Plantar heel pain, or pain under the heel, is one of the most common reasons people see a podiatrist, accounting for 15% of all adult new patients. Plantar fasciitis is the main reason for heel pain and is due to a degenerative inflammatory injury to the ligament that stretches across the arch, from the heel bone to the ball of the foot. The function of the plantar fascia is to support the arch of the foot as you are walking. Inflammation can occur anywhere along the ligament but commonly where it joins onto the heel. It feels like a dull ache most of the time but is most painful when first resuming activity, such as getting out of bed in the morning or standing after sitting. Other less common causes of heel pain include pinching a new near the heel, stress fracture of the heel, a complete or partial plantar fascia tear, or a systemic inflammatory condition such as rheumatoid arthritis.

Like many foot problems, there is usually not a single cause but several factors, so more than one treatment is necessary. Factors contributing to heel pain include age, increase in activity level, for example, when starting an exercise or walking program, change of footwear from well-supporting walking or athletic shoes to floppy sandals, occupations where you may be standing or walking on hard surfaces for long periods, recent weight gains, and abnormal foot function (biomechanics) such as flat or excessively high arched feet and tight calf muscles.

Sometimes, on an x-ray, you will see a spur of bone, but they are not the cause of heel pain. They are usually due to chronic inflammatory changes where the plantar fascia joins onto the heel. X-rays may show a spur on the heel, but research has shown that about 16% of the population have heel spurs visible on X-rays, yet less than 4% have any pain. Other people have pretty significant heel pain but no spur. Diagnostic ultrasound, which looks mainly at soft tissue, is much more helpful in determining the structures causing the pain.

Given other potential causes of heel pain, correct diagnosis is the first step. This involves a clinical examination and sometimes an ultrasound examination. Treatment is directed not only at reducing the inflammation associated with the plantar fascia but also at addressing the cause of the inflammation.

Stretching exercises, particularly in the morning, is helpful with some of the initial pain when you start walking.

Ice and massage at the end of the day. Ice is an excellent anti-inflammatory.

Non-steroidal anti-inflammatory medication, such as Ibuprofen or Voltaren, can be helpful for a short period but not very beneficial in the long term.

Strapping the foot can relieve heel pain by reducing the tension on the plantar fascia. We will do this for two reasons: first, to give some relief, and second, as a diagnostic test to see if reducing the tension can ease the pain. We will follow this up with support.

Orthotic devices are used to continue the relief as strapping is not practical to use in the long term. Orthotics are beneficial when there is abnormal foot function. They are usually custom-made using a digital scan of your foot. There are many different types of orthoses and readymade varieties. Everybody has individual needs, which vary depending on the kind of devices used. We will prescribe an appropriate orthotic to your needs if orthoses are indicated.

Compression sleeves around the foot and heel can help reduce swelling and provide additional support.

Footwear is also related to the support you can achieve with an orthotic. Orthoses are not suitable for all types of shoes, but these days, quite a lot of shoes provide good support without needing orthoses. Plantar fasciitis is one condition that is improved by wearing a shoe with a slight heel.

Cortisone injections into the areas of inflammation can give fast relief, but unless you also address the underlying cause of plantar fasciitis, the pain can come back.  Cortisone works best when combined with other treatment modalities such as orthoses, stretching, and appropriate shoes.

Plasma-rich protein (PRP) therapy is a treatment provided by some radiology practices and shows some potential.

Extracorporeal shock wave therapy (ECSWT) is used in some recalcitrant heel pain. It involves a course of three treatments spaced out weekly. It uses a pulsed high-intensity ultrasound beam directed into the heel. Research has shown relief is not instant; the peak effect takes 6-8 weeks. ECSWT has become very popular and is a valuable treatment for recalcitrant heel pain.

Dry Needling is another treatment that is gaining popularity as an alternative treatment.

Surgery may be necessary if you don’t respond to conservative, non-surgical treatment. Surgery is directed at releasing a portion of the plantar fascia and can be done through a small incision in the instep. If a spur is present, it is rarely removed. Surgery, in most cases, is not required, but it is worth considering if your heel pain significantly affects your lifestyle and is unresponsive to conservative treatment.

Most heel pain will settle down in time. We talk about the 90/90 rule with plantar fasciitis, in that 90% of patients can achieve 90% improvement with treatment, but unfortunately, there is still that minority of patients who do not settle down. Some people recommend no treatment at all for plantar fasciitis, which is ok if you don’t mind putting up with the pain, but most people seek therapy due to the amount of discomfort.