Plantar fasciitis (pronounced PLAN-tar fashee-EYE-tiss) is an inflammation of the fascia (also called aponeurosis) on the bottom of the foot. The fascia is a ligament-like tissue that connects the ball to the heel and helps support the arch. The fascia endures a great amount of tension during normal walking and standing. Plantar fasciitis is often considered the same as, or confused with, heel spurs. Here is a picture of the plantar fascia. It is usually caused by a change or increase in activities, lack of flexibility in the calf muscles, being overweight, a sudden injury, using bad shoes on hard ground, or spending lots of time on the feet. Those with flat feet or high arches are more likely to get plantar fasciitis ( heel spur ). It is very common. The pain is usually in the front and bottom of the heel. It can also be over the entire bottom area of the foot. The pain can be mild or debilitating. It can last a few months or a lifetime. It can often appear to be cured, only to return in a few weeks or months. Despite the claims of various product manufacturers, there is not a "cure-all". Different combinations of treatments will help different people. The most successful treatments are stretching the calf muscles without re-injuring the fascia, decreasing or changing activities, losing weight, better fitting shoes (with an arch support and/or raised heel), shoe inserts that have good arch support (like the hard Spenco or Superfeet), heel pads (1/2" or more when compressed - many designs like Tuli cups are often too thin), applying ice for 5 minutes after activities, and anti-inflammatory medication such as aspirin, Aleve, or Ibuprofen (but not Tylenol). Keeping the foot raised above the heart and/or compressed by wrapping with ace bandage will help. Trying to "walk-through the pain" can cause a mild case to become long-term and debilitating.
Symptoms
If you have heel pain at the inside, front, and bottom of your heel, especially if it's in the morning or after sitting a long time, then you probably have plantar fasciitis ( heel spur ). Doctors know exactly where to press to make it hurt, providing strong evidence of plantar fasciitis (or, more accurately, nerve or bone(?) sensitivity caused by plantar fasciitis). When the pain is severe, it is believed to be the result of bone and/or nerve irritation that is the result of too much tension, inflammation, or scar tissue in the fascia. The pain often increases with more walking and standing. The pain is usually where the fascia attaches to the heel, but it can be over the entire bottom area of the foot. Placing 1" of carefully folded paper under the heel or stretching the calf muscles may immediately relieve the pain. Pressing the toes down while walking transfers tension from the fascia to tendons and muscles and thereby can reduce the pain. Pointing the foot inward towards the other foot while walking also often helps because it reduces the tension in the fascia. If the heel pain began concurrently with a change or increase in activity, or an increase in weight, then it can be considered more evidence of plantar fasciitis ( heel spur ). A stress fracture where the fascia attaches to the heel is often seen in bone scans, especially if the pain is severe. A bone scan can rule out severe stress fractures. Distinguishing between any number of conditions (stress fracture, "nerve damage", arthritis, heel spur, etc.) and plantar fasciitis may not be easy and may be a judgement call on the part of the doctor(s). You may have a combination of conditions. The conditions are often not seperate entities. 50% of the visitors to this page who fill out the survey say the pain is constant. About 60% say it hurts when pressed with a finger. One source says a diagnosis of plantar fasciitis is questionable if it does not hurt when pressed on the inside, bottom, front of the heel. A nerve study (using electrodes that may be painful) by a neurologist can help rule out tarsal tunnel syndrome or other nerve problems. Blood tests can look for the possibility of arthritis. MRI may be used to help confirm plantar fasciitis, but another source says MRI is not very useful for this. One source says it's in both feet in 15% of the cases. Plantar fasciitis is referred to as Policeman's heel (on their feet alot walking the street hard surface)) in the U.K. and Australia.
Heel spur and Plantar Fasciitis
A heel spur on the back of the heel may be helped by many of the treatments on this page, but the heel spurs to which this page is referring are the more common type which are located on the inside, front, and bottom of the heel (a.k.a. medial subcalcaneal exostosis). These pages and links are directed towards plantar fasciitis. There is confusion in the medical literature as to if there is a difference between plantar fasciitis and heel spurs. They are bony growths that are the result of stress in the plantar fascia (or abductor muscle of the big toe according to one source) where it attaches to the heel. Heel spurs may only be a symptom of plantar fasciitis rather than a direct cause of the pain. Studies indicate 8% to 21% of the population has heel spur, but less than 1% of the population experiences substantial heel pain. Studies indicate 30% to 70% of those with heel pain have a heel spur. The Merck Manual says a true heel spur "tends to be painful during its early development, when little or no x-ray evidence is present. As the spur enlarges, pain often diminishes...." Heel spurs are commonly removed, but some sources since 1990 indicate they should not be removed. According to doctor Lundeen (www.drlundeen.com) "Beware if a surgeon says the spur needs to be removed...." Here is a picture of a heel spur. A journal article says "Radiographically it was noted that, despite complete excision, subcalcaneal exostoses [heel spur] often reformed ... findings of this study suggest that changes within the fascia, rather than the spur, are primarily responsible for the pathogenesis of the syndrome." The link above says "not in any case the calcaneal [heel] spur found [by X-ray] induces pain or tenderness. ... Results of the surgical removal of the painful calcaneal heel spur have been disapointing. ... Since chiselling down the calcaneal [heel] spur also removes the attachment of the plantar aponeurosis [fascia], patients must accept subsequent lowering of the arch of the foot." Another journal article abstract: "Four patients developed calcaneal fractures while walking, soon after bone removal from the undersurface of the calcaneus. Heel spur or osteomyelitic bone removal can lead to this complication." Should heel spurs be removed? I don't know.
