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Our staff writers, medical team and others, writing about plantar fasciitis and its treatment

What is plantar fasciitis?

If you’re arrived at this article, there’s every chance you’ve been to see your GP because of pain in your feet, or more specifically pain in your heel or heels. You may have been diagnosed with a common and painful condition called plantar fasciitis.

So, let’s start with some basic definitions like what it is and how to pronounce it. The plantar fasciitis (phonetically pronounced – with emphasis on the bold text as plan-ter fash-ee-eye-tus) is the most common cause of heel pain in both men and women.

The condition is named from the plantar fascia which is a ligament flat on the base of the foot that connects the ball of the foot and the toes to your heel bone. You can think of it as a band of tissue that holds the bones of your foot together, expanding and contracting when working properly to allow the foot to flex, thus supporting walking and movement.

When we experience pain in our feet, and especially in the heel, it is often due to a strain of the plantar fascia. That strain manifests as pain, maybe at the front or centre of the heel bone, or it may be across the whole base of your foot. The connective tissue that is the plantar fascia has very little stretch and therefore can become inflamed, swollen and thus weakened. This pain can be experienced as an uncomfortable ache or a crippling pain, depending on the severity of the swelling of the plantar fascia, hence the term plantar fasciitis.

The condition is often felt most acutely first thing in the morning on waking when we try to take our first steps or after walking or light exercise. The heel pain may be more extremely if walking or running. The condition will be aggravated for those who have to spend all day on their feet at work or who are used to taking exercise or doing sport that involves running or jumping.

If the heel pain you’re experiencing is severe enough, your GP, who will probably have examined your foot to look out for any bruising and redness, may also send you for an X-ray or even an MRI scan. The reason for this is to rule out any other causes of pain such as a broken bone or a trapped nerve. Your doctor may also look at whether you are flat footed and what sort of support you have within the structure of your shoes. He or she may ask you if you often wear flat shoes or go barefoot. All of these aspects may contribute or point towards a diagnosis of plantar fasciitis.

Based on your answers to the above questions, diagnosis is often made without the need for further investigation, especially if you are able to recognise the following key symptoms yourself:

  • Waking up with pain on taking your first step in the morning
  • Feeling of an ache or bruising in the foot
  • Increased pain after walking or exercise
  • Radiated pain into the ankle
  • Easing of pain after rest or gentle stretching

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Avoiding painful feet – or – How not to get plantar fasciitis!

Believe me, you do not want this condition, not under any circumstances at any time. It is agony, agony to get out of bed in the morning, to walk, to run, to cook dinner at the end of the working day, to enjoy a day on the beach with the children.

If you don’t mind hobbling around like a very old person walking on broken glass, then ignore what I say. But if you have a job where you stand most of the time, especially in high heels, or if you spend long hours walking on hard pavements in soft ill-fitting shoes or if you are a jogger or athlete who allows his or her running shoes to wear out then take heed. Plantar fasciitis is absolute hell.

So what is the first symptom of this painful foot problem? You happily carry on with your usual activities until one day your heel feels very sore. Or maybe it is the ball of your foot. (or both of them – woe betide you if you get it in both feet at once). You notice the pain is very bad when getting out of bed. If you walk any distance the pain gets worse and soon it is the sole of your foot that hurts and sends stabbing shooting pains up your leg. If you have flat feet or fallen arches you might be tempted to blame these. You might even wonder if the bunion you inherited from your mother is the cause but don’t be fooled.

Now is the time to take measures to prevent the condition worsening because if the offending ligament in the sole of your foot weakens and tears you are in big trouble. At the moment you merely have inflammation, which is bad enough, as a result of overdoing the wear and tear on your poor tootsies. To begin with I would suggest resting with your feet up as much as possible. Scour the internet for some well made supportive shoes and junk the worn ones. If standing for long periods try a rubber mat to relieve the stress and spend a few moments before you get out of bed in the morning massaging the Achilles tendon above your ankles and stretching your feet forward and back.

You may have to give up the jogging or at least alternate your running with other sports. Stretch your Achilles tendon before exercise and lose some weight if you pound round the track like an elephant. If all this advice fails and the agony becomes more intense you will give up smiling and consider going to the doctor.

First though, you might try some of those insoles that are designed to support the feet. Then look for some simple exercises on the web, like rolling the foot backwards and forwards on a tin can or a bottle of water. Your family will wonder what you are up to but hey, they don’t have the pain. Any stretching exercise would be good too, with a long stretchy length of material like a towel. The stretching will loosen the tight ligament. Even pulling your foot forward with your hands will help.

