Plantar Fasciitis

Plantar Fasciitis

Article by J. Miller, A.Clarke

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 calcaneus’s bottom surface (heel bone) and extending along the sole 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 inflamed, it is known as plantar fasciitis.

plantar fasciitis

What Causes Plantar Fasciitis?

Plantar fasciitis is one of those injuries that magically seems to appear for no apparent reason. However, we believe there are two leading causes of plantar fasciitis. 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

You can exacerbate plantar fasciitis symptoms via “traction” (or stretching) forces on the plantar fascia. In simple terms, you repeatedly overstretch your plantar fascia. The most common reason for the overstretching is an elongated arch due to either poor foot biomechanics (e.g. overpronation) or your foot arch muscles’ weakness.

Compression Plantar Fasciitis

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

The location of plantar fasciitis pain would 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, often described as a “stone bruise”.

What are the Symptoms of Plantar Fasciitis?

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:

  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 at rest!

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

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

How is Plantar Fasciitis Diagnosed?

Your physiotherapist or sports doctor plantar fasciitis diagnosis bases itself upon your symptoms, history and clinical examination.

After confirming your plantar fasciitis, they will investigate WHY you are likely to be predisposed to it 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, known as a calcaneal or heel spur.

Ultrasound scans and MRI 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, limiting ankle movement, e.g. 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, leading to mechanical problems and inflammation.

On your feet – You have a job that requires a lot of walking or standing on hard surfaces, i.e. factory workers, teachers and waitresses.

Flat Feet or High Foot Arches – Changes in the arch of your foot change the shock absorption ability and stretch and strain the plantar fascia, which then has to absorb the additional force.

Middle-Aged or Older – With ageing, your foot’s arch may begin to sag – putting extra stress on the plantar fascia.

You Were Wearing Unsupporting Shoes.

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, leading 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 per cent 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 short-term benefits, but researchers could retard your medium to long-term progress, 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 vital to thoroughly assess and correct your foot and leg biomechanics to prevent future plantar fasciitis episodes or develop a heel spur.

Your physiotherapist is highly skilled in foot control assessment and its dynamic biomechanical correction. Depending upon your specific clinical examination, your physiotherapist may provide manual therapy techniques to loosen stiff joints. They may also offer soft-tissue massage or release, muscle flexibility or stretches, foot strapping, foot and lower limb strengthening exercises and occasionally night splints. The treatment of plantar fasciitis does vary from person to person, so please seek your foot care practitioner’s advice.

They may recommend that you seek a podiatrist’s advice, an expert in prescription passive foot devices such as orthotics. Foot orthosis may assist some sufferers of plantar fasciitis.

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

Researchers have concluded that eight stages need to be covered to rehabilitate plantar fasciitis and prevent recurrence effectively. 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 undertake physiotherapy or podiatric assessment. NSAID’s and corticosteroid injection is most effective when combined with biomechanical correction.

Mechanical treatment that involves taping and orthoses is more effective than either anti-inflammatories or accommodative modalities.

Plantar fascia night splints can sometimes work to provide short-term pain relief. The braces essentially overstretch the plantar fascia, which may give you some short-term relief, but ultimately elongates your passive arch structures. The medium and long-term benefits make no sense of this rationale. On the contrary, permanent elongation will predispose you to flatter arches and likely recurrent heel pain. Based on this, we do NOT currently recommend plantar fascia night splints in most instances.

Weight loss and load management are important influences on plantar fasciitis and heel spurs’ initiation and duration. Your weight may impact your plantar fascia or heel spurs, so weight loss should be a priority for patients carrying excess weight.

Researchers have concluded that eight stages need to be covered to rehabilitate plantar fasciitis and prevent recurrence effectively. 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. Active rest 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 to simultaneously provide some gentle plantar fascia massage.

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

To support and protect your plantar fascia, you may need to wear a plantar fascia braceheel 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.

They 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 damaged 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 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 uses essential foot arch muscles, which be weak or have poor endurance. These foot muscles are vital as the main dynamically stable base for your foot and prevent excessive loading through your plantar fascia.

Any deficiencies will be an essential component of your rehabilitation. Your physiotherapist is an expert in the assessment and correction of your dynamic foot control. They will help you 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 challenging to comprehend, but all of your leg (calf, thigh and hip) muscles play an essential 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. We may recommend a soft orthotic or a custom-made orthotic prescribed by a podiatrist after a biomechanical assessment.

Phase 6: Improve Your Running and Landing Technique

If your plantar fasciitis originates from training, it is usually during repetitive activities, which place enormous forces on your plantar fascia.

To prevent a recurrence as you return to your sport, your physiotherapist will guide you with technique correction and exercises to address these critical components of rehabilitation to avoid repeated bouts.

Depending on what your sport or lifestyle entails, a speed, agility, proprioception and power program customised to prepare 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 help treat 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 substantially 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. Based on this, we do NOT recommend plantar fascia night splints in most instances. On the contrary, permanent elongation will most likely predispose you to flatter arches and likely recurrent heel pain. Active foot control exercises, which aim to support your foot arch dynamically, and thereby reduce the passive elongation of your plantar fascia, seem to be the better approach in the medium to long-term management of plantar fasciitis.

Plantar Fasciitis Socks

Plantar fasciitis socks have grown in popularity as a more comfortable option to evening splints. They work on providing passive support via foot arch compression that helps to de-load the plantar fascia. Some other clever products appear to work favourably with plantar fasciitis sufferers.