The Prognosis
Heel pain is probably the most common foot complaint. One source says 2 million cases are reported in the U.S. each year. Doctors report that 2% to 10% of their patients have it for more than a year. Out of the 1st 1,200 responses to one of the surveys at this web site, 38% had it over a year. If there is little success after 9 to 12 months of proper conservative treatment, patients are often advised to have surgery. Surgery fails 2% to 35% of the time, depending on which source is quoted. According to several visitors, a failed surgery can ruin the patient's ability to walk. Those who delay seeing a doctor, have it in both feet, or are overweight are more likely to have it for a long time. It is important for the patient to be active in their treatment.
Causes of Plantar fasciitis ( heel spur )
An evolutionary theorist's explanation as to why we have plantar fasciitis is that mammals did not originally evolve to walk on two feet. More recently, humans did not evolved to have so much sugar in the diet (overweight cases) and to be inactive (unconditioned cases). Plantar fasciitis ( heel spur ) is very often caused or exacerbated by being mildly or severely overweight (possibly 70% of the cases) or by engaging in certain sports such as aerobics (especially step aerobics), stair climbing, volleyball, and excessive running. Hiking, basketball, or lunging forward in a singles' game of tennis are other examples. A long-term inactive lifestyle increases the chances of small changes in activity causing it because the fascia or its attachment to the heel are unconditioned for the extra stress. But once it's injured, a decrease in activity is necessary before beginning the slow process of increasing activity to regain strength in the fascia. Bad shoes (no arch support, no heel, worn out, no cushion, does not bend under the ball). Pushing a car is an ideal way to injure the fascia because of the sudden increase in unusual activity, the steep angle of the foot bending back, and the strength that is necessary. Pushing a lawn mower in the spring after an inactive winter is another way. These activities put a large amount of tension in the fascia when the ball of the foot (instead of the heel) pushes on the ground. An increase in weight or an increase or change in activity can cause it. In many cases, a lack of flexibility in the calf muscles is the cause of plantar fasciitis ( heel spur ). This places more strain on the fascia when the trailing leg pushes and lifts the heel off the ground during normal walking and running (see the flexibility diagrams). Stretching the calf muscles is almost always recommended. Irritating the fascia often causes inflammation that may not be obvious. Inflammation in the heel area places more pressure on tissue in the area, causing more pain. The fascia suffers the greatest amount of strain where it attaches to the heel because it attaches to a smaller area of bone than at the other end (the ball of the foot). Having weak foot muscles that control the toes and ball of the foot may also help cause plantar fasciitis ( heel spur ) because these muscles normally help absorb some of the tension that would otherwise be in the fascia (during walking and running but not during standing). Those with flat feet or high arches are more likely to get it. Flat feet often "pronate" which places more strain in the fascia. Some pronation is normal. The foot is said to over-pronate when the inside ankle bone "rolls" down and inward as the foot passes under the torso during normal walking or running. Arch support and/or a "medial wedge" (called a "post" when placed under an orthotic) under the forefoot and rearfoot will prevent over-pronation. Under-pronation ("supination") is common in those with a high arch and can also be a contributing factor. Those with a high arch should place emphasis on getting the "first ray" (ball at the base of big toe) to bend back when stretching the calf muscles. Other "biomechanical abnormalities" such one leg being 1/2" longer than the other may also cause it. One source suggests a "viscious cycle" in which injury leads to scar tissue which leads to more injury. Another source claims fascia scar tissue can adhere to other tissue in the area, causing more pain (and damage) when the fascia is under stress. Scar tissue is not as flexible and strong as the original tissue. Applying ice immediately after injury helps to minimize the amount of scar tissue. The fascia can get thicker (from 3 to 15 mm) with more injury, causing more pressure on the nerves. Nurses, mail carriers, and teachers may get plantar fasciitis by spending too much time on their feet. Shoes with arch support may help. Switching from a shoe with a
Other Causes of Heel Pain
Plantar fasciitis ( heel spur ) is the most common cause of heel pain. When the pain is severe, it is believed to be the result of bone and/or nerve irritation that is the result of too much tension, inflammation, or scar tissue in the fascia. Distinguishing between any number of conditions (stress fracture, "nerve damage", arthritis, heel spur, etc.) and plantar fasciitis may not be easy and may be a judgement call on the part of the doctor(s). You may have a combination. The conditions are often not seperate entities. Tarsal tunnel syndrome - a burning and/or tingling sensation on the bottom of the foot - tapping the tarsal tunnel between the heel and inside ankle bone may produce tingling on the bottom of the foot - this is called Tinel's sign. 200 mg/day of B6 will reduce tendon inflammation. Surgery can cure it. Arthritis (it's important to take chondroitin sulfate and glucosamine sulfate, lots of B vitamins, and omega-3 fattay acids - see the vitamin section below), tendonitis (rest, ice, anti-inflammatories, and 200 mg a day of vitamin B6), damage to the long plantar ligament (pain should be deeper and not so sensitive to touch - should be treated identically to PF, but DO NOT get the PF release surgery), seronegative spondarthritis, and stress fracture (bone damage - needs rest and calcium) are the the most easily confused with plantar fasciitis. The cause of heel pain is often hard to diagnose, but most of the treatments described on this page are not dangerous to implement and will help many cases of heel pain. Other causes of heel pain are the loss of resilient tissue in the heel pad, heel bursitis, thrombophlebitis of the subcalcaneal plexus, Reiter's Syndrome, ankylosing spondylitis, psoriatic arthropathy, Sever's disease (usually ages 9 to 14 - treatment is similar to PF), sacral radiculopathy, entrapment of the first lateral branch of the posterior tibialis nerves, necrotizing fasciitis, and even AIDS. Someone emailed me to say "plantar faciitis is also commonly found with fibromyalgia patients and polymyalgia rheumatica." Also peroneal tendon dysfunction and Lupus?
