Plantar fasciitis (PF) is one the most common musculoskeletal conditions that is seen in the foot, and refers to the interruption of the plantar fascia, which is a strong band of tissue that runs through the bottom of your foot from your heel bone (the calcaneus) to the joints in the ball of your foot (the metatarso-phalangeal joints). The plantar fascia has three main roles in the foot;
Maintaining an arch height.
Providing the mechanism required to push off when you take a step in walking and running.
When the plantar fascia is loaded; in an abnormal way, excessively or over an extended period it can damaged. This can lead to inflammation and pain, usually located near its attachment on the heel bone. In the initial stages of the condition pain is usually only felt either after periods of rest or after exercise. As the condition progresses, however, it can become increasingly debilitating and pain can begin to be present throughout normal activities of daily living.
What to look out for?
A typical presentation of plantar fasciitis is pain under the heel or arch of the foot especially with the first steps in the morning. In the initial stages of the condition, the pain is usually reduced as the day goes on with increased movement. If ignored the condition can progress and become worse, leading to a significant decrease in function and pain with all activity involving weight bearing. Typically, the symptoms of plantar fasciitis are as follows;
Heel pain with initial steps after long periods rest or after sleep.
Decreased ability to bring foot towards shin (dorsiflexion).
Tightness felt at back of ankle – at achilles tendon.
Pain can be increased when not wearing shoes.
Stair ambulation can be aggravating.
Tenderness to the anterior medial heel.
How did I get it?
Plantar fasciitis is a condition that is usually brought about through a degenerative process from overuse. A wide variety of the community can acquire plantar fasciitis and there are a number of risk factors that can contribute to the development of the condition. They include;
Activities such as running.
Altered foot biomechanics (flat feet, or excessively high arch).
Being over weight.
Occupations that include increased time on feet throughout the day.
Poor, unsupportive footwear.
More common as we age due to degenerative/deconditioning of the muscles in the foot.
These risk factors alter the mechanics at the foot and place loads on the plantar fascia that it is not equip to deal with. Due to the change in force load and direction, the plantar fascia can be damaged. Over an extended period of time this can result in chronic changes to the tissue, leading to plantar fasciitis.
Ultrasound scans are routinely used in confirming a diagnosis of plantar fasciitis. If found, the scan will show a swelling of the plantar fascia and occasionally, in chronic conditions, calcification or tears in the tissue. X-ray scans are also use frequently and can show the presence of a bone spur near the attachment site of the plantar fascia on the heel bone.
Whilst, heel spurs can be related to the abnormal tension placed on the foot and plantar fascia, they have been observed in healthy pain free feet. Therefore, the presence of a heel spur cannot always provide an accurate verdict of causation of pain or further confirm the diagnosis of plantar fasciitis.
What can I do about it?
Plantar fasciitis can be extremely debilitating and painful. It is a relief then to know, that most people who suffer from the condition can be treated effectively with a significant reduction in symptoms through physiotherapy.
Like most conditions, the longer the condition has been around, the longer it will often take to heal and that is why early intervention is always important. In the initial phases controlling pain, inflammation and protecting the injured tissue is most important. Once there is an initial decrease in symptoms it is time for the gradual return to real function. Regaining range of motion, control of the foot posture, increasing strength and then using strategies to support your foot is key in preventing reoccurrence of the condition.
It is sometimes useful to stretch and move the foot in the morning before getting out of bed to avoid the initial pain response in the morning and allow for better function from the first steps in the morning. Every abnormal step, limp or altered walking pattern is delaying the time to full recovery.
Phase 1: Reduce inflammation, protect tissue.
Aim: Decrease pain in the area, allow time for tissue to undergo healing process and decrease ongoing stress to the plantar fascia.
Relative rest – avoid aggravating activities but attempt to keep foot mobile and loaded.
Ice massage – use of a frozen bottle under the arch of the foot can help with tension and inflammation at the injury site.
Taping and bracing to support the arch of the foot.
Soft tissue release through the calf and plantar fascia.
Pain free mobility exercises at the ankle and foot to retain as much range of motion as possible.
Phase 2: Restore full range of motion at the ankle and foot.
Aim: Regain full pain free range of motion in the ankle and foot.
Joint mobilisations at the ankle and foot.
Weight-bearing stretching exercises for the calf muscles and plantar fascia.
Increase activity levels – modifications to continue to avoid increase in pain and inflammation.
Phase 3: Improve foot, ankle and lower leg muscle control.
Aim: Increase the muscular strength and control in the muscle that’s support the foot arch and ankle.
Foot stabilisation exercises.
Weight-bearing strengthening exercises for the calf muscles.
Address deficiencies that are likely causes of altered foot mechanics.
Phase 4: Address biomechanics foot position and increase neuromuscular control.
Aim: With full ROM and strength around the ankle and foot – begin to address the biomechanical causes that are leading to plantar fasciitis.
Footwear analysis, modification and prescription.
Look at muscular imbalances at the hip and knee to help align the lower limb.
Podiatry review with the potential for orthotic prescription.
Work on balance, proprioception to develop better dynamic control around the foot and ankle.
Phase 5: Increase load on tissue, adding sport specific/dynamic exercise.
Aim: Prepare the foot and lower limb for more explosive movements to gradual progress back to full function.
Addition of plyometric training – look at technique with jumping and landing (address alignment/technique during movements).
Begin running program and focus on gradual load build up to avoid re-injury.
Begin to participate in sport/activity specific training to eventually progress back into full function.
Phase 6: Return to full function.
Aim: Return to activity of choice pain free with strategies to avoid re-occurrence of injury.
Sport specific exercises progressing to full games.
Re-iterate importance of self-management strategies.
Understanding importance of changes in load and load management (increase gradually and avoid large spikes in training).
Long term treatment goals should be about understanding what caused the plantar fasciitis in the first place. Whether it is related to, poor foot mechanics, alignment or just an addition of multiple risk factors, a review from a podiatrist can help with prevention.
Individualised foot orthotics have been shown to be extremely effective at managing plantar fasciitis for the long term without the need to stop doing the activities you want to do. Your podiatrist can assist with developing an orthotic device to assist correcting any alignment issues that are creating unwanted strain on the soft tissue.
If you are suffering from foot pain our experienced physiotherapist can help. Book an appointment online or call our friendly staff on 07 3352 5116.