Plantar fasciitis is one of the most common causes of heel pain and one of the most common conditions that us podiatrists see clients presenting with. It was previously thought to be an inflammatory condition but recent research has shown it to be a degenerative condition due to the micro tears that can be seen within the fascia. Pain is at its worst first thing in the morning after getting out of bed and after an extended period of rest. Plantar fasciitis can be caused by a variety and combination of reasons including activity load, weight, age, foot position and muscle strength and conditioning to name a few.
Anatomy of the Plantar Fascia
The plantar fascia or plantar aponeurosis as it’s also known, runs along the bottom of the foot from the heel bone and then connects to the base of the toes. The main function of the plantar fascia is to provide shock absorption as well as supporting the medial longitudinal arch. It also helps to distribute plantar pressures evenly around the foot. Heel spurs can be commonly associated with the plantar fascia. If there is repetitive pulling at the attachment site of the plantar fascia at the heel bone, then a little bone spur may develop.
Cause of Plantar Fasciitis
Plantar fasciitis occurs as the result of excess pressure and strain which is unsustainable for a particular period of time which then results in micro tears through the plantar fascia. This strain and increased load is normally the result of an array of contributing factors. As mentioned above, heel spurs can develop as a result of this extra strain however these are not always painful and majority of the time a heel spur will be asymptomatic. There are many risk factors for plantar fasciitis.
Biomechanical factors play a major role in the development of plantar fasciitis, this includes the positioning of your foot and how it operates during your gait cycle. For example those who are flat footed or have an movement known as over pronation occurring during this cycle are placing excess load on the fascia which over time can result in micro tears. Joint range of motion, particularly the ankle joint and muscle flexibility, mainly the gastrocnemius and soleus, can both place extra load on the plantar fascia if these structures have a limited range of movement. The strength and conditioning of the muscles, ligaments and tendons within the lower leg and foot also play a major role in the development of plantar fasciitis. If structures lack the strength to carry the required load then that pressure is shifted elsewhere and often in the case of the foot, the plantar fascia wears most of the excess load.
There are also some common risk factors associated with the development of plantar fasciitis. Middle aged people as well as females are more likely to suffer from this condition due to the ligaments and tendons loosening over time as well as hormonal changes in females. Sudden weight gain and overweight/obesity are risk factors for development of plantar fasciitis due to an a larger body mass putting extra strain through the structures of the feet. Poor footwear can also be a common cause of plantar fasciitis as non supportive and ill fitting footwear forces your foot to function in a way it is not designed to thus requiring structures to carry more than their intended load. Standing on a hard surface for an extended period of time has also been linked to the development of plantar fascial pain. Long distance runners are also more likely to suffer from plantar fasciitis due to the force the plantar fascia must absorb over the course of an extended duration.
Plantar Fasciitis Symptoms
Symptoms of plantar fasciitis can include their heel pain being associated with their first steps out of bed in the morning. Similarly it may also be felt after extended periods of rest, for example sitting down for 20 minutes to have lunch. Often people will find their pain decreases once they are up and moving and the plantar fascia has had a chance to warm up. Pain will often be localised to the medial aspect (inside) of the heel and then it can also be felt through the arch of the foot. Pain is typically only felt while weight bearing. It will also feel much worse after completing exercise or work for the day whereas during exercise it will feel better.
If you have any of those associated symptoms then you are best suited to call up your podiatrist and book into see them so they can do a thorough physical examination. Footwear will also be examined including arch support. After the examination they will be able to provide you with a diagnosis and treatment for your heel pain.
