Plantar Fasciitis is one of the most common causes of foot pain affecting about 1 of 10 people. It is caused by injury to the thick tissue or fascia that connects the heel to the toes and transfers the force of the calf muscles to the ball of the foot. This tissue is vital for supporting the arch of the foot when you walk or run. Plantar Fasciitis can start traumatically but it is more often an overuse injury that slowly worsens over time. The most common location for Plantar Fasciitis to develop is where it attaches to the bottom of the heel.
The most common symptom of plantar fasciitis is pain with the first few steps in the morning or after a period of inactivity. One may also have worsened pain after prolonged standing or walking. Rising up onto one’s toes, running, and jumping are also painful.
Predisposing risk factors include:
- Age: Plantar fasciitis can occur at any age but is most common between the ages of 40 and 60.
- High activity levels that are demanding on the plantar facia such as long-distance running or dance. Training errors often precipitate the onset of Plantar Fasciitis. These training errors may include improper footwear, to aggressive advancement of training protocol, or running on unyielding surfaces.
- Foot mechanics: both flat feet and a high arch can place increased stress on the plantar facia and thus increased your risk of developing plantar fasciitis.
- Obesity: because increased weight puts more strain on the plantar facia it is not surprising that obesity is also a risk factor.
- Occupations that require prolonged standing – particularly on hard surfaces.
- Decreased strength in the foot and ankle.
- Decreased range of motion into dorsiflexion of the ankle or tightness in your calf muscles.
Plantar fasciitis is diagnosed clinically by your physician or physical therapist. There is usually no need for imaging unless there is reason to suspect other pathologies (stress fractures for example).
Treatment can be divided into three main categories based on their objective:
- Symptom control
- Reduction of the stress placed on the plantar fasciitis
- Improving the plantar fasciitis’s ability to tolerate the stress placed on it.
Reducing the stress placed on the plantar fascia:
- Orthotics: Either over the counter or custom orthotics may be used to decrease the stress placed on the plantar fascia and thus reduce pain. Interestingly research indicates that there does not appear to be any difference between custom and over the counter orthotics. Furthermore, the benefit appears to be relatively short term 3 months to 1 year. There is currently no evidence supporting long term (> 1 year) use of either custom or over the counter orthotics for plantar fasciitis.
- Stretching: Improving the range of motion at the ankle can reduce the strain placed on the plantar fascia and thus improves healing. Not everyone has restriction in ankle and calf mobility, but if you do it will significantly impair your ability to recover.
- Activity modification: Decreasing one’s activity level and limiting aggravating activities can be an important aspect of recovery. Your physical therapist can help guide you in what to limit and what activities are appropriate for you to continue.
Improving the plantar fasciitis’s ability to tolerate the stress placed on it:
- This is the most important treatment component and is often the most neglected. Without improving the tissue’s ability to tolerate the stress of your normal activities you will not achieve long lasting recovery.
- Strengthening: A progressive strengthening program at a level that is hard enough to encourage adaptive strengthening but not so hard that it injures the tissue is imperative. This can be a tricky process and is highly individual. Your physical therapist will help you acheive this balancing act.
- Manual therapy techniques: Instrumented assisted soft tissue mobilization techniques can be utilized by your physical therapist to provide a mechanical stress to the tissue to stimulate adaptive strengthening and improve your tissue’s ability to tolerate stress placed on it. It is an adjunct to strengthening and is not to replace strengthening but can be a valuable addition to the treatment plan.
Treatment should focus on the individual’s impairments and stage of recovery. In the acute phase anti-inflammatory measures and rest may be most appropriate. However, as the patient progresses it becomes more important to address tightness and weakness in the patient’s calf muscle. Night splints and/or warm up stretches to improve pain with the first step in the morning is also often helpful.
Returning to your prior level of activity can be tricky for people and should be guided by your physical therapist. The strengthening exercises should be tailored by your physical therapist to help you return to your specific activities.
If you are experiencing heel pain, give us a call. We would be glad to help you recover from your heel pain. Plantar fasciitis does not have to end your active lifestyle.