One of the most common causes of heel pain, Plantar fasciitis (PF) typically causes pain that usually appears on the bottom of the foot, around the heel and arch. It is often more acute first thing in the morning, especially during the first steps in the morning. The disorder involves inflammation of the plantar fascia – a thick band of tough, fibrous tissue which runs across the bottom of the foot and connects the heel bone to the toes. It also supports the longitudinal arch of the foot and takes a lot of the load during walking and running. Plantar fasciitis is more commonly found in runners, people who are overweight and those that are more sedentary.
It can be difficult to treat and resistant to a host of different approaches. PF also tends to be self-limiting – it can go away of its own accord, this, however, may take a considerable amount of time, sometimes up to or over a year.
Symptoms of Plantar Fasciitis
One of the most common symptoms is pain, this tends to be felt in the sole of the foot with tenderness on palpation, and in the medial tubercle of the heel bone. Often the first few steps in the morning are the most painful, however, this gradually settles during movement. Movement such as running, walking barefoot or on your toes and going up stairs all tend to aggravate the pain.
Diagnosing Plantar Fasciitis
Diagnosis is typically through a detailed medical history and a physical examination and evaluation of symptoms. X-rays, MRI scans and other investigations are thought to be of limited value in cases of PF. Occasionally further investigation may be requested to rule out a differential diagnosis, for example, something else that could be causing the pain. An X-ray may reveal a heel spur, these are said to be present in around 50% of patients with PF, but are also present in around 20% of people without PF so the presence or absence of a heel spur may not be helpful in diagnosing PF.
The exact cause of PF is poorly understood, it can be present in sedentary, overweight individuals or very fit active runners and occurs when the plantar fasciitis itself is strained – this can happen for several reasons:
An Increased Load
PF is generally thought to occur when there is an increased load placed on the plantar fascia, either by certain activities (such as running) or by the patient’s individual biomechanics, or a combination of both. An increased load or strain may be the result of a number of reasons including:
- Certain types of exercise – running, ballet, aerobics, dancing.
- Running or exercising on hard surfaces.
- An increased amount of exercise.
- Exercising with a tight calf or heel.
- Foot mechanics, having flat feet, a high arch or an abnormal gait can put additional strain onto the plantar fasciitis.
- Being overweight.
- Inappropriate footwear.
- Age – it is more common between the ages of 40 and 60.
- Certain occupations – factory workers, teachers, hairdressers, or any other type of occupation which involves standing on hard surfaces for long periods of time.
Running and Training
Like many overload problems in runners, PF can be caused by training error – doing too much, too soon increased training volume or intensity, and hill work have all been identified as potential causes.
PF is sometimes associated with the shape of the foot – individuals with both a low arch and a high arch. Other biomechanical factors that increase the stress on the plantar fascia may also play a role, this can include overpronation and leg length discrepancy. Poor control of movement at the knee and at the hip is often associated with overpronation – typically, however, overpronation is accompanied by hip adduction (moving toward the other hip) and poor impact control.
Tight tissue can also lead to an increased risk of PF, one of the most common areas for this to occur is around the calf muscles. The Achilles tendon blends with the plantar fascia, therefore any tightness in this area places a greater strain on the fascia. Most treatment regimens involve gastrocnemius and soleus stretching as a result. If the tissue in the plantar fascia itself become tight, there are specific stretches recommended for this.
Old or inappropriate footwear can lead to an increase of stress upon the PF and cause pain. Shoe selection for managing PF can be difficult, as in some cases it may exacerbate the problem, rather than provide relief – irritation can occur when additional arch support pushes into the fascia, which may already be painful. In theory, a combination of support and cushioning should be useful to help to support the fascia without irritating it. Footwear with a reasonable heel-to-toe drop should in theory reduce stress on the plantar fascia, although people respond differently to different types of footwear and support, making it a good idea to try them out first by walking or running in them.
Running and Footwear
Running in flat or minimalist shoes can potentially cause or aggravate PF. Due to the much smaller (or non-existent) heel section, the ankle may be required to dorsiflex more during the impact part of running, this places greater stress on the Achilles and plantar fascia, depending on individual running style and form. A recent sudden change of shoes or trying minimalist running can provoke PF, making it important to ensure that any alterations should be performed gradually to reduce the chance.
Some shoes are designed to control foot position through the heel and have a heel counter or, in some, a rearfoot posting- a wedge shape under the heel to control its position. Arch support can be useful for those with high arches, as feet with high arches tend to be less flexible – another factor that can lead to PF – a cushioned shoe may be useful in these cases.
