By Dr. Steven Gershman, DPM
Plantar fasciitis is causing "A real pain in the foot”. That is what many patients complain about to me as it disrupts their life. It makes it hard to stand, walk, run, and work. Many patients have severe issues working with this foot condition as plantar fasciitis pain can be very debilitating. So, what can seem like just "foot pain" can be life altering.
What is plantar fasciitis?
Well the story starts with discussing the culprit, the plantar fascia, a thick, web like ligament on the bottom of the foot. The plantar fascia lies just under the skin and in most people can be easily seen and felt by pulling the toes up. This causes the fascia to tighten and stick out to be easily visualized and palpated, especially in the arch area. It feels like a tight band there.
Anatomically, the plantar fascia connects from the calcaneus (the heel bone) to the base of the toes which means it stretches almost the full length of the foot. Like a ligament it connects bone to bone, but structurally it is closer to a tendon with limited blood and nerve supply. These characteristics are part of the reason it is often slow to heal from injury. The plantar fascia is made of collagen based connective tissue and as it stretches out in a wide band it is properly called an Aponeurosis.
Functionally the fascia acts like a tie-rod to hold the foot together as it connects the toes to the heel. When the arch is at maximal height the fascia is shorter as the foot is shorter. As a person stands and the arch drops, the foot lengthens and stretches, elongating and tightening the fascia. In the gait cycle when walking or running, as a person pushes off, the toes flex back which causes the fascia to tighten and raises the arch to stabilize the foot for propulsion. This is called the "windless mechanism". Dysfunction in this action is one of the causes of plantar fasciitis as will be discussed later in this blog.
Symptoms of Plantar Fasciitis
Plantar fasciitis is pain anywhere on the fascia including the most common bottom of the heel pain. The most prevalent scenario is pain when first standing and then it often temporarily improves after moving around, only to get worse as there is continued activity. Often the more time on the feet, the worse the pain. It is not truly an inflammation as much as actual micro trauma damage to the fascia with some structural breakdown due to being overworked or stressed. There can also be periostitis of the heel bone, inflammation of the periosteum, the coating over the bone. As the fascia connects to the periosteum it becomes all involved and is called plantar fasciitis. In my 31 years of treating heel pain, this is more common than pain further up the fascia in the arch.
Another type of pain in the bottom of the foot can involve neuritis or nerve pain as the heel has several nerve branches passing along and under it. If these nerves are irritated there can be a burning pain radiating around the heel and often pain up the leg. Often neuritis occurs together with fasciitis causing foot and leg pain. As we age, the fat pad on the bottom of the heel thins out which can lead to periostitis from direct trauma to the bone/periosteum and/or neuritis from the nerve under the heel being compressed between the bone and the floor.
What causes plantar fasciitis?
There are multiple causes of this syndrome. Often in a patient there is more than one cause.
- Dysfunction in the windless mechanism mentioned above is a major cause. The fascia is over worked and stretched when the mechanism malfunctions which leads to micro tears, structural damage and pain. A major cause of the windless mechanism malfunctioning is dysfunction of the big toe joint to the foot. If the big toe can’t flex properly the windless mechanism will not work correctly and this can damage the fascia. Big toe joint dysfunction can occur from actual damage to the joint from arthritis or from over pronation where the arch flattens on stance jamming the joint.
- Other causes of plantar fasciitis are weight gain which puts physical stress on the foot. The fascia being a tie-rod stabilizing the foot will be overworked by excess weight as it works harder to handle the increased physical force. As mentioned above, fat pad atrophy with age can also cause pain in the heel at the fascia insertion on the heel. Simple overpronation where the arch drops cause lengthening of the foot which puts a stretch force on the fascia as it attempts to hold the foot together. This over works the fascia causing micro trauma and pain. This issue can be exacerbated by poor shoes or soft worn out shoes as pronation is often worse with soft or poor shoes.
Heel spur syndrome is not plantar fasciitis!
