Plantar Fasciitis

Plantar Fasciitis

What is Plantar Fasciitis?

Plantar fasciitis is one of the most common sources of heel pain.

Your plantar fascia is a thick fibrous band of connective tissue originating on the bottom surface of the calcaneus (which is our heel bone) and extends along the sole of the foot towards the toes.

Our plantar fascia acts as a passive limitation to the over flattening of your arch. When your plantar fascia develops micro tears or becomes inflamed it is known as plantar fasciitis.

First Of All…What Causes Plantar Fasciitis?

Plantar fasciitis is one of those injuries that sometimes seems to appear for no apparent reason. However, plantar fasciitis is caused by one of two methods. They are either traction or compression injuries.

Plantar fasciitis is most often associated with impact and running sports, especially those that involve toe running rather than heel running styles.

It is also commonly diagnosed in individuals with poor foot biomechanics that stress the plantar fascia. Flat feet or weak foot arch control muscles are two common causes of plantar fasciitis, and there are certain conditions that increases the risks of developing plantar fasciitis, which includes:

  • being overweight / obese
  • over-training
  • over-use
  • accident by slamming heel or foot onto hard surface
  • etc

Traction Plantar Fasciitis

Plantar fasciitis symptoms are usually exacerbated via “traction” (pulling or stretching) forces on the plantar fascia.

In simple terms, your plantar fascia is repeatedly overstretched. The most common reason for the overstretching is an elongated arch due to either

  • poor foot biomechanics (eg overpronation) or
  • weakness of your foot arch muscles

Compression Plantar Fasciitis

Compression type plantar fascia injuries have a traumatic history. Landing on a sharp object that bruises your plantar fascia is the most likely trauma.

The location of plantar fasciitis pain will be further under your arch than under your heel, which is more likely to be a fat pad contusion if a single trauma caused your pain.

The compression type plantar fasciitis can be confused with a fat pad contusion that is often described as a “stone bruise”.

What are the Symptoms of Plantar Fasciitis?

You’ll typically first notice early plantar fasciitis pain under your heel or in your foot arch

  • in the morning or
  • after a period of not moving (immobility) and resting

Your heel pain will be worse with the first steps and improves with activity as it warms up.

A typical description by patients is painful in their heel when they get up in the morning and stepping on the floor to stand up. They will stagger a couple of steps (or minutes) and the pain improves rapidly typically.

How Does Plantar Fasciitis Worsen?

As plantar fasciitis deteriorates, the pain will be present more often. You can determine what stage you are in using the following guidelines:

  1. No Heel Pain – Normal.
  2. Heel pain after exercise.
  3. Heel pain before and after exercise.
  4. Heel pain before, during and after exercise.
  5. Heel pain all the time. Including pain  even during rest.

This symptom progression is consistent with the four stages of a typical overuse injury.

Ultimately, further trauma and delayed healing will result in the formation of calcium (bone) within the plantar fascia. When this occurs adjacent to the heel bone it is known as heel spurs, which have a longer rehabilitation period.

How is Plantar Fasciitis Diagnosed?

Plantar fasciitis is usually diagnosed by your physiotherapist or sports doctor based on your

  • symptoms
  • history and
  • clinical examination

After confirming your plantar fasciitis they will investigate WHY you have higher risk of plantar fasciitis and they will develop a treatment plan to decrease your chance of future recurrence.

X-rays may show calcification within the plantar fascia or at its insertion into the calcaneus, which is known as a calcaneal or heel spur.

Ultrasound scans and MRI are used to identify any plantar fasciitis

  • tears
  • inflammation or
  • calcification

Pathology tests (including screening for HLA B27 antigen) may identify spondyloarthritis, which can cause symptoms similar to plantar fasciitis.