Research has suggested that weak calf and intrinsic foot muscles could both place greater stress on the plantar fascia. The calf muscles are involved in controlling impact and preventing excessive dorsiflexion and intrinsic muscles of the foot help to support the arch. Tibialis Posterior also has a role in supporting the arch of the foot – theoretically, a weak Tibialis Posterior or PTTD could also be a factor in PF.
Treatments for Plantar Fasciitis
Settle The Pain
There are a host of treatment options available from injections to extracorporeal shock therapy – treatment will very much depend on the individual. Initial treatment typically begins by trying to settle the acute symptoms; progressing straight to stretching may aggravate the pain caused by the inflammation within the fascia. A course of NSAIDs or application of an anti-inflammatory gel may offer some pain relief. RICE (rest, ice, compression, and elevation) can also help to settle symptoms. It is a good idea to avoid any activities or habits which may worsen symptoms such as walking barefoot, running, or prolonged standing.
Offloading the plantar fascia – this can be done using low dye taping and kinesiology tape to support the arch and reduce peak plantar pressures. Gel heel pads or a Tuli cup may be helpful, as well as orthotics. There are a huge variety of these products available both online and on the high street – it may be necessary to try out more than one product to see which one works best.
Calf Muscle Stretches
Calf stretches are possibly the most widely recommended treatment for PF and should be performed 2 to 3 times per day with 3 to 5 repetitions being held for 30 seconds each time. It may also be useful to turn the foot in or out a little during the stretch with the foot pointing straight forward.
A foam roller can also be useful in relieving tight tissue – this may be painful initially, but symptoms should improve with perseverance.
The calf muscles can also be strengthened with calf raises, although great care should be taken not to worsen symptoms.
Specific Plantar Fascia Stretch
This can be achieved by crossing the leg of the affected side over the other leg, then by grasping the toes and stretching them toes upwards – the area along the plantar fascia should remain taut. Then stretch the mid foot over a cold or frozen bottle/ can or a Pedi roller. If the ice proves too painful, this exercise can be performed with the Pedi roller.
Strengthening The Intrinsic Muscles of The Foot
A straightforward and effective way of strengthening the intrinsic muscles of the foot is to use the toes to pick up marbles or scrunch up a towel. This exercise can be performed several times a day at regular intervals to help to build strength.
These are designed to place a stretch on the Achilles and plantar fascia overnight, some people find this type of treatment useful.
Steroid is a potent anti-inflammatory that works well when inflammation is present. There may be some inflammation in acute PF, however, in more chronic cases it is thought to be a more degenerate condition, like tendinopathy, with minimal inflammation. The structure of the fascia changes and becomes less effective in managing load, in this case, a steroid injection is less likely to be beneficial and has been associated with rupture of the plantar fascia.
Extracorporeal Shockwave Therapy (ESWT)
Extracorporeal shockwave therapy (ESWT) is a minimally invasive, non-surgical treatment that delivers acoustic shock waves to specific soft tissue injuries. The impulses of energy offer effective pain relief and help to accelerate the healing process, this is achieved by causing minor but deliberate damage to the tissues of the affected area. The shockwaves break down cells and scar tissue formed in response to the initial injury, prompting the body to reinitiate the healing process by sending blood and nutrients to the affected area to repair the damage. Consequently, the recovery rate is faster and pain relief is improved.
Shockwave therapy can be used to treat a range of disorders including Plantar Fasciitis.
Returning To Training
Returning to an exercise program can be challenging for anyone following an injury, and especially so for those with PF. A return to exercise should be built up gradually for any type of high load exercise, with extra care taken during running. Shorter distances with smaller strides and at a reduced speed initially, with a graded increase – hills should be avoided and if acute painful symptoms return, then it is a good idea to rest until the symptoms settle.
Warm-Up and Cool Down
Prior to any type of exercise, it is important to warm up properly by loosening the calf muscles and by stretching everything out. Post-workout or run, the calf and plantar fascia stretches should be used as part of the cool down.
How We Can Help
Plantar fasciitis can be a challenging condition to treat, however by identifying the cause and treating the symptoms it can be successfully managed. We offer a wide range of physiotherapy related services. Our professional team of physiotherapists are highly qualified in their respective areas of expertise, including treatment for plantar fasciitis as well as a wide range of other sports-related injuries. For more information on our physiotherapy services and our wider range of services, get in touch today.