Plantar heel pain AKA plantar fasciitis is an overuse condition of the plantar fascia often at its origin and attachment to the heel bone (calcaneus). Those that have had it know how painful and frustrating this injury can be. Some describe it as walking on broken glass every morning. Ouch! Over the years, treatment for this condition has changed slightly as new research emerges. Fortunately, there are many things that can be done to help with this injury and the research sheds some light on what works and what doesn’t.
What is the plantar fascia and what does it do?
The plantar fascia is a thick tough tissue on the bottom of the foot that acts to stabilise the foot and transfer load during walking and running. It has similar properties to a tendon and helps with energy transfer and recoil during certain movements, so when irritated shows similar changes as a tendinopathy.
As the toes make contact with the ground during push off, the plantar fascia becomes taut and lifts the arch of the foot, allowing for a spring mechanism. This is called the “Windlass mechanism” and provides the body with a strong base to be able to effectively support the body. During stance, the plantar fascia becomes more relaxed, allowing for more efficient walking and running.
What is plantar fasciitis?
Plantar fasciitis is the most common cause of heel pain and affects both active and sedentary people. Research suggests that 1 in 10 people experience heel pain at some point in their life and one of the biggest causes is when the plantar fascia is exposed to an unaccustomed load. This results in an irritation of the plantar fascia and may include inflammation and changes in the structural properties of the tissue. You may or may not have a “heel spur” however, you do not need to have a heel spur to develop plantar fasciitis.
Signs and symptoms of plantar fasciitis
- Pain and tenderness at the base of the foot on the instep
- Pain can be described as sharp and stabbing, or as an ache
- Pain is usually of gradual onset
- Pain and stiffness often worse first thing in the morning and improves with activity
- Pain worse with first few steps after prolonged sitting or getting out of bed
- Worse with increased walking or running
Do I need a scan?
Often your physiotherapist can accurately diagnose the cause of your heel pain with a detailed assessment, and a scan in most cases will not be needed. However, if your physio wants to rule out any other causes of your heel pain, they might send you off for a scan.
What factors can contribute to me developing plantar fasciitis?
Age: Plantar fasciitis is more commonly seen in middle aged people – 40-60 years old. There is no known reason for this apart from the fact that as we get older, we lose some elasticity, we have higher BMI and reduced ability to tolerate high loads. However, if you fall outside of that age bracket, you are not immune!
Standing occupations: People who spend prolonged periods standing or walking as part of their job have a higher risk of this injury. It is not hard to see why, because the foot and plantar fascia is loaded during this time and this may cause an irritation and overload to the tissue, eventually possibly leading to plantar fasciitis. This may include chefs, teachers, factory workers, security guards, retail workers and more.
Foot biomechanics: Flat feet (pes planus), high arches or abnormal gait patterns can influence the load distribution and increase the stress on the plantar fascia. Keep in mind, that just because you have altered foot biomechanics, that does not mean this is the cause of your pain and that it should be corrected. A running or walking assessment is essential to be able to identify spec contributing factors to your injury.
Changes in load: Sudden spikes in unaccustomed loads or changes in normal loading patterns can trigger plantar fasciitis. It might be that you have increased your running speed, changed your shoes, added hills, played tennis for the first time in a year or even as simple as increased walking on your holiday.
Weight/BMI: High BMI has been associated with increased risk of developing plantar fasciitis in sedentary populations due to the increased weight placed on the plantar fascia
Flexibility and strength: Research suggests reduced ankle dorsiflexion and big toe extension range of motion is associated with this injury. There has also been association with big toe flexor and ankle evertor strength and hamstring flexibility.
Treatment
Treating plantar fasciitis first requires a thorough assessment to provide an accurate diagnosis and to pinpoint underlying contributing factors that can be addressed.
Follow these steps and you will be on the road to recovery!
- Deload
- Reduce pain and stress
- Address underlying factors
- Exercise
Deload
This will look different for each person depending on the level of activity you were doing and the severity of your symptoms. It does not mean complete rest either! Relative rest is what we are aiming for here, where we aim to reduce the impact and stress on the plantar fascia. There is no set protocol; it is done on an individual basis so it is best to seek advice from a physiotherapist as this can be a tricky step!
Reduce pain and stress
Taping– low dye taping is an effective way to offload the plantar fascia. To learn how to tape your own foot with this technique, click here
Gel inserts– heel inserts can help ease the pressure on the heel, especially if your shoes are not great or your activity involves a fair bit of impact such as dress shoes or working on your feet all day.
Orthotics– not everybody will require orthotics and they are not for everybody, but they can be a good adjunct to treatment to correct foot biomechanics and provide extra support for the foot. You may be referred to a podiatrist for orthotics.
Soft tissue massage/dry needling – to the surrounding musculature- this may help with pain reduction and reducing the tension around the foot and ankle to allow for better loading and adherence to exercise.
Exercise Therapy
Exercise is the mainstay and the most evidence-based treatment for plantar fasciitis. There are 3 main components that will make up a rehab program which will help your recovery in the long term. These are:
- Pain relief – stretching and ball rolling
- Mobility/flexibility – stretching and range of motion
- Strengthening
Stretching
Stretching the plantar fascia and calf muscles as well as rolling the plantar fascia on a ball can be effective in the early phases of treatment to reduce pain and sensitivity. This is used as an adjunct to other treatments listed in this blog.
Mobility
Addressing foot and ankle joint range of motion is also a great way to help with plantar fasciitis as it has been found to be a risk factor for developing this injury. Specific mobility exercises based on your individual deficits will be most effective.
Strengthening
Research suggests that high load strengthening of the plantar fascia is effective for long term relief. This is optimised when the toes are in extension. A progressive high load program performed slowly has been shown to be the most effective.
Depending on each individual’s requirements, gluteal strengthening, intrinsic foot strengthening, and balance drills may also be effective in your program. This is where your physiotherapist comes in and can give you the appropriate exercises. For athletes, higher load plyometric exercises, such as jumping might also be added to the program once symptoms settle.
Following is a generic program your physio might prescribe to treat plantar fasciitis. Keep in mind that each individual is different and you will need an individualised program focused on your needs…that’s where we can help!
Do I need an injection?
A corticosteroid injection is a decision that should be made on a case by case basis and should be avoided at first but may be utilised if symptoms are not settling easily, or if symptoms are severe. Steroid injections have been linked with plantar fascia ruptures so this should only be a last resort! And they’re painful so don’t rush for it!
While plantar fasciitis is fairly straight forward to recognise and diagnose, the rehabilitation can be quite tricky to navigate and can leave you feeling frustrated and confused, so seeing a physiotherapist is very important to help you achieve long term results. Fortunately, there are several ways we can help to treat this injury. At Revive Physiotherapy & Pilates, we can help to accurately diagnose, assess and treat your heel pain so that you can get back to doing what you love! Book an appointment to see a physiotherapist by calling (03) 9391-2600 or book online via our website.
