Plantar Fasciitis (or 'plantar fasciopathy')
The TLDR (too long/didn’t read) version: Foot/Ankle concern? = Refer to Podiatry/See a Podiatrist
What is Plantar Fasciitis?
Plantar fasciitis is the overuse of the plantar aponeurosis/fascia in the foot.
The reasons why an overuse occurs are so varied that we cover this in another education piece.
How does it present?
Typically pain under the foot. The pain usually starts around the heel and can be either localised and focal (“I feel like I’m stepping on a stone”) or more generalised and spread throughout the plantar aspect.
Symptoms are often worse 1st step after rest (think mornings, getting out of a car after a drive) and can warm up a little, then regress with more loading. But not always. Some people present with constant weight bearing pain or pain that lingers at night.
What to do about Plantar Fasciitis
See a podiatrist or refer to a podiatrist ASAP. Any delay in therapy can lead to risks relating to further damage including rupture, chronic pain and kinesiophobia (extensive research on this relating to plantar fasciitis).
Symptom guidance can be advised upon to manage whilst awaiting podiatry assessment and intervention. As the reason(s) for developing plantar fasciitis are varied, not everyone will respond in the same manner.
While awaiting podiatry assessment therapeutic advice that is unlikely to cause harm and potentially be beneficial is:
- Education: Pain education, reassurance, avoidance of nocebic language.
- NSAIDS topically (Voltaren Gel). If safe to proceed systemically can be trialled (often no positive effect).
- Self Massage (thumbs/tennis ball/water bottle).
- Wear shoes you feel MORE comfortable in
- Footwear can increase or decrease plantar fascia loading (even runners can inc/dec loads).
- Warm up your feet prior to standing up after rest. Ankle movements (circles/alphabet shapes).
- Refer or see a podiatrist:
"The podiatrist will assess you and give a clear diagnosis, work out why it is happening and plan to get you back to where you want to go. They will look at capacity, loading and plan accordingly. You might need to change your shoes, do appropriate exercises, use devices like orthotics to manage loading. They will advise you what is needed for your sore feet."
What not to do
- Inject. Corticosteroid injections have shown to lead to significant negative effects. Also 50% people have symptoms 10 years post CSI + other adverse effects. The role for CSI in PF is very limited and not a front line treatment modality.
- Delay. X-rays are unlikely to be beneficial, ultrasound not required most times. If referring for imaging is going to delay expert assessment, cloud patients understanding of pathology, it’s not needed.
- Nothing. It is not a self limiting condition. Doing nothing is a clinical decision that is related to short/long term harm.
Want to Know More About Plantar Fasciitis? Here's the Knitty-Gritty Referenced Details
What is it?
An overload of the plantar fascia, the thick, fibrous band of tissue that originates at the medial calcaneal tubercle and inserts near the MTPJ’s in the flexor tendons.
The plantar fascia’s role is support and energy storage. During gait the plantar fascia undergoes tensile loading (which it loves, all the fibres line up ready to take massive tensile loads) where it provides an internal supinatory moment around the STJ axis. As the plantar fascia is loaded it’s stretches and stores kinetic energy which is then utilised to further plantar flex the digits during midstance through to propulsion.
Simple terms - it’s a big rubber band that makes walking and running easier.
The plantar fascia has not developed to take compressive loads very well (similar to tendons and the opposite of bones). It does not take much compressive load to lead to pathology/pain. Compressive loading of the plantar fascia occurs when the calcaneus inverts or everts significantly during weight bearing phase of gait.
Typically painful and sharp. Like most fascia and tendon pathologies the pain is worse on first steps in the morning or after periods of rest. Often the pain will warm up and settle (particularly in the early days of pathology) and then deteriorate with increased loading (hours on feet at work, a long run etc.)
Clients symptoms will vary but a common thread is a sharp feeling on weight bearing, feeling like standing on a stone, a burning sensation through the arch when over done it and when chronic - a burning at rest as well.
