March 7, 2022
By Mary Rose Strickland, PT, DPT, OCS
Foot pain in the general population is very common; as many as 1 in 10 people1 experience pain on the bottom of their foot, known as plantar fasciitis. If often presents as pain in your heel or foot when you stand up after sleeping or sitting for long periods of time. Often times it improves with movement. This problem has been the topic of considerable amounts of research over the recent years and the verdict is out: conservative care should be exhausted before even considering injections or surgery for plantar fasciitis.
Plantar Fasciitis starts as inflammation and irritation to the fascia tissue that is on the bottom of the foot – extending from the heel to the ball of the foot. There are a variety of things that can cause this irritation, with most common factors including dysfunction somewhere else in the body (often times the hips, sometimes even the core musculature or upper back); to footwear; to potentially the environment and tasks you do throughout your daily life. Sometimes the added mechanical stress on the foot can cause your body to signal increase bone production and lead to eventual spur in your heel. The good news? While there is an association with plantar fasciitis and heel spurs, up to 32% of people with no foot or heel pain have a heel spur visable on x-ray3. The bottom line – this is often a mechanical (related to how we move) problem. So if you are considering fixing this problem with the use of a biochemical solution (medications, injections) or one time surgeries, you should think twice.
Plantar fasciitis takes time to heal. Usually symptoms will resolve in six months (often on its own)2, but who has six months to wait? We tend to be a “fix it now” society and wanting a resolution sooner than that. Traditionally individuals suffering from plantar fasciitis have sought out everything from physical therapy to surgical consults, not to mention “Dr. Google” to see what help can be found online.
The American Orthopaedic Foot and Ankle Society as well as the Othopaedic Section of the American Physical Therapy Association have put out patient handouts that warn against jumping too quickly in to surgery or injections. Surgery has inherent risks – outside of the standard risks associated with anesthesia include local risks of nerve damage, permanent changes in foot shape, flat feet, more pain than before the surgery, numbness in the heel, and a price tag of $10,000+. Costs vary based on surgeon’s fees, facilities costs, and services such as anesthesia and follow-up care2. Not to mention, if you go through this surgery to file down a bone spur, looking at high chance that it will return if you do not address the underlying biomechanical problems that caused it to begin with! A cortisone may be a better alternative to surgery, but should be considered a “last ditch” effort and it is important that this can only occur once as extra injections don’t help and have risk2.
Ok, you are getting the idea of what may NOT be the best thing, especially in the early months of treating plantar fasciitis, but what should you do? Evidence-based research best supports the combination of manual therapy and supervised exercises as part of a formal physical therapy plan of care. A physical therapist, as the movement expert, can go one step beyond Dr. Google’s recommendation to roll on a frozen water bottle and do a calf stretch. A PT can assess your movement, strength, stability, balance and coordination, and put together a picture of how that all functions together in your particular environment and for your specific tasks (be it home, work, recreation, etc). For example: the irritation to your plantar fascia may be because your ankle joint doesn’t move as well as it should and as a result your toes are forced to move more and it tugs on the tissue. Or your hip on the OPPOSITE side may not extend well when you walk, putting abnormal mechanics through your foot – and so forth. Manual therapy to improve mobility of those problematic joints combined with specific exercise will assist in restoring normal mechanics to how you walk, stand, bend, lift, walk on uneven ground, etc.
In addition to manual therapy and exercise, footwear and arch supports should be considered. Many times over-the-counter orthotics will do the trick, however if those do not work for you a more custom option may be necessary. Based on the extent and timeframe of your pain, other things may be helpful include wearing a splint to bed, shock wave therapy, or anti-inflammatory drugs in conjunction with a more active approach2.
After reading this article, my take away points for you are this: look to address and fix the actual problem; don’t settle for ignoring or just altering the symptoms. Be patient. Plantar Fasciitis doesn’t develop overnight, and it won’t go away overnight. Consider evidence-based recommendations for safest and value-based options vs. being quick to jump to what you may consider a quick, or easy fix.
1 J Orthop Sports Phys Ther 2017;47(2):56. doi:10.2519/jospt.2017.0501
2Treating Plantar Fasciitis: Before considering surgery, try other options first. Developed by the American Orthopaedic foot and ankle society for Choosing Wisely, a project of the ABIM Foundation. www.choosingwisely.org/patient-resources.
3Johal KS, Milner SA. Plantar fasciitis and the calcaneal spur: Fact or fiction? Foot Ankle Surg. 2012 Mar;18(1)39-41.
Dr. Mary Rose is a Physical Therapist, President, and Co-Owner of New Life Physical Therapy. She is board certified in Orthopedic Physical Therapy through the American Board of Physical Therapy Specialties, and is board certified in Lifestyle Medicine through the American College & Board of Lifestyle Medicine. She can be reached at DrMaryRose@newlifept.com