Plantar fasciitis is one of the most common causes of heel pain seen by podiatrists. Heel pain can be noticed most when getting out of bed, during the first few steps in the morning. It may also be noticed during prolonged exercise or after getting up after a period of rest. Shortly, as the person moves the pain subsides, however may recur as a throb or ache once the person is back on their feet for a long period of time. The good news is that plantar fasciitis can be treated. The most effective treatment for plantar fasciitis encompasses using many different treatment options, not only one, tailored to an individuals needs and all put together in a plan.
Causes of plantar fasciitis
The plantar fascia is a tendon which helps support the arch of the foot by providing shock absorption during activity. The muscles and ligaments in our body, like any mechanical structure are only able to withstand a certain amount of stress and force. The same principle applies to the plantar fascia. The plantar fascia being subject to increased stress and tension, more than it can tolerate leads to pain, swelling and inflammation. The pain under the heel or in the arch of the foot is then known as plantar fasciitis, commonly referred to as heel pain.
The cause of plantar fasciitis can be different to each person. Originally, plantar fasciitis was thought to be an inflammatory condition whereas research now shows its a degenerative condition due to the micro tears that can develop in the fascia. It can develop without an obvious cause or some may be able to pinpoint the beginning of their pain to a certain event or time. This being said, there are multiple risk factors to developing plantar fasciitis.
Active individuals between the ages of forty and sixty are at a higher risk; and plantar fasciitis is most common in this age group. Women, more than men, are also at a higher risk of developing plantar fasciitis. This is due to women being able to carry out pregnancies. Pregnant women are more prone, especially during the final stages of pregnancy due to rapid weight gain. The rapid weight gain causes sudden increased and unexpected stress on the plantar fascia. This is also applicable if someone undergoes a rapid increase in weight.
The type of work or exercise one completes can also play a role the development of plantar fasciitis. Certain types of sports or work. Sports that are heavily reliant on the lower limbs, long hours of work or movement conducted on hard surfaces are causative risk factors. Examples of this may include long distance runners, dancers or hospitality workers.
On the other hand, in conjunction to external factors or standalone, a foot’s structural build can be a cause. Flat feet, high arches, tight calf muscles or abnormal gait patterns which may develop over time can affect the manner weight and force is distributed on the plantar fascia.
Another common cause of plantar fasciitis are shoes. Wearing shoes lacking arch support or wearing shoes with incredibly soft soles can increase the risk of developing plantar fasciitis because they decrease or do not provide enough support to the plantar fascia.
Plantar fasciitis testing and diagnosis
Pain from plantar fasciitis can be localised to an area on the heel bone where the plantar fascia attaches or higher up in the feet on the bands of the plantar fascia, i.e., within the muscle.
Firstly, your foot specialist will take a thorough history, focusing on the kind of work and activities you undertake followed by the footwear you wear and exercise routines.
Next a physical examination is performed on the feet to test whether focal points of tenderness can be elicited. The test is performed by flexing your toes backwards to pull the plantar fascia taught, then palpating from the heel towards your toes, noting any inflammation or swelling. The lower leg and calf muscles may also be palpated to elicit if there are any contributing areas of tightness. This information helps identify points that may benefit from shockwave therapy, massage or dry needling. Palpation is then followed by joint range of motion testing to elicit a decrease or hyperflexibility in a joint is a contributing factor. This is followed by muscle testing, focusing on both their flexibility and strength.
Muscle and joint testing may be followed by a biomechanical gait analysis. A biomechanical gait analysis consists of the person walking and a podiatrist studying their walk. Any disturbances to the gait is noted by the podiatrist that may benefit from modifications.
Although not regularly necessary, radiographic studies may also be ordered to show evidence of inflammation, thickening or tears of the plantar fascia. It may also be used as a diagnostic tool to differentiate between other foot pathologies.
