Plantar fasciitis: treatment and when surgery is considered

What is plantar fasciitis?

The plantar fascia is a thick band of tissue that runs from the heel bone to the base of the toes and supports the arch. In plantar fasciitis it becomes irritated and painful where it attaches to the heel.

It is one of the most common causes of heel pain, affecting about two million people a year, most often between the ages of 40 and 60.^[1] Risk factors include:

• repetitive stress, such as running or long periods of standing or walking
• higher body weight
• a flat foot or a high arch
• a tight calf muscle and limited ankle motion^[1]

Symptoms

The classic symptom is pain at the inner part of the heel, sharpest with the first steps after getting up, which often eases after a few minutes of walking and can return after long periods of standing.^[1,2]

When heel pain is something else

Heel pain has a wide list of possible causes, and the location helps narrow it down. Plantar heel pain can also come from a stress fracture of the heel bone (pain that steadily worsens after an increase in activity), from nerve entrapment (pain with burning, tingling or numbness), from a fat-pad problem (a deep, bruise-like pain in the middle of the heel), or from a wart. Pain behind the heel is more likely to be from the Achilles tendon (see Achilles tendon injuries) or from a prominence on the heel bone.^[2] Most heel pain is mechanical, but neurologic, arthritic, traumatic, infectious and other causes must be considered.^[4]

If your heel pain comes with burning, tingling or numbness, or hasn’t responded to usual care, a nerve may be involved. Our sister specialty practice, Lower Extremity Nerve Institute (external site), evaluates nerve conditions of the foot and ankle, including entrapment of a small nerve near the heel.

How it’s evaluated

The history and a hands-on examination are usually enough: where the pain is, when it is worst, how tight the calf is, and how the foot is shaped and loaded. X-rays are used to rule out a fracture or arthritis.^[1] Ultrasound or MRI is used when the diagnosis is unclear or the pain is not settling as expected.

Non-surgical care

Care is typically stepped: simple self-management first, then additional treatments if needed. Ozturk Foot & Ankle’s heel pain page (external site) covers the treatments offered in the office.

• Stretching and education: stretching the plantar fascia and calf, together with advice about footwear and activity, form the core of self-management. In a systematic review with expert input, plantar fascia stretching and taping reduced first-step pain in the short term.^[3]
• Footwear, heel cushioning and orthoses: supportive shoes, cushioned heel pads or inserts. Foot orthoses reduced pain more than sham orthoses in the medium term, but it is uncertain whether the change is large enough to matter, and custom and prefabricated orthoses performed similarly.^[5]
• Night splints, rest from aggravating activities and anti-inflammatory medicine: used by many people, especially early on.^[1]
• Shockwave therapy: across a large meta-analysis, shockwave was the intervention that improved pain in the medium and long term.^[6,3]
• Injections: a corticosteroid injection can reduce pain in the short term, but the benefit is not clear beyond a few weeks. In a meta-analysis of 47 trials it was similar to placebo in some comparisons, and when trials at high risk of bias were excluded the differences were not significant. Because injections have possible side effects, the benefits and risks are discussed first and repeat injections are limited.^[7]

Improvement is often slow. Give each treatment a fair trial before deciding whether to add or change something.

Minimally invasive options: Tenex and TenJet

For heel pain that has lasted six months or more despite appropriate non-surgical care, the American College of Foot and Ankle Surgeons says surgery can be considered.^[8] Before a traditional release, two minimally invasive procedures are offered here. Both remove the damaged part of the plantar fascia through an incision of about 5 mm, guided by ultrasound, under local anesthetic. Tenex uses ultrasonic energy; TenJet uses a fine, high-pressure jet of saline. Both devices are FDA-cleared.^[9,10,11]

• In a Mayo Clinic series of 58 procedures, average pain fell from 6.8 to 0.7 out of 10, and 91% of treated feet were rated satisfied an average of 6.6 years later, with no complications.^[12]
• In a prospective study of 67 patients, pain improved by almost 6 points out of 10, and 94% were satisfied at one year.^[13]
• Across 289 ultrasonic procedures in one series covering several parts of the body, the complication rate was 0.7%, and a walking boot was typically worn for one to two weeks.^[9]

The studies so far are case series rather than randomized trials, TenJet’s published results come from other tendons, and some insurers don’t yet cover the procedure.^[14,15] A tight calf may be better treated by calf lengthening, which is discussed below.^[8] Ozturk Foot & Ankle’s article on Tenex and TenJet (external site) goes through the evidence in detail.

When surgery is considered

Surgery is generally saved for people who haven’t improved after about 12 months of aggressive non-surgical treatment.^[1] Two operations are used most often: a partial release of the plantar fascia (done through an open or endoscopic approach) and lengthening of the calf muscle (gastrocnemius recession), which reduces tension across the heel.^[1]

A recent network meta-analysis of 21 studies of surgery for recalcitrant plantar fasciitis found that endoscopic approaches produced greater improvement than open or percutaneous techniques, and that gastrocnemius recession (see gastrocnemius recession) produced better pain scores than the other mechanisms; the studies had a moderate to high risk of bias, so the findings should be treated with caution.^[16] Recovery includes a period of protected weight-bearing, and although good outcomes are typical, chronic pain can persist.^[1]

When to seek care

Consider an evaluation if heel pain lasts more than a few weeks despite rest, stretching and better shoes, or if it is getting worse.