Are You Overweight?
Being overweight is well-known to be a major contributing factor to plantar fasciitis ( heel spur ). Losing weight will help almost all forms of foot pain. In a survey of 416 visitors to this site, 60% were overweight (BMI>26) and 7% were underweight (BMI<21) based on their self-reported height and weight measurements. The more you weigh, the more likely you will not be cured. Two other sites with good weight charts are the Metlife table and another site. The BMI number is your weight in kilograms divided by your height in meters squared. If your heel pain is severe, I would go for the low end of the acceptable range (BMI=20). Some will be too skinny at this level. It's supposed to be a healthier weight unless you are a "large frame" or have and want to keep lots of muscle. However, on average, people live much longer if their BMI is 20 instead of 25. See the bottom of this page for more statistics on weight and heel pain. Here's another weight chart. Plantar fasciitis ( heel spur ) can begin with pregnancy because of the increase in weight. All the other techniques described on this page may help, but losing weight, shoes or inserts with arch support, and/or taping may help the most for those who are overweight. Weight-lifters use a combination of ephedrine, caffeine, and aspirin, to burn off fat. This is called the ECA stack. One reliable product for this is TwinLab's Diet Fuel line of pills. Along with many other brands, it is a serious and potent combination of herbs and chromium. Ma Huang supplies the ephedrine. This is potent stuff. Do not take if you have high blood pressure or heart trouble. Avoid sugar, especially high fructose soft-drinks, like the plague. Eat small meals, never fill up, and try not to eat white flour products.
Too Much Time on My Feet
A study reported 50% of its sample of 411 plantar fasciitis ( heel spur ) patients were on their feet most of the day. All the other techniques described on this page may help, but lower weight, shoes with arch support (Birkenstocks) or inserts with arch support, and/or taping may help the most. Air Nike may be good for those who are on their feet a lot. But the best treatment is to spend less time on your feet.
Running
Approximately 10% of running injuries are heel pain. Long strides and hills increases damage to the fascia because of the increase in the angle that the foot has to bend back. Stretching the calf muscles before and after running will help. It is usually necessary to decrease the amount of running until the pain is gone. Swimming is a good alternative activity. Bicycling has been suggested as an alternative, but it will still place strain in the fascia when the ball of the foot pushes on the pedals. Running shoes have raised heels to help prevent plantar fasciitis ( heel spur ) and Achille's tendonitis. Taping is sometimes used by runners to relieve the pain, but it is difficult to apply tape correctly and it may cause Achille's tendonitis or severe skin irritation. Some runners have said dual sole shoes like Nike Air and ASICS Gel cause plantar fasciitis ( heel spur ). Non-runners have said they help prevent it. A soft heel pad or a rigid shoe can cause Achille's tendonitis and plantar fasciitis ( heel spur ). Shoes should bend under the ball of the foot. Not in the middle. Firm heel pads help prevent and relieve Achille's tendonitis and plantar fasciitis ( heel spur ). Use a straight last for flat feet and a curved last for high arches. See also Dr. Prubit's page on runners and stretching and Dr. Block's sporting foot page.
Curing Plantar Fasciitis ( heel spur )
Decreasing activity, stretching the calf muscles without re-injuring the fascia, and/or better arch support are often the cure for plantar fasciitis ( heel spur ).
Decrease activity or switch to swimming. Do not do anything that causes an increase in pain. Be patient, it may take months of reduced activity. Increase activities VERY slowly. Complete rest is not good.
Stretching. Stretching is almost always recommended. In the few cases where it is caused by a sudden injury, stretching and strengthening may not be necessary. Stretching can re-injure the fascia.
Taping can help to simply protect the fascia, or enable a patient to walk again. The tape should be tight when you stand and the pain immediately relieved (unless the pain is 24 hours). If not, consider the "other causes" section.
Arch support and Medial Wedges. Certain shoes, inserts (Superfeet or Spenco), or custom-made orthotics can give more arch support. Heel pads can sometimes be worn under inserts.
Vitamins See below for details.
Heel pads, 1/2" to 1" thick in both shoes. The waffle-bottomed Tuli cups or viscoelastic designs do not work nearly as well because they are too thin when compressed. Placing folded paper under thin heel pads to make them thicker will help. Playing tennis or similar activity while wearing high heel pads can cause a serious ankle injury.
Reduce inflammation with pills, compression, and elevation. The swelling may not be noticeable, but it is often there and causes pain by putting pressure on tissue in the area.
Ice immediately after activities or injury. I place ice on a towel and step on it for 5 minutes.