Risk Factors for Plantar Fasciitis

You are more likely to develop plantar fasciitis if you are:

  • Active – Sports that place excessive stress on the heel bone and attached tissue, especially if you have tight calf muscles or a stiff ankle from a previous ankle sprain, which limits ankle movement eg. running, ballet dancing and aerobics.
  • Overweight – Carrying around extra weight increases the strain and stress on your plantar fascia.
  • Pregnant – The weight gain and swelling associated with pregnancy can cause ligaments to become more relaxed, which can lead to mechanical problems and inflammation.
  • On your feet often – Having a job that requires a lot of walking or standing on hard surfaces ie factory workers, teachers and waitresses.
  • Flat Feet or High Foot Arches – Changes in the arch of your foot changes the shock absorption ability and can stretch and strain the plantar fascia, which then has to absorb the additional force.
  • Middle-Aged or Older – With ageing the arch of your foot may begin to sag – putting extra stress on the plantar fascia.
  • Wearing shoes with poor support or new shoes/footwear as a whole
  • Weak Foot Arch Muscles. Muscle fatigue allows your plantar fascia to overstress and cause injury.
  • Arthritis. Some types of arthritis can cause inflammation in the tendons in the bottom of your foot, which may lead to plantar fasciitis.
  • Diabetic. Although doctors don’t know why plantar fasciitis occurs more often in people with diabetes, we think that patients with diabetes may have slower healing rate which increases risk of injuries.

Plantar Fasciitis Treatment

The good news is that plantar fasciitis is reversible and very successfully treated. About 90 percent of people with plantar fasciitis improve significantly within two months of initial treatment.

If your plantar fasciitis continues after a few months of conservative treatment, your doctor may inject your heel with steroidal anti-inflammatory medications (corticosteroid). Cortisone injections have been shown to have short-term benefits but they actually retard your progress in the medium to long-term, which usually means that you will suffer recurrent bouts for longer.

What is the Best Treatment for Plantar Fasciitis?

Due to poor foot biomechanics being the primary cause of your plantar fasciitis, it is very important to thoroughly assess, diagnose and correct your foot and leg biomechanics to prevent future plantar fasciitis episodes or the development or progression of a heel spur.

Depending upon your specific clinical assessment, your physiotherapist may provide you with manual therapy techniques such as

  • joint mobilisations to loosen stiff joints
  • soft tissue massage or release
  • muscle flexibility or stretches
  • foot taping
  • foot, and lower limb strengthening exercises and
  • occasionally night splints

The treatment of plantar fasciitis does vary from person to person so please seek the advice of your foot care practitioner.

They may recommend that you seek the advice of a podiatrist, who is an expert in the prescription on passive foot devices such as orthotics. Foot orthosis have been shown to potentially assist some sufferers of plantar fasciitis.

Active foot stabilisation exercises are an excellent long-term solution to prevent and control plantar fasciitis that may be prescribed by your physiotherapist.

Researchers have concluded that there are essentially 8 stages that need to be covered to effectively rehabilitate plantar fasciitis and prevent recurrence. These are:

  1. Early Injury Protection: Pain Relief & Anti-inflammatory Modalities
  2. Regain Full Range of Motion
  3. Restore Foot Arch Muscle Control
  4. Restore Normal Calf & Leg Muscle Control
  5. Restore Normal Foot Biomechanics
  6. Improve Your Running and Landing Technique
  7. Return to Sport or Work
  8. Footwear Analysis

Treatment of heel spurs is similar to plantar fasciitis treatment. Your physiotherapist will select the most appropriate treatment modalities for you.

Ultimately, biomechanical correction is the aim. Foot intrinsic muscle strengthening (including tibialis posterior and peroneus longus) and calf (gastrocnemius and soleus) stretches are almost always required.

Cases of moderate to severe biomechanical deformity should be referred for physiotherapy or podiatric assessment to prevent chronic recurrence. NSAID’s and corticosteroid injection is most effective when combined with biomechanical correction.

Mechanical treatment that involves taping and orthoses has been shown to be more effective than either anti-inflammatories or accommodative modalities.

Plantar fascia night splints can sometimes work to provide short-term pain relief. The splints essentially overstretch the plantar fascia, which may provide you with some short-term relief, but ultimately elongates your passive arch structures. That means that long term splinting is a no-no. To make things worse, permanent elongation will predispose you to flatter arches and more likelihood of recurrent heel pain.

Weight loss and load management are an important influence upon the initiation and duration of plantar fasciitis and heel spurs. Your weight may be impacting upon your plantar fascia or heel spurs, so weight loss should be a priority for those patients who are carrying excess weight.