Myths, falsehoods and quarter truths
“There’s no need to do much because plantar fasciitis is self-limiting”
NOPE. A study looking at people with plantar fasciitis found that almost half(!!!) still had symptoms 10 years after initial diagnosis. (Hansen et al)
“Stretching will fix it”.
Mostly nope. Stretching has been shown to be beneficial for some, but not all. And what to stretch? The calves? The plantar fascia? Best see a podiatrist for thorough advice.
“It’s a heel spur.”
Heel spurs are almost always asymptomatic “incidentalomas” that show up on imaging in line with our decade of life. 40% of people in their 40’s, 50% of people in their 50’s have calcaneal heel spurs. These findings do not correlate to plantar fasciitis symptoms. In podiatric circles, it is thought that the overuse of imaging (in particular X-rays) has led to such a large population of people blaming heel spurs for their inferior heel pain. There is a very small subset of inferior heel pain sufferers who do get pain related to their heel spur - also known as Baxter’s nerve entrapment. This pain pattern is usually different from typical plantar fasciitis symptoms.
Why? A thorough history and clinical examination should give you a 95% certainty of diagnosis. If you suspect something sinister like osteosarcoma then imaging is certainly warranted but otherwise, imaging referrals delay timely access to expert health professionals.
Of course, if a client’s goals are imaging related “doc I really want to get a scan done on my sore heel” then person-centred care could allow for a referral for imaging and to an expert at the same time.
As it is an overload on the tissue, doing less, in theory, could be an option. But not a good one. Doing less on our feet has significant deleterious effects on our health, mood, lifestyle and sporting performance.
Treatment should focus on three aspects. Load optimisation, capacity building and education.
Load optimisation is where we work out what loading is essential and what is potentially pathological. The main focus for plantar fasciitis is encouraging tensile loading (which the PF loves) and discouraging compressive loading which the PF is not fond of.
We do this via:
- Gait Training (for runners)
Capacity building is taking the fixed capacity of work that the plantar fascia is currently doing, and increasing it. This can be done with resistance training much in the same way we train a muscle or a tendon as the plantar fascia has contractile tissues exactly like the two formers. There’s been some excellent work completed by Rathleff et al (2014) into this in recent years.
Education here really means pain education. When we take the time to talk through pain in terms of nociception it empowers our clients to take charge of their musculoskeletal complaints. It’s frightening to read (Cotchett et al) about the number of people with significant mental health challenges AND heel pain so this part of our therapy is critical for success.
We also take the time to explain to every client the exact reason for their plantar fasciitis, their symptoms and allow opportunities for discussion and questions. This leads to the critical step of goal setting.
There’s also the 5% ‘ers. This can include pain modulation with NSAID’s, massage, and icing. Cortisone has sometimes been shown to be useful for short term pain relief (similar to strapping and orthotics) but no better long term (+ side effects).
ECSWT (extracorporeal shockwave therapy) has been shown to also work for short term pain relief for some sufferers. The procedure itself is quite painful to undergo and has yet to be proven to be more beneficial than other treatments with less adverse effects. The pride team have been monitoring this closely but as yet cannot see where it would fit into almost every treatment plan we develop for people with plantar fasciitis and do not offer this service currently.
DN (Dry needling) does have some positive evidence for plantar heel pain (Cotchett & Munteanu). It’s a potentially useful adjunctive therapy although downsides include risk of adverse events as well as passive nature of therapy reducing self-management and empowerment of a client with their own plan.
Such an overlooked yet critical aspect of health care, actually asking what our clients want and why. A client suffering from plantar fasciitis symptoms for only a short period of time vs. those with chronic symptoms will have different goals and expectations although almost always pain relief will be there. Goal setting in the short, medium and long term provides a useful framework to fall back on when compliance/adherence or life gets in the way of best-made plans.
