What is Plantar Fasciitis?
Plantar fasciitis is one of the most common sources of heel pain.
Plantar fasciitis is most often associated with impact and running sports, especially those that involve toe running rather than heel running styles.
It is also commonly diagnosed in individuals with poor foot biomechanics (e.g. flat feet) that stress the plantar fascia.
What Causes Plantar Fasciitis?
Plantar fasciitis is one of those injuries that magically seems to appear for no apparent reason.
Typically, plantar fasciitis is caused by one of two methods.
They are traction or compression injuries. More about them shortly.
How Does Plantar Fasciitis Progress?
You'll typically first notice early plantar fasciitis pain in the morning.
Your heel pain will be worse with the first steps in the morning and improves with activity (as it warms up). The symptoms will progress with further injury.
As plantar fasciitis deteriorates, the pain will be present more often. You can determine what stage your are in using the following guidelines:
- No Heel Pain - Normal!
- Heel pain after exercise.
- Heel pain before and after exercise.
- Heel pain before, during and after exercise.
- Heel pain all the time. Including at rest!
This symptom progression is consistent with the four stages of a typical overuse injury.
What are the Types of Plantar Fasciitis Injuries?
Plantar fasciitis symptoms are usually exacerbated via "traction" (or stretching) forces on the plantar fascia although a"compression" (or impact) style pain may be evident.
The compression type plantar fasciitis can confused with a fat pad contusion that is often described as a "stone bruise".
Compression type injuries have a traumatic history. The location of plantar fasciitis pain will be further under your arch than under your heel, which is more likely to be a fat pad contusion.
If a compression style injury sounds like your problem then a deloading heel cup such as a Tuli's heel cup are usually very effective in easing your compression pain.
You'll also find that electrotherapy agents providing by your physiotherapist will hasten your healing time.
More information about Heel Cups…
Traction style injuries don't tend to benefit from heel cups. Among other treatment suggestions that will be discussed shortly, traction style plantar fasciitis is more likely to benefit from foot arch taping, special plantar fascia braces or soft orthotics. This is of course in addition to the exercise regime that will be discuss later.
What about Plantar Fasciitis Night Splints?
You will see plantar fascia night splints advertised on the internet. These splints essentially overstretch the plantar fascia, which may provide you some short-term relief, but ultimately elongates your passive arch structures.
The medium and long-term benefits makes no sense of this rationale. To the contrary, permanent elogation will predispose you to flatter arches and more likelihood of recurrent heel pain. Based on this we do NOT recommend plantar fascia night splints in most instances.
How to Confirm the Diagnosis of Plantar Fasciitis
After suspecting plantar fasciitis from your history, your physiotherapist will undertake a thorough examination of your foot and if needed, your spine or legs. Symptoms that help us to confirm the diagnosis include:
- Inferior heel pain will be present over the medial tubercle of the calcaneum or along the medial border of the plantar fascia.
- Palpable thickening in the medial border of the plantar fascia.
Common Plantar Fasciitis Findings:
- Most feet are overpronated (or flattened arches) but this is not diagnostic as a lesser percentage are pes cavus.
- Tightness of the calf muscles or reduced ankle joint dorsiflexion is a common finding.
- A reduction of talocrural dorsiflexion range (e.g. post-ankle sprain or post-fracture), which causes a compensatory increase in midfoot motion that tractions the plantar fascia.
- There may be pain reproduced on active toe raise or on passive dorsiflexion stretching.
Other Diagnostic Tests?
- X-ray will identify calcification within the plantar fascia or a calcaneal spur in advanced cases.
- Bone scan is useful to exclude stress fractures and osteomas in recalcitrant conditions.
- MRI is the most useful diagnostic tool in plantar fasciitis.
- Pathology tests (including screening for HLA B27 antigen) may identify spondyloarthritis.
Beware of Other Sources of Plantar Fasciitis
It is best to seek the advice of your sports physiotherapist or doctor if your symptoms are not resolving with routine treatment. You may be treating the wrong injury source!
Other Common and Potential Sources include:
- Systemic Causes: Spondyloarthropathies, Osteoma, Osteomyelitis
Does Having "Flat Feet" Make You Vulnerable?
Flat feet people (known medically as overpronators) are prime candidates
due to the increased plantar fascia stretch as the arch collapses.
To a lesser degree a rigid high arch (pes cavus) foot is also vulnerable
due to its inability to adequately absorb ground forces. These
additional forces are absorbed by the plantar fascia, causing fasciitis.
Basically, normal foot biomechanics are your best chance of not experiencing plantar fasciitis.
What is the Best Treatment for Plantar Fasciitis?
Your physiotherapist will select the most appropriate treatment modalities for you.
- Pain reduction is the primary initial aim. This may include rest from aggravating activities, ice applications, gentle plantar fascia stretching, massage techniques and electrotherapy e.g. ultrasound and electrical stimulation
- Foot arch taping is an extremely effective method of providing immediate pain relief. Kinesiology taping has proven to be extremely effective in recent years.
- Ice and electrical stimulation e.g. a tens unit can often speed up recovery and reduce the need for drugs. Ultimately, biomechanical correction is the aim.
- NSAID's and corticosteroid injection is most effective when combined with biomechanical correction.
- Mechanical treatment that involves taping and orthoses has been shown to be more effective than either anti-inflammatories or accommodative modalities.
After your pain is settling the next aim is to fully resolve your plantar fasciitis and STOP it coming back.
Here's how:
- Cases of moderate to severe biomechanical deformity should be referred for physiotherapy or podiatric assessment for a biomechanics assessment to prevent chronic recurrence.
- Foot intrinsic muscle strengthening (including tibialis posterior and peroneus longs) is highly effective and rec ommended in most cases of plantar fasciitis. At PhysioWorks, we incorporate this muscle retraining into our active foot stabilisation program.
- Ankle range of motion techniques and calf stretches (gastrocnemius and soleus) are almost always required.
- Useful products include soft orthotics (overpronators / traction type pain) or heel cups (compression pain). A soft orthotic when used in conjunction with a stretching program is more likely to improve acute symptoms than a custom polypropylene orthotic device.
- Footwear Analysis. Often it is poorly designed footwear that can predispose to the injury. Seek the professional advice of your health care practitioner
- While traditional methods alone are ultimately effective, iontophoresis in addition to traditional modalities has shown a quicker reduction in pain.
- Extracorpeal shockwave therapy is being increasingly used for plantar fasciitis, but limited evidence supports its use.
What if you Do Nothing about your Plantar Fasciitis?
Unfortunately, untreated Plantar Fasciitis will not only continue to cause you pain and hamper your life, but the condition can deteriorate and cause either calcification within the plantar fascia itself or result in calcaneal heel spurs.
More information about Calcaneal Heel Spurs here...
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