Plantar fasciitis treatment
There is a myriad of treatment modalities for plantar fasciitis. Typically, these options are exhausted from the least invasive to the most invasive and can be personalised to each individual based on their causative factors. Treatment options may include:
Rest – The first line of treatment is rest. Rest provides a decrease of stress and time for the plantar fascia to heal. Rest in conjunction with icing and elevating can provide additional pain relief.
Strapping – A rigid sports tape is used to redistribute plantar pressure. By redistributing pressure onto other areas of the foot, the load on the plantar fascia is decreased. This provides support and an opportunity to heal.
Stretching and strengthening – A specific program targeting the foot and calf muscles can be provided to improve strength and mobility. This is modified to each individual, taking into consideration their life, workload and goals.
Non-steroidal anti-inflammatory medication – Your doctor may recommend medication such as Ibuprofen or Voltaren can be utilised to relieve pain from inflammation. If non steroidal anti inflammatory medicat are not an option, rubbing Voltaren or an alternative muscle pain relief lotion can provide relief.
Shockwave therapy – Your foot doctor may recommend shockwave therapy compromises of using a machine which sends pulses to areas targeted by a podiatrist. These pulses help stimulate blood flow which contains oxygen and other healing molecules to the area to aid the healing process.
Dry Needling – Dry needling uses very thin needles, inserted into tight areas within a muscle to that may be contributing to the condition
Footwear changes – Changes may be to the innersole of the shoe or recommendations around footwear
Orthotics/ insoles – Orthotics or insoles can be provided to permanently redistribute pressure for long term relief. Orthotics are custom made devices, specifically prescribed by a podiatrist to match each foot.
CAM Boots – In the event where complete offloading is required, a CAM boot may be utilised for a number of weeks. By doing so, this provides a period of complete rest to the plantar fascia
Cortisone injection – Referral for a cortisone injection may be provided if conservative treatment does not yield significant results. Here a mixture of cortisone and anaesthetic is injected specifically into the painful area to reduce inflammation and provide pain relief
Surgery – Although rare, surgery may be explored if conservative treatment options have been exhausted. Surgery may also be utilised if the plantar fasciitis is a result of a structural cause and cannot be rectified without surgery.
Plantar fasciitis surgery
Surgery for plantar fasciitis is usually the last resort for treatment. For the surgery, there are two different kinds of surgical approaches that may be used.
The first approach is called a plantar fascial release. This surgery involves a surgeon partially detaching a part of the plantar fascia from its attachment at the heel bone. By “releasing” the tendon, the tension on the tendon is also released.
The second approach may be a gastrocnemius recession. The gastrocnemius is a large muscle that makes up part of your calf muscle complex. The gastrocnemius is connected to your Achilles tendon located behind your heel bone which also houses the insertion of the plantar fascia. Tightness within the calf muscle complex can cause increased tension on the plantar fascia. The surgery involves lengthening the gastrocnemius to provide a larger range of motion to your ankle, ultimately decreasing stress on the plantar fascia.
Plantar fasciitis exercises
One of the most important parts of treatment are plantar fascia exercises, which usually encompass both the plantar fascia and the calf muscles. Here are some examples of exercises that can be performed.
Calf stretches – The calf muscles and plantar fascia work together as one big complex. Together they provide range of motion to the ankle, to provide the necessary movement it needs to go through gait. Hence, stretching your calf muscles can provide relief to the plantar fascia.
- Lean hands against a wall,
- Straighten the knee of the affected foot
- Bend the other knee in front.
- Keep both heels on the ground
- Hold for thirty seconds and repeat three times
Rolling a ball -Giving your arches a good massage can help relieve tension and inflammation. Many items such as a tennis ball/ massage ball, foam roller or even a water bottle with iced water in it can be used. The goal is to firmly roll the object under the feet along the plantar fascia to provide a good massage. This can be performed for two minutes or as long as someone wishes.
