Article by John Miller
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 (heel bone) and extending along the sole of the foot towards the toes. Your plantar fascia acts as a passive limitation to the over flattening of your arch. When your plantar fascia develops micro tears or becomes inflammed it is known as plantar fasciitis.
What Causes Plantar Fasciitis?
Plantar fasciitis is one of those injuries that magically 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.
Traction Plantar Fasciitis
Plantar fasciitis symptoms are usually exacerbated via "traction" (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 your 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 resting.
Your heel pain will be worse with the first steps and improves with activity as it warms up.
How Does Plantar Fasciitis Progress?
As plantar fasciitis deteriorates, the pain will be present more often. You can determine what stage you are in using the following guidelines:
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 are likely to be predisposed to plantar fasciitis and develop a treatment plan to decrease your chance of future bouts.
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 – 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.
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.
Diabetes. Although doctors don't know why plantar fasciitis occurs more often in people with diabetes.
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.
Due to poor foot biomechanics being the primary cause of your plantar fasciitis it is vital to thoroughly assess and correct your foot and leg biomechanics to prevent future plantar fasciitis episodes or the development of a heel spur.
Your physiotherapist is an expert in foot assessment and its dynamic biomechanical correction. 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.
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 utilise a range of pain relieving techniques including joint mobilisations for stiff joints, massage, electrotherapy, acupuncture or 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. Inflammed 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 manoeuvre. Your physiotherapist will guide 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
You may find it difficult to comprehend, but 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.
Your PhysioWorks physiotherapist will discuss your goals, time frames and training schedules with you to optimise you for a complete return to sport or work. Work-related injuries will often require a discussion between your doctor, rehabilitation counsellor 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.
What about Plantar Fasciitis Night Splints?
Boatwright et al. (2016) reviewed six studies to investigate the effectiveness of night splints in plantar fasciitis. They found the evidence to support the use of night splints as weak in all six research papers. Based on this evidence, it suggests that while night splints may be helpful treating plantar fasciitis there is little scientific proof recommending their use. Patient compliance is another issue, with anterior splints being better tolerated than posterior splints. Roos et al. (2006), Attard and Singh (2012).
Plantar fascia night splints essentially maintain an overstretch on the plantar fascia, which may provide you with some short-term relief. Ultimately this elongates your passive arch structures and the medium and long-term benefits fail to make sense to support this rationale. To the contrary, permanent elongation will most likely predispose you to flatter arches and more likelihood of recurrent heel pain. Based on this we do NOT recommend plantar fascia night splints in most instances. Active foot control exercises, which aim to dynamically support your foot arch, and thereby reduce the passive elongation of your plantar fascia, does seem to be the better approach in the medium to long-term management of plantar fasciitis.
For more specific advice about your plantar fasciitis, please contact your PhysioWorks physiotherapist.
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