What is Plantar Fasciitis?

Plantar fasciitis (more accurately known as plantar fasciopathy) is a term commonly used to describe pain in the sole and inner border of the heel. This condition is thought to be due to ’overload’ associated with increased training volume in the athletic population, especially runners and dancers, but also due to lifestyle factors.

Symptoms

The condition is typically characterised by pain just below the heel or along the arch of the foot after a prolonged period of rest, i.e., stepping first thing in the morning, which then eases with movement but is exacerbated by prolonged periods of activities like walking, standing or running. Plantar fasciitis is the third most common injury in runners. Although common, it can sometimes be stubborn to treat, which is why we have multiple available treatment options.

Factors associated with this condition are reduced ankle range of movement, tight calf muscles and weakness of the intrinsic foot muscles.

Anatomy

The plantar fascia is a thick band of fibrous tissue that is attached to the heel and the metatarsal bones (ball of foot/ the base of the toes). Its function is to help support the medial arch along with intrinsic foot muscles via the Windlass mechanism. This mechanism is the tightening of the fascia when our toes bend backwards, creating increased tension within it.

Although the term fasciitis implies inflammation, recent literature has suggested that the pathology resembles that of a tendinopathy with thickening of the fascial attachment, changes in the collagen structure and sometimes underlying bone oedema, so it should really be addressed as fasciosis or more simply ‘plantar heel pain’. Several other structures around the heel can also be affected, e.g. the fat pad, bursa, tendons, and nerves. The exact diagnosis will depend on history, clinical examination and may sometimes involve imaging.

Causes

The exact cause of plantar fasciitis is poorly understood. It is thought to be thought to occur when there is an increased load placed on the plantar fascia (the ligament that connects your heel bone to your toes), either by certain activities, like running, an individual’s specific biomechanics or training error, i.e. “too much, too soon.”

Factors that can be involved are:

• Biomechanics – any biomechanical factor that increases the stress on the plantar fascia may have a role. This can include excessive pronation (rolling in), leg length discrepancy, poor control of movement at the knee and hip
• Tissue tightness – the most common cause is often considered to be tight calf muscles. The Achilles tendon blends with the plantar fascia, so if it is tight, it places greater stress on the fascia
• Footwear – old or inappropriate footwear can lead to increased stress and cause pain. See below for tips
• Muscle weakness – weak calf, Tibialis Posterior muscle (muscle located within the back side of the calf, which provides stability) and intrinsic foot muscles.

Treatment

Plantar fasciitis is a multi-factorial injury, which can be challenging to treat. It is important to try to identify the cause and address it. Rest or modifying training, ice, offloading and anti-inflammatories may help to settle symptoms.

Stretching the calf and fascia and strengthening the calf and intrinsic muscles will also help reduce symptoms. Changes to training and running technique may be helpful and have the potential to reduce load on the plantar fascia and help alleviate symptoms. However, emerging research is focusing on progressive loading programmes.

Therefore, combining load modification with an increased fascial load capacity while addressing individual contributing factors may prove the most effective approach for long-term treatment of plantar fasciitis.

Treatment options commonly used are the use of gel heel cups, which can be bought over the counter, and regular stretching of the fascia and calf muscles. Sports Doctors can also be consulted for further investigations, and based on the assessment, Podiatrists can also provide valuable input for the tight musculature and custom insoles.

The list of options is extensive and includes:

• Stretching

• Muscle strengthening

• Footwear advise

• Running technique

• Extracorporeal Shockwave Therapy (ECSWT)

• Radiotherapy

• Low-dye taping

• NSAID’s

• Surgery

• Tension night splints

• Myofascial Trigger Point Therapy

• Corticosteroid infiltration

• Custom orthoses and prefabs

• Infiltration of platelet-rich plasma

Interesting recent studies have shown changes in pain and function following high-load strength training similar to the treatment of tendinopathies. Strengthening the hip muscles, which control the movement in the knee and foot, helps to decrease the load on the fascia and has shown beneficial effects.

Treatment at Home

1. Settle your symptoms

Firstly, aim to settle your symptoms as best as possible, namely by resting from aggravating factors such as walking barefoot, running or prolonged standing. In mild cases, you may be able to modify these things (e.g. only running as far as is pain-free or using different shoes) rather than resting altogether.

2. Stretch the calf and plantar fascia

Calf stretches

Probably the most widely recommended treatment. If calf tightness is an issue for you, try stretching both muscles:

• Gastrocnemius – by leaning with both hands on a wall and taking one foot a step behind the other, and bending at the elbows to lean closer to the wall, feeling the stretch in the back of your leg.
• Soleus – again with both hands on the wall and one foot a step behind the other, this time bending in the back leg knee to feel the stretch in the front of your leg.

Hold each for 30 seconds, 3-5 reps, 2-3 times per day. In both cases, the leg at the back is the one being stretched.

Specific stretches for the plantar fascia

Cross the leg of the affected side over the other leg. Grasp the toes and stretch them upward. Hold the stretch for 10 seconds; repeat 10 times. Do 3 times per day, including before you take your first steps in the morning.