Massage In the morning. Sometimes used to break up scar tissue.
Injections. Shots are often VERY painful. Injections are a controversial topic. They help a great deal in some cases, and do significant harm in others. The benefits often last only from a week to a month.
Ultrasound if you have the time and money. Questionable.
Cast for 4 to 6 weeks forces the patient to give it rest and neutral stretching.
Surgery Endoscopic Plantar Fasciotomy has a faster healing time, but other methods allow more investigative viewing and precision cutting. Surgery has been said to sometimes cause permanent disability. Choose your doctor carefully.
Other: Prolotherapy, ionotopheresis, chiropractor, pedorthist, acupuncture, magnetic inserts, and praying.
Losing weight comes first if it is needed.
Decreasing Activity
Foot problems are often difficult to cure because the feet never get a rest. Rest is very important. Most of the treatments in this article are simply different ways of giving the fascia rest. It may take months of reduced activity. My best method of giving it rest has been to use tape. Do not ever walk bare-foot (as explained below). With too much rest, muscles, ligaments, tendons, and the fascia lose strength. Nevertheless, being very gentle on the feet for a very long period of time (somewhere between 1 and 4 months) and then very slowly increasing activity over the course of months in the absence of any pain appears to be the only solution for many victims. Swimming is the best alternative activity. Slowly return to activity by increasing 10% or less each week or month, unless pain starts to return. There is one theory that says scar tissue will adhere to other tissue in the area as it grows in the absence of activity and cause pain when greater activity resumes.
Stretching the Calf Muscles
Stretching the calf muscles is needed in most cases of plantar fasciitis ( heel spur ). Those with a high arch should place emphasis on getting the "first ray" (ball at the base of big toe) to bend back when stretching the calf muscles. Stretches can be 30 seconds long, with 15 second breaks, repeated 3 times with the legs straight (knees not bent). Repeat with the knees bent. Do this 3 times each day. Stretch gently and do not bounce. This is the standard conservative approach. I have much more success standing on an inclined plane (described below) for 3 to 5 minutes twice a day. Apply tape (see taping instructions) to protect the plantar fascia if the pain increases. Too much stretching can re-injure the fascia and cause Achille's tendoniitis. Reduce stretching if there is pain in the Achille's tendon. Apply ice to the Achille's tendon after stretching if this occurs. See the flexibility diagrams for an explanation of why stretching is often needed. Apply ice to the fascia if you think some harm was done during stretching. Applying ice to the calf muscle after strething is used by some physical therapists to "preserve the elastic deformation" of the muscle (that is, it retains the stretch better).
Lack of flexibility in the calf muscles is the cause of many chronic cases (although simply being overweight is also a cause of many chronic cases). The lack of flexibility continually places the plantar fascia under strain, continually re-injuring it. Simply following a stretching routine is not enough: you should be able to see an increase in the angle your feet can bend back after the first week. I stretched for months using a mild approach and saw no improvement. I switched to a more aggressive routine and saw dramatic improvement. Muscles, not ligaments or tendons, lengthen while stretching, so you should feel the stretch in your calf muscles and NOT 6 inches above the back of your heel (in the Achille's tendon). Most sources say cold muscles should not be stretched, but stretching when first getting out of bed every morning is necessary to prevent re-injury due to lack of flexibility. The calf muscles and fascia can be warmed up in the morning (before walking and stretching) by using a heating pad and/or massaging device, but few will need to go as far as this. Stretching is more effective when the muscles are warm after activity. There may be substantial benefit to stretching the fascia as well as the calf muscles, so tape is not recommended unless there is an increase in pain due to the stretching.
I stand on a 12"x12"x1" board with one end on top of a brick like this. This allows both legs to be stretched at the same time and the angle to be adjusted. I can see my progress by how far the brick can be placed under the board, which increases the angle. If you do not see any progress, increase the overall amount of time each day you spend stretching. A high level of flexibility has been achieved when you can stand straight on a 30 degree incline. Most people never achieve this angle. The average person can bend the foot back 20 degrees. A 30 degree angle is created when one edge of a 12 inch board is 6 inches above the ground. That is the angle of "wedges" such as the Thera-Wedge (a non-adjustable equivalent to my brick-and-board method) used by physical therapists (I've seen 3 different designs use a 30 degree wedge). Some people have difficulty standing straight on a 15 degree incline, and yet they do not have heel pain. Others can stand straight on a 30 degree incline, and yet they still have heel pain (they probably do not need to stretch). The objective is to see an increase in the angle without re-injuring your plantar fascia or Achille's tendon. Many people can see a reduction in pain immediately or after a only few days stretching.
Flexing the muscles while stretching. This method is better than the plain "static" stretching described above. More weight can be placed on one foot while flexing the calf muscle to bring the heel barely off the angled wedge for 15 to 30 seconds. If you don't have a wedge, you can flex the calf muscles while leaning against a wall. It's possible to see the calf muscles loosen up and allow the foot to bend back in only 15 seconds. The static method cannot acheive such quick results. Flexing the calf muscles while stretching can be done only once or twice per day. Another way to flex the calf muscles while stretching is to place the balls of your feet on the edge of a step (or set of books) and slowly lower your heels down towards the step below, concentrate on flexing the calf muscles, and hold this position for 30 seconds. It can and sometimes should be repeated twice, 3 times a day. This method may also increase your chance of getting Achille's tendoniitis.