4. High-load strength training improves outcomes in patients with plantar fasciitis: A randomised controlled trial with 12-month follow up. Scandinavian Journal of Medicine and Science in Sports. (2014). Rathleff M, Molgaard C, Fredburg U, Kaalund S, Anderson K, Jensen T, Aaskov S & Olesenj.
5. The association between pain catastrophising and kinesiophobia with pain and function in people with plantar heel pain. The Foot (Edinb.) 2017. Cotchett M, Lennecke A, Medica VG, Whittaker GA, Bonanno DR.
6. Long-Term Prognosis of Plantar Fasciitis: A 5- to 15-Year Follow-up Study of 174 Patients With Ultrasound Examination. Orthopaedic Journal of Sports Medicine (2018). Liselotte Hansen, Thøger Persson Krogh, Torkell Ellingsen, Lars Bolvig, and Ulrich Fredberg
7. Effectiveness of Trigger Point Dry Needling for Plantar Heel Pain: A Randomized Controlled Trial. Physical Therapy (2014). Cotchett M & Munteanu S.
A Plantar Fasciitis Case Study by PridePlus Health
“My heel hurts every morning and after every rest”
“It’s like walking on a stone”
“What is causing this pain?”
“I want the pain gone, it’s stopping me exercising for my overall health and well being.”
“I’d love to get back to running, I haven’t done that in years.”
43 year old male presenting with right (unilateral) heel pain. Nil previous injury history, nil recent increase in physical activity.
- 8/10 VAPS (visual analogue pain scale) on first step
- 2/10 during activity
- 7/10 with increasing activity (after 20min walking dogs)
- Pedal joints WNL except Hypermobile STJ on R
- Laterally deviated STJ axis on R>L (4th met axis vs. 3rd met axis)
- Right: PF ⅘, DF ⅘, In ⅘, Ev ⅗
- Left: PF ⅘, DF ⅘, In ⅘, Ev ⅘
- Lateral heel strike R = L
- Rapid calcaneal eversion during heel strike to midstance (R>L)
- Calcaneal inversion during midstance > propulsion (Right only)
- 2nd - 3rd digit loading at propulsion on R, 1st - 2nd on L
- Worn Asics Kayano (walk/run/fitness shoe)
- New leather men’s business shoe (work)
- Barefoot around the house
- Average 8K steps per day
- Nil current planned resistance training activity per week
- Mild OA changes to both 1st MTPJ’s
- Nil current medications, known allergies
Program and Team
Self referred to podiatry after Googling “how to fix heel pain”
6 x 1:1 sessions with podiatrist
Week 0 - Initial assessment, treatment planning. Commence load optimisation with improved footwear choices (new athletic footwear), strapping for symptom relief and commence a home exercise program
Week 1 - Pain settled with 4/10 in AM with strapping on, able to walk dogs 20min once daily pain-free (when strapped). Escalated home exercise program.
Week 3 - 3/10 AM pain when strapped, 6/10 pain if does not strap. 3D scan of foot taken and orthotics 3D printed. Home exercise program adjusted for technique.
Week 5 - Orthotics issued, fitted into athletic footwear and work shoes. Checked and adjusted exercise program.
Week 9 - 1/10 pain in AM only when had a day out at football and walked 18K steps vs. 8K normal days. Pain-free all other times. Provided ongoing education around exercise program, return to running plan.
Week 13 - Pain-free, can run/walk for 30min, increasing running under podiatrist guidance (via email correspondence). No planned podiatry review. Will present in ~ 2 years to check orthotics (expected lifespan > 10 years)
Pain-free, increased physical activity to greater than pre-injury levels. Building towards a 14Km fun run.
Having a sore foot sucks. The constant reminder that something is not right every time you get up is not a pleasant way to live our lives. With some simple load changes and an appropriate exercise program, we were able to get a great result, including a return to a running program which was not in place pre-injury.
The time taken to get to pain-free (13 weeks) might feel like a lot although during this time there were constant improvements with symptoms whilst strength and physical activity was increasing. To be able to be more active and not regress with symptoms is a definite win.