What can you do about pain under the foot?

Plantar fasciitis usually goes away within a few months – even without treatment. But most people would like treatment to relieve the pain, which is often very severe. The only treatments that have been scientifically proven to help are extracorporeal shock wave therapy (ESWT) and (for short-term relief) steroid injections. Many people find that cooling and stretching help too, and have hardly any side effects. Even if you do seek medical treatment, you’ll usually need to be patient because it can take quite some time to make a complete recovery.

The recommended approach is first to reduce the strain on the foot, cool the sole and (if possible) start doing stretching and strengthening exercises. If the pain is very strong, you can also take painkillers for a short time.

If your symptoms don’t improve after a few weeks, extracorporeal shock wave therapy (ESWT) or steroid injections can be considered. Surgery is also a possibility as a last resort. But steroids have side effects and it’s not clear whether surgery is effective.

If there are any risk factors, like a foot deformity or another inflammatory disease such as rheumatoid arthritis, it’s important to get them treated too.

You might find it soothing to cool the painful area several times a day using a cool pack like a gel cooler. Make sure you don’t overdo it though, as too much cooling can damage your skin. The soothing effect will wear off after a while.

Cooling the sole of your foot just before you put strain on it can also be helpful; for example, before carrying heavy bags or walking a long distance.

Comfortable shoes that cushion your step or protect your heel can lessen the strain on your plantar fascia. These features can be found in many sports shoes. If you have short calf muscles, shoes with a small heel of 2 to 3cm might provide short-term relief. This is because they raise your heel slightly, which reduces the tension in your plantar fascia and calf muscles.

Another thing you can try is putting a heel pad or cushion in your shoe. You can get them from medical supply stores or drugstores. Walking barefoot isn't such a good idea because there’s nothing to cushion the impact of your steps on the sole of your foot.

Stretching and strengthening exercises to help treat plantar fasciitis should focus on the sole of your foot, your Achilles tendon and your calf muscles. In Germany and other countries, you can get a prescription for physiotherapy for these exercises, or your doctor can show you how to do them. The important thing is to make sure you understand how they’re done so you can do them properly at home.

Physiotherapy treatment usually involves a combination of exercises. Sometimes the physiotherapist will also use massage or mobilization techniques. Mobilization means that the physiotherapist moves the foot around as far as it will go.

Inflammation-reducing painkillers like non-steroidal anti-inflammatory drugs (NSAIDs) can ease the pain. Examples of NSAIDs include ibuprofen and diclofenac. Unless they’ve been prescribed for you, these medications shouldn’t be taken for more than a few days. When taken for short periods of time, they’re usually well tolerated. But side effects such as nausea or stomach ache are possible. Because of this, NSAIDs are sometimes combined with medications that protect your stomach.

There are also ointments and gels containing the same active ingredients. But there's a lack of research on how plantar fasciitis responds to these painkillers that are applied directly to the affected area.

Sometimes taping is recommended but it's not clear whether this has any advantages. There is also no evidence that acupuncture or dietary supplements help in plantar fasciitis.

If the symptoms still haven’t improved after several weeks of trying various treatments, steroid injections are commonly recommended. Steroids have an inflammation-reducing effect and can relieve the pain somewhat, particularly in the short term.

The steroid medication is injected right next to the plantar fascia, often in combination with a local anesthetic. Sometimes an ultrasound scan is used to determine exactly where to insert the needle.

You will normally not be given more than two steroid injections because of the unpleasant side effects: they can damage the tissue, affect the fat pad under the heel, and increase the risk of the tissue tearing. As with all injections, there’s also a risk of infection and nerve or blood-vessel injury. Sometimes the pain straight after the injection is so severe that you need a painkiller.

ESWT involves exposing the plantar fascia to high-pressure sound waves that are passed through the skin of the heel. The aim is to promote the production of healthy tissue and speed up the healing process.

First, a gel that passes on the shock waves is applied to the painful area. Then a hand-held device is placed against the sole of the foot to send the waves into the tissue.

ESWT helps to ease the plantar fasciitis pain and make you more active. But it’s not clear whether ESWT is more or less effective than other types of treatment. Early research findings have shown that it can’t ease pain as well as steroid injections can. Having said that, it doesn’t have any serious side effects.

ESWT is considered a low-risk form of treatment but a local anesthetic may be needed because of the pain. You may have bruises, a tingling sensation and/or a rash after the therapy.

In Germany, ESWT is offered by orthopedic specialists, orthopedic/trauma surgery specialists, and physical medicine and rehabilitation specialists. Statutory health insurers will pay for up to three sessions – but only if you’ve had the plantar fasciitis for at least six months, and various conservative (non-surgical) treatments such as resting, stretching exercises and insoles haven’t provided enough relief.

Surgery is considered as a last resort when nothing else has helped. The surgeon cuts part of the plantar fascia, or all the way through it, to relieve the pressure on it. Sometimes, if the calf muscle is too short, the surgeon will “release” it by cutting into it so that it stretches further. The surgery can be open or minimally invasive (keyhole surgery – performed through a small cut in the skin).

There is no good-quality research on whether surgery helps, and to what extent. And you need to bear in mind that surgery can cause nerve damage. Other possible side effects include swelling and pain around the middle of the foot.

A range of other procedures to relieve the pain are available (including treatment using x-rays, lasers, ultrasound and electrotherapy) but they haven’t been proven to help people with plantar fasciitis. There's a lack of research in this area and the findings so far have been inconclusive. But these treatments can have side effects or involve risks such as exposure to radiation from the x-rays.

One form of electrotherapy commonly used to treat plantar fasciitis is called iontophoresis. This involves sticking electrodes to the sole of the foot and then placing the foot in a tub of water. An electrical current is then passed through your skin. The current is harmless; at most, it might cause a slight tingling feeling. Another form of electrotherapy is known as nerve stimulation. Here, electrical impulses are passed through the skin into the nervous system. The aim is to ease the pain without having to use medication.

Sometimes, people with plantar fasciitis are offered injections containing blood, plasma or high concentrations of certain parts of the blood – like growth factors or platelets (thrombocytes). But there's no proof that these injections can ease the symptoms. Actually, they can even make the pain worse for a few days and are associated with a general risk of infection and nerve and blood-vessel damage.

There is also a lack of research on injections containing other substances like botulinum toxin or certain sugars. As a result, it’s not possible to say whether these injections are actually effective and what side effects they have.