Night splints and the Strassburg Sock. Several sources have had success using a "night splint". The seems to be an improvement on the night splint. It costs half as much, is not uncomfortable to wear, and stretches the fascia as well as the calf muscles. Unlike night splints, it is also easy to adjust the angle. I have not been able to find a source that says how long these should be worn. I injured my Achille's tendon by leaving one on for only 30 minutes, 3 nights in a row. Three visitors have emailed me to say they have been injured by using a night splint or the Strassburg Sock. I have heard of using them for 2 hours for a few evenings or using them every night all night in runners. Achille's tendonitis can be caused by these products. Stop using them if there is any increase in pain in the foot or in the back of the lower leg. Apply ice afterwards to the fascia and Achille's tendon, especially if there is pain. There has not been a good study (n>30) to determine the effectiveness of night splints or the Strassburg Sock, but they were rated moderately well in our survey.
Stretch the fascia itself by bending the toes and foot back for 10 seconds, 10 times each day, may help reduce the pain when standing after long periods of sitting. It also allows injured tissue fibers to align properly while healing. Improper tissue alignment while healing reduces the flexibility and strength of the tissue. Another method is to hold two ends of a towel and gently pull the ball of the foot back for 30 seconds, with 15 second breaks, up to 6 times.
Toe and Foot Muscle Strengthening
Strong foot muscles can help take some of the tension out of the fascia. Laying a towel on the floor and pulling it towards you using only your toes is often prescribed by physical therapy. Another technique is to place your foot flat on the floor while sitting in a chair and pushing the ball of the foot off the floor by pushing down with the toes. Another method is to pick up marbles or similar objects and place them in a cup. Pressing your toes on the ground while walking can also noticeably reduce pain in your fascia. If this works, it is more evidence that your pain is in your fascia.
Taping
Athletic tape can help speed healing by protecting the fascia from re-injury, especially during stretching. In severe cases, it can enable the patient to walk again. Tape is used to supplement or replace the function of the fascia. Tension in the tape replaces tension in the fascia. If the tape is tight when you stand and walk, and the pain is not immediately relieved, then tension in your fascia is not the cause of your pain. If reducing tension in your fascia does not help relieve the pain, and if constant inflammation is not a problem, then keep in mind that it may not be plantar fasciitis. See the "other causes" section above. The following two pieces of tape can be a life-saver for those who are having trouble walking. Make sure the first piece shown is applied first. Do not let the tape go as high on the back of the heel as shown in these pictures because it can hurt the skin in that area.
You can add more tape as shown below.
Shown below is another method that uses only 2 strips of tape and is a good method if you can get it to stick. You can apply 4 more pieces as shown below, but more tape means less flexibility in the foot and increases the chances of pain in the ankle and knee. In no case should properly applied tape cause pain in other areas. When it is applied too tightly, it can hurt the ankle, foot, and knee while walking. If it is not tight enough, the heel starts hurting again. The tape should be only as tight as is needed to reduce or eliminate the pain. It takes some practice to get it where it helps the fascia and doesn't hurt other areas. The amount of slack left in the strips of tape in all methods is crucial. The fascia needs to be under some strain and use while it is healing so that the scar tissue can regain strength and flexibility. A dependency on tape can develop. Taping may harm the Achille's tendon and skin. Firm, not soft, heel pads can help prevent Achille's tendon damage when using tape. Wash the foot with soap and water in order for the tape to stick. I use tape only when it noticeably decreases the pain, or when I expect to be on my feet all day. Duct tape is not as good as athletic tape because even several layers can stretch after only about an hour of use, but it can be used in emergencies. Athletic tape is available at drugs stores and athletic stores. Just because a doctor applied the tape, it does not mean the tape was applied correctly. Think about what the tape is supposed to do (take tension out of the fascia) and use your own skill and tests to achieve that result.
Arch Support and Medial Wedges (Posts)
Better shoes, inserts, or orthotics can provide arch support. Arch support is indispensable for many if not most cases. However, too much arch support can cause the fascia to travel a longer distance. This causes it to pull harder at its attachment to the heel, causing pain. Those with flat feet may benefit more from arch support. Those who over-pronate (inside ankle bone rolls down and inward too much when walking) need to get new shoes that are not worn out on the bottom on the "medial" side (medial - inside towards the other foot). Over-pronators may also need (in addition to arch support) a "medial wedge" or "medial post" or "varus post" (an angled support that is higher on the medial side than the lateral side). The lateral side is the side opposite the other foot. It is the opposite of the medial side. Two are usually needed, one under the forefoot (ball) and one under the rearfoot (heel bone) that are about 2 to 7 mm thick on the medial side. Many health care professionals who readily mold and charge for an orthotic are not aware of this technique. Ask if you are a pronator, and if you are, then ask if you need a "medial post or wedge." Shoes with wide (especially flared) heels increase pronation. A high arch may also benefit from arch support and from a lateral wedge under the forefoot.
