as diabetes
Foot arthritis
Heel fracture
Achilles Tendinitis
Posterior Tibial Tendonitis
Low back nerve irritation secondary to disc injury, vertebral body slippage or stenosis
Bursitis
Heel spur
Bone Infection (Osteomyelitis)
In Conclusion
- Plantar Fasciitis is a painful condition that affects the connective tissue that attaches to the base of your heel and foot.
- Plantar Fasciitis is one of the most common causes of heel pain
- Symptoms of Plantar Fasciitis include: Heel pain, arch pain, morning pain, Achilles tendon tenderness or pain, and difficulty walking.
- Risk factors for Plantar Fasciitis can be grouped into three major caetgories: anatomical, mechanical and environmental.
- Plantar Fasciitis is not a simple case of inflammation but rather is a chronic degenerative process that requires your attention.
- Treatment options include conservative care, steroid injections, surgery and PRP.
- Not all heel pain is due to Plantar Fasciitis.
- PR is a patient who was diagnosed with Plantar Fasciitis so bad that she could not walk. She was scheduled for surgery. She had the wrong diagnosis as her heel pain was due to an irritated nerve in her low back.
- There are multiple causes of heel pain that include nerve entrapment, foot arthritis, fracture, tendonitis, bursitis, low back nerve irritation and infection.
If you or a loved one have ongoing heel pain, or “Plantar Fasciitis so bad I can’t walk” that has not responded to conservative treatment, please schedule a telephone candidacy discussion with a board-certified, fellowship-trained physician. At the Centeno-Schultz Clinic, we are experts in the evaluation and treatment of foot and heel injuries. From the comfort of your home or office learn what treatment options are available for you.
1.Kim W, Voloshin AS. Role of plantar fascia in the load bearing capacity of the human foot. J Biomech. 1995 Sep;28(9):1025-33. doi: 10.1016/0021-9290(94)00163-x. PMID: 7559672.
2.Schwartz EN, Su J. Plantar fasciitis: a concise review. Perm J. 2014;18(1):e105-e107. doi:10.7812/TPP/13-113
3.Dyck DD Jr, Boyajian-O’Neill LA. Plantar fasciitis. Clin J Sport Med. 2004 Sep;14(5):305-9. doi: 10.1097/00042752-200409000-00010. PMID: 15377971.
4.Thomas JL, Christensen JC, Kravitz SR, Mendicino RW, Schuberth JM, Vanore JV, Weil LS Sr, Zlotoff HJ, Bouché R, Baker J; American College of Foot and Ankle Surgeons heel pain committee. The diagnosis and treatment of heel pain: a clinical practice guideline-revision 2010. J Foot Ankle Surg. 2010 May-Jun;49(3 Suppl):S1-19. doi: 10.1053/j.jfas.2010.01.001. PMID: 20439021.
5. Wernecke C, Braun HJ, Dragoo JL. The Effect of Intra-articular Corticosteroids on Articular Cartilage: A Systematic Review. Orthop J Sports Med. 2015;3(5):2325967115581163. Published 2015 Apr 27. doi:10.1177/2325967115581163
6.Hurley ET, Shimozono Y, Hannon CP, Smyth NA, Murawski CD, Kennedy JG. Platelet-Rich Plasma Versus Corticosteroids for Plantar Fasciitis: A Systematic Review of Randomized Controlled Trials. Orthop J Sports Med. 2020;8(4):2325967120915704. Published 2020 Apr 27. doi:10.1177/2325967120915704