These are things you can do yourself but if you are unlucky enough to need the advice of a doctor your interview might go in several ways. He will diagnose the problem and begin by recommending all the measures described above. In a few months, depending on your determination to persist with the exercises the inflammation will subside, the tears will heal and you will be free of the pain.

On the other hand, if you are elderly, he may tell you that growing older inevitably brings a few aches and pains, that you probably have a touch of arthritis and you should take more exercise. He might conclude his nine and a half minutes with you by writing a prescription for painkillers. If this happens you must visit the surgery again and practice your assertion skills because every older person deserves to sail into their declining years as fit as they can possibly be without the curse of chronic pain if it can be avoided. And that is what you will get if plantar fasciitis is left untreated for long years.

Let me tell you of a friend of mine. She is in her seventies and has had foot problems for many years, assuming the pain to be part of growing old. She can no longer enjoy a morning window-shopping in the town. She can drive but must not park too far from her destination because the walk is difficult. She stays mostly at home as going anywhere has become problematic. The rest of her is in pretty good shape but she’s philosophical and accepts what her doctor tells her.

It’s probably too late now. It is likely the ligaments and muscles in her feet and ankles have become stiff and tight with multiple small tears and there probably is some arthritis too. Had she been aware in those early years and taken good advice, even nagged her doctor, she might have been tripping around like a teenager now.

So you’ve been told you have plantar fasciitis? Be warned, 23% of doctors misdiagnose the condition.

A recent study of 310 patients in the University of California research department showed a surprising statistic. Although all patients in the study had joined because they suffered from plantar fasciitis pain, a painful disorder of the plantar fascia fibres, nearly a quarter had been misdiagnosed. That’s 71 people who turned up on day one to be studied, and left the first day.

So you thought doctors were never wrong? So did we. The general understanding of the condition by the medical community in the UK is comprehensive and it is rare for doctors to get their diagnosis significantly wrong unless it is a rare and complex issue. If you’re sitting here reading this with plantar fasciitis and have been diagnosed with a simple examination of the foot then read on.

We looked at similar studies in the UK to see if the effect was replicated here. Initially there didn’t seem to be much data on misdiagnosis until we looked at Pub Med, the collection of medical research available to doctors and medical professionals. What we saw was startling. A chochrane review, that’s a review of a large number of clinical trials, showed that it was fairly common for people in medical research to start with a group of people, a cohort if you want to use the correct name, and immediately remove those who don’t suffer from the condition the researchers recruit for. In fact, over 28% of trials we looked at suffered from this early bias. That’s over a quarter who’ve been misdiagnosed. So what’s going on? We looked further into the data.

5% of the studies contained people initially withdrawn because they had flat feet or bunions. These people were originally diagnosed with heel pain and their GP reported their condition as plantar fasciitis, but on further investigation they were found to have the symptoms but not the cause. An overwhelming majority (54%) had plantar fasciitis but combined with pain in the ball of the foot. A podiatrist referral had suggested PF as the main cause of painful feet but further investigation had shown that the source of the pain was muscoskeletal rather than the plantar fascia itself. So that’s well over half already. 19% were wearing orthotics, no problem at all there, plantar fasciitis sufferers often wear orthotics and heel cushions to help with the pain. Except here, it seems the orthotics were causing the pain. In essence, misdiagnosis was wide ranging with no specific cause but significant.

So, what have we learnt? It is a fact that NHS doctors have on average 7 minutes per consultation. This includes time to meet and greet and say goodby. In between they have to diagnose the condition accurately and make a recommendation for treatment. This is particularly problematic with foot problems. Painful feet can have a number of differing causes and it seems that plantar fasciitis has become a simple catchall for doctors to use as a generic diagnosis. It is only later when a foot specialist looks into the problem, as happened with the clinical trials, that painful feet are diagnosed as something else, often a heel spur or bone spur or something which can be easily be treated with orthotics.

So the next time you’re in the doctors surgery with painful feet, remember, if you’re not convinced get a 2nd opinion. Or start with a podiatrist who specialises in foot pain. It may help save time and effort.

Have you been misdiagnosed or struggled to get your doctor to come up with a treatment plan? Let us know. We’d like to hear from you.

Doug Finnie,
Pharmacist.