Several visitors to this page have strongly recommended Birkenstock sandals (starting at $70). 1-800-761-1404 for the Birkenstock retailer nearest you. Mephisto and Dansko sandals are competitors to the Birkenstocks, but they are in the same price range. I've heard there are less expensive brands, but I have not been able to find them. Spenco and Superfeet have good over-the-counter arch supports for $14 to $30. If you use heel pads under inserts and have a high arch, you may need New Balance running shoes because they are one of the few brands that come in wide sizes. Custom orthotics are inserts designed from a mold of your foot. 70% of patients in a study reported improvement with custom orthotics, which is as high as stretching. This study has been criticized for using only "rigid" orthotics when semi-rigid orthotics are more commonly used. Orthotics cost from $100 to $400 each. A doctor's prescription is usually necessary. Physical therapists may also make a mold of your foot and send off for orthotics. See the products page for more info on all of the above.
The numbers in the paragraph below are approximately the recommendations of Linus Pauling, a 2-time nobel prize winner. These doses are absolutely safe. My other source of vitamin information is Dr. Weil (www.drweil.com).
For carpal tunnel, tarsal tunnel, arthritis, and plantar fasciitis, take 200 mg of B6, up to 500 mg of B3 (niacin), and 4,000 mg of Vitamin C. Spread the doses out over the course of a day to keep the blood concentration high. If you know that you do not have arthritis or tarsal tunnel, then only vitamin C is needed. Vitamin C may cause upset stomach and gas. See my document on Vitamin C for more info. B3 that is not the time-released nicotinic acid or the nicotinamide form can cause skin flushing and tingling. There is some evidence (according to Pauling) that it can help arthritis. B6 shrinks synovial membranes of tendons. B-100 complex twice a day can get the B3 and B6 that is needed. Vitamin C is very important for scar tissue to heal back strong. 10,000 mg per day should be taken before, during, and after surgery, if it does not cause diarrhea.
Walmart is a good and inexpensive source for vitamins.
Grape seed extract (and other sources of bioflavonoid PCO's such as Maritime Pine bark extract) may dramatically improve vascular function and tissue strength. These new compounds may be very powerful.
It's with hesitation that I mention the following because it is potent stuff and my knowledge on the subject is very weak, if not in error. Androstenedione (the Mark McGuire steroid) and other over-the-counter testosterone boosters may increase the rate of tissue repair. Side effects include feeling good or extremely good and more active and happy, possible increase in aggression, deepening of voice(?), acne(?), prostate hypertrophy(?), prostate cancer(?), other masculization effects for women such as more hair on the lip and face, and increased male-pattern hair loss in men already pre-disposed. And extra muscle when combined with workouts. Probable weight increase (but a lot of it muscle). I bought Substrate Solutions' Androdiol product and seem to be having excellent results. Testosterone boosters are not supposed to cause liver and kidney damage like the illegal weight-lifting anabolic steroids because it is a natural (not fake) steroid? The Nor-testosterone is supposed to not have most of the negative effects, but I'm skittish of it because it's not pure testosterone (it's a fake testosterone) and may cause liver damage (but I've not read that anywhere that it does). See Mesomorphosis for purchasing info. Their prices appear good.
Several visitors to this site have recommended chondroitin sulfate (1200 mg per day) and glucosamine sulfate (1500 mg per day), but this is supposed to be only good for osteoarthritis (some PF cases are actually osteoarthritis). One or two other visitors have strongly recommended calcium and magnesium supplements. Calcium may help stress fracture cases and magnesium may help to improve blood flow.
Omega-3 fatty acids are well known to reduce inflammation and alleviate arthritic symptoms. The best natural sources are sardines, herring, mackerel, and wild salmon (which has
much more omega-3 than farmed salmon). Fish oil supplements have not been shown to be as effective. I also recommend omega-3 from flax seeds from a health food store. Preferably, they should be kept in the refrigerator and, according to Dr. Weil (www.drweil.com) "grind a half cup or so at a time in your blender or coffee grinder. Sprinkle a tablespoon of the resulting meal onto salads, baked potatoes, or cereals." It has a high fiber content so it can cause gas. Flax seed oil may be as good, but it can very easily turn rancid and ineffective. Don't buy it unless the health food store keeps it in a refrigerator and observe the expiration date. Eliminate polyunsaturated vegetable oils and trans-fatty acids, such as margarine and partially hydrogenated vegetable oils.
Dr. Weil also says "To reduce inflammation, take two 500 mg capsules of powdered ginger once or twice a day with food, or one 400 to 600 mg capsule of curcumin ( obtained from the spice tumeric) three times a day." It may take 6 to 8 weeks for full effects.
Vitamin B12 injections and folic acid have also been said to help.
Heel Pads
If placing 1/2" of carefully folded paper under the heel immediately relieves the pain, stretching the calf muscles without re-injuring the fascia is needed. If you use heel pads 1/2" high, use them for both feet so that problems do not result from uneven leg length. The heel pad lessens the amount of pull the fascia experiences when the trailing leg lifts off the ground when walking. Turning the front of the foot inward towards the other foot (outward also works) while walking lessens the strain on the fascia. This is important for those early morning or middle-of-the-night walking times when you have not put on shoes that have heel pads. The fascia can be re-injured every morning or evening by walking barefoot. Most heel pads are less than 1/4" thick when compressed. Folded paper under the heel pad may be necessary to raise thin heel pads higher. Using heel pads while playing sports such as tennis greatly increases your chances of severely injuring an ankle during a turn or a stop sideways. A calf muscle stretching program should be continued while wearing heel pads so that a dependency does not develop. Heel pads should be placed under inserts. Heel pads on top of inserts or shoes with arch support nullifies the benefits of the arch support. See the products page for where to purchase heel pads.