Stretch the mid-foot over a cold or frozen bottle (beware of ice burn when doing this)

Place a gentle pressure down on the water bottle with your foot (you can also use a tennis ball; an iced water bottle may be more effective), stretching the middle of the foot and rolling it backwards and forwards for approximately 10 minutes. Be sure to stop if it is too painful.

3. Strengthening of muscles

Single leg squat

Start with a simple control exercise that has the added benefit of working into the ankle range of movement. It helps increase awareness of movement (proprioception) and serves as a useful warm-up to prepare the foot and ankle for the more challenging exercises.

Modified calf raise – Rathleff et al. (2014)

A progressive heavy loading programme using the modified calf raise (with a towel) is very effective in treating plantar fasciitis. The addition of weight helps to strengthen the foot and calf muscles, hopefully aiding in load tolerance and absorption.

Begin barefoot, with a rolled-up towel underneath your toes, slowly push up into a calf raise, hold at the top, then lower. The speed is about 3 sec up, 2 sec hold and 3 sec down. Do 3 sets and 12 reps per leg.

If it’s painful or too hard to start on both legs, if it’s too easy, gradually increase the load under the supervision of a healthcare professional.

Strengthening inversion and eversion

Tibialis posterior provides support to the arch of the foot. Sit with your legs straight and with a belt or towel tied around your foot. By pulling on one end of the belt, move your sole towards the outside and then to the inside as far as you can. Maintain the position and repeat.

Toe flexor strength

Toe flexion exercises can improve strength and jump performance. We place them at the end, as the modified calf raise is also challenging for these muscles. Push your toe down against the resistance. Hold for 3 secs, relax for 3 secs. Repeat 5-10 times per foot.

Intrinsic muscles of the foot

A common exercise for this is using the toes to pick up marbles or scrunch up a towel.

Footwear

It can be difficult to come up with a “one-size-fits-all approach”, but a combination of support and cushioning would be ideal. Support the fascia without irritating it. If you are running in flat or minimalist shoes, these could also cause or aggravate symptoms due to the much smaller (or non-existent) heel drop.

Changing your training

There’s always some debate over whether you should continue to run or rest with Plantar Fasciitis. This decision will vary considerably based on each individual’s situation and needs to be discussed with your health professional.

Changing running gait

Again, there is no “one-size fits all” and should be based on individual assessment by a podiatrist. However, there are changes which should reduce the load that may be associated with plantar fasciitis.

• Take shorter, faster steps
• Run with a quiet, soft footfall.

If you make these changes, make sure they are comfortable and don’t create pain elsewhere or make running feel much harder.

Returning to running

This can be a challenge with any injury. My initial advice would include:

• Gradually increase your distance

• Avoid hills initially

• Ideally, it should be pain-free when running and for around 48 hours after

• If your pain increases during this time or the overall trend is that it’s getting worse, you may have to rest until it’s more settled

• Warm up and cool down – before running, it’s important to loosen the calves a little with a dynamic calf stretch

Research: Plantar Fasciitis

Thing J et al. Diagnosis and Management of Plantar Fasciitis. Br J Gen Pract. 2012 Aug; 62(601):443-4.

Plantar fasciitis (PF) is a common overuse injury that occurs as a result of repetitive traction forces on the plantar fascia at its origin over the distal calcaneus. It accounts for 8–10% of running-related injuries and 80% of heel pain, and is commonly seen in primary care. Individuals with pes planus (flat foot) and pes cavus (high arch) deformity are at increased risk of developing PF, as are individuals who wear poorly supporting footwear and who undertake excessive walking or weight-bearing activity (often job-related, such as ‘policeman’s heel’). Previous heel pain and a high body mass index are also risk factors for PF. It commonly occurs in middle-aged individuals with an equal preponderance in males and females and has a lifetime prevalence of 10%.

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Full Abstract

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References

• Riel H, Cotchett M, Delahunt E, Rathleff MS, Vicenzino B, Weir A, et al. Is ‘plantar heel pain’ a more appropriate term than ‘plantar fasciitis’? Time to move on. Br J Sports Med. 2017.
• Rathleff MS, Molgaard CM, Fredberg U, Kaalund S, Andersen KB, Jensen TT, et al. High-load strength training improves outcome in patients with plantar fasciitis: A randomised controlled trial with 12-month follow-up. Scand J Med Sci Sports. 2015;25(3):e292-300.
• Huffer D, Hing W, Newton R, Clair M. Strength training for plantar fasciitis and the intrinsic foot musculature: A systematic review. Phys Ther Sport. 2017;24:44-52.
• Kamonseki DH, Goncalves GA, Yi LC, Junior IL. Effect of stretching with and without muscle strengthening exercises for the foot and hip in patients with plantar fasciitis: A randomised controlled single-blind clinical trial. Man Ther. 2016;23:76-82.
• Plantar Fasciitis: Will Physical Therapy Help My Foot Pain? J Orthop Sports Phys Ther. 2017;47(2):56