Flexing the feet – Flexing the feet is another method of giving the calf muscles a good stretch. This exercise can be performed by using a theraband or towel or anything long enough that can be wrapped around the foot and held on to. This exercise is performed sitting down; while sitting down one leg is placed straight out in front. The theraband is then wrapped around the foot and held onto. The theraband is then used to pull the toes towards the body by pulling on the theraband. This position is held for 20 seconds and repeated.
Towel curl: Towel curls are an effective exercise in focused on strengthening the plantar fascia. This exercise is performed sitting on a chair. While sitting down a towel in placed underneath the feet. The towel can then be grasped in the middle by the toes pulled in closer. Once completed the feet can then relax and the exercise is repeated.
Home remedies for plantar fasciitis
At home, gentle conservative treatments can be utilised to help ease the pain associated with the plantar fascia. These treatment may include:
Rest – As plantar fasciitis is associated with an overload in tissue stress, resting the feet can provide the easiest form of pain relief. Adequate rest can help decrease inflammation and provide the body time to heal. If possible, it is best to take a break from activity and reduce prolonged standing which causes the plantar fascia to flare up.
Ice- Ice is a great way to reduce inflammation to provide pain relief. Ice helps constrict blood vessels to decrease blood flow to the area. Another simple, yet effective home remedy is to fill up a plastic water bottle and let it freeze overnight. The water bottle can then be used to roll underneath the feet and painful areas to help massage and ice the plantar fascia at the same time.
Medication – Pain killers, usually non-steroidal anti inflammatory medication such as ibuprofen can aid reduce pain and inflammation.
Elevation – Putting your feet up! While resting the feet it is also beneficial to place the feet in an elevated position. Keeping feet in an elevated position allows gravity to help blood flow backwards. A reduction in blood flow to the painful area can help decrease pain by decreasing swelling.
Stretching – Gentle stretching can help relieve and prevent plantar fasciitis. Focusing on the muscles on the bottom of your foot and calves help loosen muscles, in turn decreasing stress.
Massage – Massaging the feet and calves can help with symptoms of plantar fasciitis. Focusing on the bottom of your foot and surrounding muscles which can become tense can be beneficial.
Braces and supports
The plantar fascia can be supported in many ways with many different options that can be tailored to suit specific needs. Some of these options include:
Heel lifts – Heel lifts are placed in shoes to lift the ankle and provide a larger range of motion to the ankle joint. In turn, this shortens the calf muscle and plantar fascia and decreases the tension through the muscles.
Insoles and footwear – Arch supporting shoe inserts or shoes with good inbuilt support can be utilised to offload the plantar fascia. This can be especially helpful if long periods of time are spent on the feet. The insoles allow the forces going through the feet to be distributed more evenly. Before purchasing shoes or insoles, it is a good idea to have a look at the function and type of support the shoe or insole provides.
Compression socks – These can provide additional support around the foot. Compression socks can also be very valuable if consistent massage and strapping is not an option.
Braces – Braces or night splints can be utilised at night to help stretch the plantar fascia. While sleeping, the toes are usually facing down. This shortens the plantar fascia, bracing the foot places it in a 90 degree angle to help stretch the plantar fascia while sleep.
All in all, plantar fasciitis, in itself, is a self-limiting condition. This means, even if no treatment is involved, it is likely to resolve on its own. However, it may take several months to subside. It is formed when the plantar fascia cannot withstand the load it is subjected to, resulting in tissue stress. For treatment, usually, the best treatment is a treatment plan which is begun as early as possible and combines a range of treatments.
This ensures the plantar fascia is provided adequate offloading and support to heal. In turn, this allows for the condition to resolve earlier. Fortunately, diagnosis is relatively easy, a physical examination and history is sufficient for the experienced practitioner. Radiographic imaging is not necessary for diagnosis, as it does not change the method of treatment, however can provide valuable insight into the extent of pathology or be an aid to rule out other pathologies. Fortunately, there are many treatment modalities, which can be customized to each individual; to address their causes for a more holistic approach.