Your podiatrist will conduct a variety of tests, they will begin your physical examination by palpating the foot which involves feeling around the foot and in particular the heel and arch to localise where exactly the pain is coming from. This can help to identify points that would benefit from some massage, shockwave therapy or dry needling. The lower leg and calf in particular may also be palpated to see if there are any trigger points within the muscle. Assessing joint function and range of motion to see if this is contributing to your pain. The muscles will also be tested, focusing on both flexibility as well as strength. You will be taken through non weight bearing testing to begin with and then proceed to exercises tailored to the muscle groups that most commonly impact the condition. These dynamic exercises will be used to assess the strength of these muscle groups and identify any areas of weakness that could be creating extra strain on the plantar fascia. The frequently assessed muscle groups include the calf, which is made up of the gastrocnemius and the soleus. One of the other main groups assessed is the intrinsic foot muscles which are all the little muscles within the foot. At the foot centre group we have a device called the toe pro. The toe pro can give us a rating of foot intrinsic strength and provide us with a benchmark to improve on. The flexibility of the calf will also be tested, this is a focus as a restricted calf can place excess strain on both the achilles tendon and the plantar aponeurosis. This can also be recorded as a benchmark score to easily track progress.
A gait analysis will also be performed which will look at the way your body and foot works during movement. This will be done by walking and if it is applicable to you, running. This is conducted as those who have a biomechanical movement called over pronation, place an increased load through the arch of their foot and therefore require the plantar fascia to absorb a larger load. By combining the findings from the gait analysis, joint and muscle testing, we will be able to determine the effect that your biomechanics is having on your condition. This will also allow your podiatrist to create a strength and conditioning program focused on the areas of weakness identified. Footwear is also a key component, all your shoes should be bought in from your runners to your work boots or shoes. If your footwear is poorly suitable to your foot type then this impacts the way you move and likely result in biomechanical imbalances that could potentially contribute to the development of plantar fasciitis.
Imaging may also be used to confirm a plantar fasciitis diagnosis. If your podiatrist has fears over a torn or ruptured plantar fascia they will likely send you for an ultrasound or magnetic resonance imaging (MRI) to confirm any major damage. They may also use imaging to locate possible plantar fibromas that could be impacting on your pain levels and require offloading.
Treatment of Plantar Fasciitis
Once all testing and assessments have been completed, your podiatrist will then be able to create a treatment plan tailored to your needs and weaknesses. The most important part of treatment for plantar fasciitis is your strength and conditioning work. A program will include muscle groups that play a role directly impacting your plantar fascia as well as any areas of significant weakness. Commonly used exercises include all variants of calf raises, foot intrinsic strength as well as balance training. It is important that your exercises are completed every day and to the number that has been specified by your podiatrist. If we can improve the strength of your muscle, ligaments and tendons that support your foot and lower leg then this will help to reduce the burden carried by the plantar aponeurosis. As well as strengthening structures, we also want to keep the body flexible and have a good range of motion. Your program may also include a stretching element such as a calf stretch. It may also include foam rolling or spikey ball rolling of particular muscle groups which can help to relieve tightness and tension within.
Extracorporeal shock wave therapy (ESWT) is another pathway your podiatrist may look into. Shockwave therapy is a non surgical intervention that has been shown to have great effects on musculoskeletal injuries including plantar fasciitis. It aims to facilitate a natural healing response/process by the human body by increasing blood flow to the treatment area. This is done via your podiatrist locating areas of your leg and foot through palpation. The machine is then used on these locations to begin the process. Shockwave therapy is done at the foot centre group at no extra cost, meaning you only pay for the price of your appointment! If you would like to learn more details about extracorporeal shock wave therapy then click on this link below to take you to a blog featured on ESWT https://www.footcentregroup.com.au/blog-shockwave-therapy/
Footwear is a key component of treatment of plantar fasciitis, after your footwear has been assessed you may be advised it would be a good time to change the sort of shoes you wear. Footwear that isn’t suitable for you can cause biomechanical imbalances and lead to extra strain on structures in your foot such as the plantar fascia. Your podiatrist will be able to give you some suggestions as well as the locations of some footwear shops such as The Running Company and Active Feet. We also suggest avoiding particular types of footwear such as flat thongs like havainas and dress shoes such as flats or heels. These shoes as well as other non supportive footwear which can include runners like nike free runs are typically not suited to your foot type and needs. However there are some brands of work shoes such as Bared that are more suitable. Archies thongs are also a great option for quick and easy, slip on shoes, ask your podiatrist about these and they can help you try a pair on after your appointment!