Researchers have concluded that there are essentially 8 stages that need to be covered to effectively rehabilitate plantar fasciitis and prevent recurrence. These are:

Phase 1 – Early Injury Protection: Pain Relief & Anti-inflammatory Tips

As with most soft tissue injuries the initial treatment is Rest, Ice, and Protection.

In the early phase, you’ll most likely be unable to walk pain-free. Our first aim is to provide you with some active rest from pain-provoking foot postures. This means that you should stop doing any movement or activity that provoked your foot pain in the first place.

Ice is a simple and effective modality to reduce your pain and swelling. Please apply for 20-30 minutes each 2 to 4 hours during the initial phase or when you notice that your injury is warm or hot. A frozen water bottle can provide you with an ice foot roller that can simultaneously provide you with some gentle plantar fascia massage.

Anti-inflammatory medication (if tolerated) and natural substances eg arnica may help reduce your pain and swelling. However, it is best to avoid anti-inflammatory drugs during the initial 48 to 72 hours when they may encourage additional bleeding. Most people can tolerate paracetamol as a pain reducing medication.

To support and protect your plantar fascia, you may need to wear a plantar fascia brace, heel cups or have your foot taped to provide pain relief. As mentioned earlier, the cause of your plantar fasciitis will determine what works best for you. Your physiotherapist will guide you.

Your physiotherapist will guide you and utilize a range of pain relieving techniques including

  • joint mobilizations for stiff joints
  • massage
  • electrotherapy
  • acupuncture
  • dry needling

to assist you during this painful phase.

Phase 2: Regain Full Range of Motion

If you protect your injured plantar fascia appropriately the injured tissues will heal. Inflamed structures will settle when protected from additional damage, which can help you avoid long-standing degenerative changes.

Plantar fasciitis may take from several weeks (through to many months) to heal while we await Mother Nature to form and mature the new scar tissue, which takes at least six weeks. During this time period, you should be aiming to optimally remould your scar tissue to prevent a poorly formed scar that may become lumpy or potentially re-tear in the future. It is important to lengthen and orientate your healing scar tissue via massage, gentle stretches, and light active exercises.

In most cases, your physiotherapist will identify stiff joints within your foot and ankle complex that they will need to loosen to help you avoid plantar fascia overstress.

A sign that you may have a stiff ankle joint can be a limited range of ankle bend during a squat maneuver. Your physiotherapist will guide and teach you.

Phase 3: Restore Foot Arch Muscle Control

Your foot arch is dynamically controlled via important foot arch muscles, which be weak or have poor endurance.

These foot muscles have a vital role as the main dynamically stable base for your foot and prevent excessive loading through your plantar fascia.

Any deficiencies will be an important component of your rehabilitation. Your physiotherapist is an expert in the assessment and correction of your dynamic foot control. They will be able to help you to correct your normal foot biomechanics and provide you with foot stabilisation exercises if necessary.

Phase 4: Restore Normal Calf & Leg Muscle Control

All of your leg (calf, thigh and hip) muscles play an important role in controlling your foot arch and its normal function.

Your physiotherapist will assess your leg muscle function and provide you with the necessary treatment or exercises as required.

Phase 5: Restore Normal Foot Biomechanics

Your foot biomechanics are the main predisposing factor for plantar fasciitis. After a biomechanical assessment, you may be recommended a soft orthotic or a custom-made orthotic prescribed by a podiatrist.

Phase 6: Improve Your Running and Landing Technique

If your plantar fasciitis has been caused by sport it is usually during repetitive activities, which place enormous forces on your plantar fascia.

In order to prevent a recurrence as you return to your sport, your physiotherapist will guide you with technique correction and exercises to address these important components of rehabilitation to both prevent a recurrence and improve your sporting performance.

Depending on what your sport or lifestyle entails, a speed, agility, proprioception and power program will be customised to prepares you for light sport-specific training.

Phase 7: Return to Sport or Work

Depending on the demands of your chosen sport or your job, you will require specific sport-specific or work-specific exercises and a progressed training regime to enable a safe and injury-free return to your chosen sport or employment.

Treatment with physiotherapy will aim to optimize you for a complete return to sport or work. Work-related injuries will often require a discussion between your doctor, rehabilitation counselor or employer.

Phase 8: Footwear Analysis

Often it is poorly designed footwear that can predispose to the injury. Seek the professional advice of your healthcare practitioner.