Reducing the Inflammation
Inflammation in the heel area (even though you may not be able to see it) can increase the amount of heel pain, 24 hours a day. To alleviate the pain due to inflammation, elevate the heel as high above the heart as possible for as long as possible. Sleep on your stomach with your foot on top of two pillows. Prop your feet up on your desk. It takes 15 to 60 minutes in order to see the difference (or maybe several hours for several days in a row). Compression using Ace bandage is also very helpful. See the vitamin section above on omega-3 fatty acids, ginger, etc. Anti-inflammatory medication: Doctors usually prescribe a non-steroidal anti-inflammatory ("NSAID") pill such as Naprosyn (naproxen) (same as over-the-counter Aleve except in a double-strength dose) or
Daypro (oxaprozin) (works great for me) or a corticosteroid such as Deltasone (prednisone) in other cases. I've been told by two sources that 4 Ibuprofens (Advil, Motrin) (200 mg each) 3 times a day (12 per day) will reduce inflammation, but the bottle says "Do not exceed 6 caplets in 24 hours unless directed by a doctor." Taking NSAIDs with food and water is highly recommended because of the upset stomach they can cause. Long-term use of anti-inflammatory medications causes intestinal damage that kills an estimated 8,000 each year. Be sure to read the dangers associated with your particular NSAID such as not drinking alcohol, staying out of the sun, and interactions with other blood thinners. Some NSAIDs are significantly dangerous to your gastro-intestinal tract. Aspirin and Ibuprofen are excellent NSAIDs but Tylenol is not an NSAID. A good source for prescription drug info is www.rxlist.com.
Massage
Frequent massage of the fascia, especially in the morning, increases fluid flow in the area which speeds healing. Massaging the calf muscle before stretching in the morning can also help. Vigorous, deep massage of the fascia may also help by breaking up scar tissue. Once sources claims that once it is broken up, stretching the fascia by bending the toes back for 10 seconds, 10 times each day, will allow the tissue to heal back stronger and more resilient. Vigorous massage to break up scar tissue before getting an injection has been recommended.
Injections
Corticosteroid injections are often used to reduce pain and inflammation. It is a controversial topic among doctors. Some doctors report a lot of success with shots. Other doctors strongly advise against shots because they slow down the healing process and can cause long-term damage. The relief is often only temporary. 35% to 50% of our survey respondents have had shots. Shots will mask the pain, so it may not be wise to jump back into activity. One source says there are "water-soluble" and "fat-soluble" cortisones, and that the "fat-soluble" type stays in the tissue longer, thereby causing withmore tissue damage (but more pain relief). Vigorous massage to break up scar tissue before getting an injection has been suggested. Shots are often very painful. One source says that in order to reduce the pain when injecting, a medial approach using a long and small diameter needle and local anesthesia are necessary. Another source says cooling the area with ice or a spray before injecting helps. 50% of 500 visitors to this page who had shots said they were "pretty bad" or "horrific". The other 50% said they were "not too bad". Some doctors will give shots before resorting to a cast or surgery. Doctors usually do not give more than 3 shots. A new journal article says shots sometimes cause significant harm to the fascia. In response to our survey question "Have you stopped seeing a doctor to avoid further injections?" 17% of those that had shots said "yes". 14% said "sort of". This could mean a high percentage of cases are being considered by doctors as "cured" when patients are avoiding further shots. Since 50% of the shots are reported as not being very painful, this means at least twice as many as 17% (34%) and up to (17+14)x2=62% of the painfully applied shots could be counted as successes when they are actually failures. However, keep in mind our surveys select a very biased group of sufferers (probably chronic, hard-to-cure cases) in the sense that the survey respondent has to be interested enough in plantar fasciitis to look it up on the internet and fill out a survey.
Casts
A study reports 63% of their 40 patients who wore a cast reported mild to excellent success. Four to Six weeks in a cast provides rest and neutral stretching. See the journal articles page for info on that study. There are removable casts available from some doctors that are an excellent alternative. Doctors or physical therapists can make a cast that is open on the top so that the patient can strap their foot and ankle inside using ace bandage. However, I believe the Strassburg sock is a better alternative.
Surgery
In our survey of 1300 visitors, it appeared 6% to 8% had surgery.
A podiatrist/lawyer emailed to say they have represented clients in the mis-use of EPF. See www.footlaw.com
Vitamin C is very important for scar tissue to heal back strong. Vitamin C is required in several of the steps in collagen formation. At least 4,000 mg spread out over each day should be taken before, during, and after surgery. Vitamin C used to be used to speed recovery from surgery.
