My Heel is Killing Me. Is This “The Plantar Fascia, Whatever It Is?”
Dr. Christopher Hyer
Foot & Ankle Specialist
Ortho Montana-Bozeman
Plantar Fasciitis is one of the most common foot complaints. Probably everyone has either had it or known someone that has. It usually starts suddenly over a couple of days with a very painful ‘bottom of the heel’ that is most noticeable when you first get up on your foot, especially after sitting or resting. It can be difficult to walk due to the pain and it seems to ‘loosen up’ after some time walking but it comes back in full force after the next time you rest.
What is the Plantar Fascia (PF)?
The PF is the tendon on the bottom of the foot that helps support your arch. Imagine the arch of your foot is a bow like in bow and arrow, and the Plantar Fascia is the bow string. Every time you stand on your foot, your body weight comes down, and your arch naturally wants to sag a bit. The PF is supposed to stretch a bit like that bow string, support the arch and spring back. If that Plantar Fascia has gotten tight or lost some flexibility, it can get micro tears within the tendon causing pain. Unfortunately, once it’s painful, you tend to compensate and avoid using the tendon which only gets the fascia tighter, and the cycle continues and worsens.
How Can I Get This to Go Away?
In my many years of battling PF, I’ve found there is no one ‘magic pill’ that works every time and for everyone. In my experience, a three-pronged attack done together works about 90% to get it to go away and more importantly, stay away. In broad strokes, we need to get the pain to go away, to get the flexibility back to the tendon and to make sure we are supporting the foot.
Here are Some Specific Solutions of the 3-Pronged Attack:
- Get the Pain to Go Away: Anti-inflammatories can sometimes work for this but usually people have already tried them and by itself, they won’t work.
- Usually a cortisone-type steroid is the next step, either as medication by mouth for 5 days or as an injection around the PF. I usually prefer the oral medication option for 2 reasons; One, the injection around an already angry PF is usually not pleasant, and two, steroid injections around the PF have the chance of weakening the tendon and for 6 weeks, there is a risk of a spontaneous tear of the tendon during activities. That risk isn’t there with the oral medication.
- Topical medications with Camphor, Menthol, CBD and Arnica can be a helpful addition for pain relief.
- Physical Therapy modalities like deep tissue massage, stretching and active release techniques (ART), electrical stimulation, therapeutic ultrasound and dry needling are excellent tools to use as well.
- Get the Flexibility Back to the Tendon (s): Stretching and deep tissue massage are going to be very helpful here. You can do this yourself anytime, but PF often improves with a Physical Therapist’s range of treatments. I will regularly prescribe 6 weeks of physical therapy. They will help relieve the acute pain, work on improving both the flexibility of the PF but also the other lower leg muscles involved in this problem and very importantly, give strategizes to help prevent this in the future.
- Support the Foot: In many cases, we find the PF got flared up due to a lack of support of the arch. Maybe it was a pair of old running shoes that were just too broken down or maybe a new pair of shoes that are too flexible and not stable enough for your foot type or maybe the dreaded standing in lines at Disney for 3 days and now your foot won’t forgive you…. Wearing the right type of shoe for your foot and for the right activity are important both for treatment and prevention. In some cases, you may need more arch support than the shoe provides. There are good over-the-counter options and custom prescription options when needed.
What if I’ve Done All of This and it is Still Painful? I did say that the treatments work about 90% of the time….so someone must be in the other 10%, sorry if it’s you. Certainly, we’d want to make sure we covered all and didn’t miss anything in prior treatment. There are still other options that have high success rates, even when the other treatments haven’t worked.
Other Options for Chronic Cases:
- ESWT/EPAT or “Shockwave”- a non-invasive mechanical shockwave device that used successfully to treat chronic muscle, tendon and soft tissue injuries through-out the body. The idea is the shockwaves are disrupting chronic scar tissue and stimulating your body’s own regenerative and repair abilities. This is done in an office setting, no need for anesthesia and walk out the door when the treatment is done. Depending on the condition, there may be the need for 4-6 once a week treatment.
- PRP or “Platelet-Rich Plasma”- this one people may be more familiar with. We’re basically taking the growth factors and chemicals in your blood that stimulate your body’s own regenerative and repair mechanisms, filtering those out, concentrate them and then inject them under ultrasound guidance in and around the damaged tissues, in this case, the Plantar Fascia. In many cases, we’ll combine this with ‘needling’ the tissue to induce ‘micro injuries’ to also stimulate repair. So, this is ‘minimally invasive’ and may need a little down time and recovery depending on the specific situation.
- Radiofrequency Ablation (RFA) and PF Micro Tenotomy- this is a minimally invasive surgery, making multiple small tenotomies or incisions into the PF to both disrupt the scar tissue and force the tendon to stretch. Then the RFA is done with a small microwave-like device used inside the tendon to also break up scar tissue, release growth factors and to stimulate repair and create pain relief. I’ll usually combine PRP or bone marrow aspirate (BMA) ‘stem cells’ injected into the PF to throw everything we have at it. This has a recovery time of non-weight on the foot for 1 week and then 2 weeks walking in a boot walker before back into an athletic shoe.
Plantar Fasciitis is one of the most common foot complaints and can be challenging to get rid of, but there are many treatment options and this condition should not be something that runs your life.
Dr. Hyer is a fellowship-trained foot & ankle surgeon with Ortho Montana-Bozeman.
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View this article in the Bozeman Daily Chronicle