Orthotics may also be used depending on your needs and foot biomechanics. Before this is discussed your podiatrist will likely use taping to support the plantar fascia and the arch of the foot. This may help to give you some idea of the benefits you could receive from a pair of orthotics. If the taping is found to be very beneficial your podiatrist will likely have a discussion around orthotics and providing extra arch support. Orthotics are a pair of insoles placed into your shoes which help to improve the position of your foot and therefore its function. If the foot is placed in the correct position then this allows all the surrounding structures to function and carry the load they are designed to. In the case of the plantar fascia, we often see people who over pronate (roll in) during the gait cycle placing excess pressure on the medial arch. We can reduce this movement with the use of an orthotic as well as designing a groove within the shell for the plantar fascia to sit in thus taking some of the load off the area. Offloading can also be incorporated into this via modifications to your devices. We can see this used to take pressure off heel spurs via added cut out padding to the heel of your orthotic or insole.
Your podiatrist may also look to modify your exercise/workload if this is potentially going to be an issue. Due to the nature of plantar fasciitis there is no reason for you to completely rest and immobilise your foot, in fact it is recommended you still keep active outside of your exercises. We may need to reduce the distance of your running or sport you are playing. Depending on your individual goals we may even suggest swapping some activities such as running for less load bearing exercises on your feet such as swimming or cycling.
Dry Needling is another treatment option your podiatrist may look to explore. This involves inserting an acupuncture needle (dry needle) into a muscular trigger point. By doing this it helps to release these points and stimulate blood flow in the area which helps to relax and elongate the muscle fibres. If you would like to find out more about what dry needling is then click on this link https://www.footcentregroup.com.au/what-is-dry-needling/
Depending on your pain levels, they may discuss a corticosteroid injection which is performed under a guided ultrasound by a doctor or foot and ankle surgeons. This is normally a last resort option as it does not fix the problem but simply provides some short term pain relief and is helpful for treatment of chronic plantar fasciitis.
Plantar Fasciitis Surgery
If it has been between 6-12 months of conservative treatment and you are not seeing the progress we are hopeful for then some surgical interventions may be discussed. This is only done after we have attempted all non surgical interventions and had limited success. You will likely be sent for some form of imaging. Your podiatrist can then write up a referral for a surgical consultation with someone they recommended or someone of your choice.
Home Remedies For Plantar Fasciitis
There are a few things you can be doing at home to aid with your treatment of plantar fasciitis. The main focus at home should be the strict following of your assigned strength and conditioning program. Do this according to the guidelines prescribed by your podiatrist. Rolling underneath the foot with a ball of some sort, whether it be a spikey, tennis, golf or lacrosse ball, to massage the foot and keep it warm. This helps to keep the fascia active and reduce those pains felt when first getting up after a period of rest. It is highly recommended to have one next to where you sleep so that way before you even step out of bed you can warm up the plantar fascia to make those first few steps even easier.
You may also try some nonsteroidal anti inflammatory medication to reduce the pain and inflammation in the area. Anti inflammatory drugs should be taken as the instructions on the box specify. You may also take some panadol to help with the pain if it’s needed. Icing can also be a good way to reduce inflammation, you can just use a regular ice pack to achieve this. Another way of icing can be to use a frozen water bottle to massage underneath your foot, that way you get the icing element as well as the massage side. Compression socks are also something that can be tried at home, this is something we look at doing when taping or orthotics are not suitable options.
In conclusion plantar fasciitis is a commonly seen condition at our clinic. It is a condition that takes a variety of treatment options due to the wide range of factors impacting on the plantar fascia. Our podiatrists will be able to create a treatment plan tailored to your needs to get you back into everyday life without being crippled by pain.