Endoscopic Plantar Fasciotomy (EPF) is often the last resort. There are several other surgery options. Surgery has a success rate of 60% to 95%, depending on which source is quoted (or on which doctor performs it). EPF is the newest method. Other surgical techniques are still more common and require a larger incision (up to 2 inches) that takes longer to heal (8 to 12 weeks), but doctors may prefer the older methods to endoscopic plantar fasciotomy because it allows them to see better and cut more accurately (possibly to relieve nerve entrapment). Some cases heal in 3 weeks, but others can take several months. Several sources say EPF surgery is ultimately required in about 10% of the cases. You may need to display symptoms a full year under proper treatment before a doctor will consider it. Endoscopic plantar fasciotomy is relatively new and requires equipment that some doctors may not have. Endoscopic plantar fasciotomy was first performed around 1991. It takes 20 minutes to an hour and does not require a stay in the hospital. The surgeon detaches (cuts) a portion of the fascia from the heel. A slotted tube is inserted through two small incisions (less than 1/2") in the skin on each side of the heel. Sometimes an incision is made only on the inside of the heel. A knife inserted down the tube pokes out of the slot, cutting the fascia. An endoscopic camera is inserted into the tube to allow the surgeon to see what he is cutting. The cut fascia usually relieves pain and pressure in the area. New fascia tissue grows into the gap created by the cut. Practice on cadavers is necessary. The two-portal (two incisions) method was patented by Dr. Barrett in 1993. Dr. Barrett says "Most patients return to their regular shoes in 3-5 days. Most return to work after the first week, and return to their normal activities by the end of the third week. Everyone heals slightly differently. Other
factors such as age, weight, and occupation can contribute to healing times." The arch may fall some or have other problems after surgery. Using orthotics after surgery was recommended by one source. One journal article says surgery in those with flat feet may not be good (the exact quote is: "The data suggest that operations involving fasciotomy affect arch stability and should not be performed in patients with evidence of concomitant pes planus deformity, because of the likelihood of further deformation"). I have not seen any other article on EPF surgery that suggests those with flat feet should not get the surgery. A doctor informed me that he has seen about 500 cases of plantar fasciitis ( heel spur ) in the past two years. 50% of his patients get better with better shoes (New Balance-especially if you have wide feet, Nike, ASIC gels, Rockport dress shoes), rest, NSAIDs, frequent massage, ice, and stretching. He subjects the other 50% to the shots. Out of ten patients, 5 get the shots. 3 of those 5 are cured with the first shot. The other 2 get the second shot. One of those is cured. The last one (out of the initial ten) gets EPF surgery. He reports only 1 or 2 surgery failures out of 50. After the surgery, patients are walking the same day without pain. In 4 weeks their activities are back to normal without pain. He no longer performs surgery on both feet at the same time. Dr. Lundeen (www.drlundeen.com) says "Beware if a surgeon says the spur needs to be removed, a cast or cast brace is needed after surgery, or if your doctor does not perform other arthroscopic procedures." See the surgery page for more information. Complications: The most pessimistic outcome I've read is that it causes the arch to drop some and/or cause other foot problems in addition to not curing the original problem. Two other sources say pain, infection, slow healing, and numbness due to nerve problems are more common. Dr. Lutter says "Surgical techniques that involve partial or complete resection of the plantar fascia are based on the erroneous premise that total release of the plantar fascia is necessary. Currently, removal of only a small (one third) portion of the plantar fascia is recommended."
Loss of sensation or tingling in the toes may indicate that the nerves in the heel have been damaged. The doctor may accidentally cut a nerve during surgery or inflammation from surgery may put pressure on the nerve and cause pain, loss of sensation, and/or tingling. The doctor may call it "peripheral neuropathy" without admitting any fault. It is not necessarily permanent damage. Surgery has also been said (by a doctor in England) to pose the risk of injuring arteries supplying blood and thereby increasing healing time.
Other
These are methods of which I have only recently become aware or consider questionable. Prolotherapy is a series of injections (different from those described above) that are supposed to speed healing of ligament tissue (fascia is similar to ligament). See www.prolotherapy.com for more info. Ionotopheresis is applying current through electrode pads placed on the skin which is covered with a gel or solution of steroids or other chemical. The current carries the chemical through the skin. The current itself may also help. You may see this at your physical therapist's office. Study info on iontopheresis: 6 times for 2 weeks helped some but there did not seem to be a lasting effect after 1 month. A pedorthists, I think, are some type of shoe and orthotic specialists. Acupuncture, magnetic inserts (or a magnet at the painful spot - radio shack has special strong small magnets), and chiropractors have been used, but I think they are questionable treatments for plantar fasciitis.
Overweight Study Information
A study reported 77% of its sample of 411 plantar fasciitis ( heel spur ) patients were overweight. Another study of 14 patients indicated the patients were an average of 20 pounds overweight. The only patient that clearly failed treatment in that study was 60 pounds over weight. A third study reports 23% of overweight women had plantar fasciitis ( heel spur ) compared to 8% of the normal body weight group. About 1/3 of the visitors to this page weigh 200 pounds or more. For comparison, the average 6 foot American adult male weighs 186 pounds. Women with plantar fasciitis have been said to be much more likely than the men to be overweight.
Heart Disease, Cancer, and Diabetes
Strong anecdotal evidence indicates 5,000 milligrams of lysine and 5,000 milligrams or more of vitamin C spread out over each day will reverse angina in 2 to 4 weeks. Email me at if you try to cure your angina using this method and have either success or failure in 4 weeks. Lysine is an amino acid (a component of protien) and is perfectly safe at almost any dosage (unless there are serious kidney troubles). For cancer, 10,000 mg or more vitamin C spread out over each day for cancer, along with high doses of vitamins A, E, selenium, other antioxidants, and the B vitamins. Diabetes: 5,000 mg or more vitamin C, up to 800 mcg chromium, and magnesium. Be careful, your need for insulin and glucotrol pills can decrease dramatically - be sure to monitor your blood sugar. See also http://heelspurs.com/cure.html.