At this point I also want to discuss "heel spur syndrome " as it is often confused with plantar fasciitis especially when the pain is on the bottom of the heel. As the fascia connects to the bottom of the heel there can be fascia pain directly at the insertion point on the heel. This also can cause heel bone periostitis as the fascia connects to the periosteum. There is often a heel spur that develops on the tubercle on the bottom of the heel bone where the fascia inserts. The spur usually has little to do with the pain. In fact, on x-ray the foot with no pain had a bigger spur then the painful foot. I tell my patients the spur is often more of a barometer measuring stresses on the foot but not actually the cause of the symptoms. This means we don’t treat the spur itself and don’t need to remove it to minimize pain.
How to treat plantar fasciitis
- With almost no exceptions I ALWAYS start with SHOES for plantar fasciitis treatment. We ask patients to bring in most of their shoes for their initial visit and anytime thereafter they have pain. As noted above, shoes can be a major cause of fasciitis and other foot pain. If the shoes are worn out or improper, I start treatment with having them purchase new and more appropriate shoes. The shoes need to fit correctly as I often find patients wear shoes too short or too tight. This can affect the big toe joint function which damages the fascia as can over pronation from poor shoes. I have seen many patients improve in 2 to 3 weeks from just purchasing new more appropriate shoes that fit well. Each patient is different so I can’t recommend a blanket one style of shoe, but in general plantar fasciitis shoes need a solid heel counter to control motion, have a solid outer sole, and have some motion control features. Many patients need extra depth and width for unrestricted toe movement and a pressure free environment. Orthofeet, an orthopedic footwear brand, is one such company that biomedically designs plantar fasciitis shoes that help alleviate strain on the plantar fascia. Featuring ergonomic soles, they reduce impacts on the heel and provide soft protective cushioning. To learn more about Orthofeet plantar fasciitis shoes and view the styles click here.
- The next step in treatment usually involves some type of plantar fasciitis insole or orthotic. Since many patient’s main symptom is heel pain, the insert should cup and cushion the heel and support the arch. In general, a well-made insole will reduce pronation and help improve big toe joint function while cushioning the heel. This is the starting point in my office for most of these patients. For over 25 years I have used the Orthofeet Bio-Sole Gel non custom orthotic as my first line of treatment along with shoes. This insole has a gel heel pad in the heel cup, an anatomical arch support and tends to mold to the specific shape of the foot over time. I have tried many other non-custom or temporary orthotics and none have compared to these in positive effect and comfort. They are very comfortable from the moment they are inserted in the shoes, which patients really appreciate and will actually wear them as a result. Click here to view Orthofeet Bio-Sole Gel orthotics. If this treatment doesn't work well enough, I will consider custom foot orthotics if they are appropriate for the patient.
- Cortico-steroid ("cortisone ") injections are another treatment. It may require 2 to 3 injections. I usually wait until the patient has proper shoes and inserts before I administer this as the injection success rate is higher when administered in conjunction with the shoes and inserts. Also, another option for plantar fasciitis pain relief is oral steroids such as prednisone or non-steroids such as ibuprofen.
- If all the above fails, I will have the patient wear an immobilizing boot 24 hours a day for a few weeks. To further increase effectiveness, the insole is inserted in the boot. From my findings, simple night splints are not very beneficial, but the walking boot worn also at night does have a powerful impact.
- Finally, if all the above treatment options don’t work, shock wave treatment may prove beneficial or surgery as a last resort. The issue with surgery is that it may improve symptoms initially, but it does destabilize the foot in the long run often leading to new pain later. For the most part, plantar fasciitis will resolve regardless in a year or less. Treatment helps speed it up.
So, going back to the title, can plantar fasciitis cause leg pain? The answer is a definite YES. In addition to foot pain there can be pain radiating up the leg. This can occur directly from nerve pain at the calcaneus branches which can radiate back up the nerve tract in the leg causing ankle and calf pain. Another cause of leg pain is when there is pain on the foot and in particular at the heel, people often change their stance and gait to avoid the painful area. This alters normal lower extremity mechanics which can lead to overuse injuries/pain to the muscles and tendons in the lower leg and sometimes in the upper leg, hip, and back. So, treatment for plantar fasciitis can affect more than just the foot.
Finally, plantar fasciitis is very common. If you develop pain on the bottom of the foot, the sooner you seek out medical help, such as a podiatrist, the sooner you will improve. Waiting longer just causes more pain and is more complicated to treat as well as slower.
The good news is plantar fasciitis is very treatable. No one should have to live with "A PAIN IN THE FOOT".