Plantar Fasciitis

Plantar Fasciitis is a condition causing tissue damage and pain at the attachment of the plantar fascia to the underside of the calcaneus (heel bone).

Anatomy
Plantar Fasciitis is the Latin term for “inflammation of the plantar fascia”. The plantar fascia is a thick, fibrous ligament that runs under the foot from the heel bone to the toes. It forms the arch of the foot and functions as our natural shock-absorbing mechanism. Unlike muscle tissue, the plantar fascia is not very elastic and therefore is very limited in its capacity to stretch or elongate. Herein lies the problem: when too much traction is placed on the plantar fascia (for various reasons) micro-tearing will occur, resulting in irritation, inflammation and pain.

In many cases, plantar fasciitis is associated with a heel spur. Surprisingly, the spur itself does not cause pain, and may often be found in the other foot without symptoms.

What is a Heel Spur?
A heel spur is a bony growth at the front/underside of the heel bone. This type of calcification is also referred to “calcaneal spur” (calcaneus is Latin for heel bone). The reason for the development of a spur is that the body ‘responds’ to the constant traction and pulling from the plantar fascia ligament away from the heel bone. The ligament itself cannot become any longer, so instead the bone will ‘assist’ the ligament and grow.

A heel spur will show clearly on an X-Ray of your foot. After diagnosis of the Plantar Fasciitis, some doctors will recommend you have X-Rays taken. However, it should be noted that calcaneal spurs are not painful. They are not the problem. Pain is only caused because of inflammation of the tissue surrounding the heel spur.

It is interesting to note that most people suffering from Plantar Fasciitis pain do not have a heel spur! And vice-versa, there are people with a spur under one or both heels, but they have never experienced any foot pain. Spurs take many years to develop, they can also be found at the back of the heel (near the Achilles Tendon) or in other parts of the body.

Risk Factors for Plantar Fasciitis

• Certain sports:  Activities that place a lot of stress on the heel bone and attached tissue, i.e. running, dance and aerobics.
• Flat-feet or high arches:  People with flat feet may have reduced shock absorption, increasing strain on the plantar fascia. High arched feet have tighter plantar tissue, leading to similar effects.
• Middle-aged or older: Heel pain tends to be more common with ageing as muscles supporting the arch of the foot become weaker, putting stress on the plantar fascia.
• Overweight:  Weight places a greater mechanical load on the plantar fascia. There is evidence that overweight and inactivity lead to chemical damage to the plantar fascia, with a worsening of pain.
• Pregnancy:  Weight gain, swelling and hormonal changes that accompany pregnancy may lead to mechanical overload of the plantar fascia.
• Being on your feet:  People with occupations that require a lot of walking or standing on hard surfaces may suffer plantar fascia pain.
• Wearing shoes with poor arch support or stiff soles:  Poorly designed shoes may contribute to problems.

Prevention

• Maintaining a healthy weight to minimise the stress on the plantar fascia.
• Choosing supportive shoes. Avoiding stiletto heels and shoes with excessively low heels like ballet flats. Buying shoes with a low to moderate heel, good arch support and shock absorption. Reducing your time barefoot, especially on hard surfaces.
• Not wearing worn-out runners. Replacing old runners before they stop supporting and cushioning the feet.  If a sport involves a lot of running, replacing shoes after about 650 kilometres of use.
• Starting activity slowly. Warming up before starting any activity or sport, and starting a new exercise program slowly.
• Undertaking training prior to competition to ensure readiness to play.
• Allowing adequate recovery time between workouts or training sessions.
• Drinking water before, during and after play.
• Avoiding activities that cause pain.

What are the symptoms, why is the pain worse in the morning or after sitting?
Heel pain is in most cases experienced in the centre of the underside of the heel, or at the front or sides of the underside of the heel. The pain is more intense with your first steps out of bed in the morning or after sitting for a while. The reason for this is that during rest our muscles and ligaments tend to shorten and tighten up. The tightening of the plantar fascia means more traction on the ligament making the tissue even more sensitive. With sudden weight-bearing the tissue is being traumatised, resulting in a stabbing pain.

After walking around for a while the ligament warms up, becomes a little bit more flexible and adapts itself, making the pain go way entirely or becoming more of a dull ache. However, after walking a long distance or standing for hours the pain will come back again.

To prevent the sudden sharp pain in the morning or after sitting, it is important to give the feet a little warm-up first with some simple exercises. Also, any barefoot walking should be avoided, especially first thing in the morning, as this will damage to the plantar fascia tissue.

Apart from pain in the heel or symptoms may include a mild swelling under the heel. In addition, heel pain is often associated with tightness in the calf muscles. Tight calf muscles are a major contributing factor to Plantar Fasciitis.

Immediate Management
Initial treatment includes offloading the area, wearing supportive cushioned footwear with a slight raise at the heel and avoiding flip flops, ballet flats and un-supportive stiff soled shoes. By booking an appointment with your podiatrist as soon as possible they will be able to assess your foot and the causative factors. They are able to apply a specific taping technique to your foot to rest the plantar fascia long enough for it to heal and for you to continue walking. They will then guide you with appropriate home exercises including important and specific stretching and strengthening of the lower leg and foot. They may also prescribe a heel lift and advice on appropriate footwear and may look at other modalities if required. A reduction in weight is also beneficial in assisting healing if you have increased body weight recently.

Treatment – Ongoing if required

• Night splints/Strassburg Sock:  Your podiatrist may recommend wearing a splint or sock fitted to the calf and foot while sleeping. This holds the plantar fascia and Achilles tendon in a lengthened position overnight.
• Orthotics.  A Podiatrist is the most specifically trained health professional to assess your biomechanics and may prescribe off-the-shelf or custom-fitted arch supports (orthotics) to help distribute pressure to the feet more evenly, and to stimulate the small foot muscles.
• Physiotherapy.  A physiotherapist can give instruction on a series of exercises to stretch the plantar fascia and Achilles tendon and to strengthen lower leg muscles, which stabilises the ankle and heel. A physiotherapist may also instruct how to apply athletic taping to support the bottom of the foot. Your podiatrist will refer you for this should you need it.
• Other Modalities – for the chronic case which can be discussed with your podiatrist are Acupuncture, Trigger point massage, ESWT (shock wave therapy), Cortisone Injections, Medication. These measures are for the most persistent cases, and do not replace the need for the treatment methods detailed above.
• Surgery – is the last resort once all of the above conservative treatment options have been exhausted.

Rehabilitation and return to play

Aims of rehabilitation

• Decrease initial pain and inflammation.
• Identify biomechanical dysfunction.
• Improve flexibility.
• Strengthen the plantar fascia, intrinsic foot muscles and lower limb
• Return to full fitness.
• Injury prevention.

Reducing pain and inflammation

• Reduce activities that cause pain.
• Maintain fitness by swimming or cycling. Take the opportunity to work on upper body strength.
• Taping gives excellent support while allowing the foot to heal.
• If taping is effective then it is likely that orthotics will also be effective in correcting foot biomechanics and helping to prevent the injury returning once normal training has resumed.
• Apply cold therapy.  Ice massage for 10 minutes to the site of pain – several times a day if possible. A frozen drink bottle used like a rolling pin is an easy way of performing ice massage.

Return to play

• Follow the advice given by a sports medicine professional.
• After a week of no pain running can be started again.
• This should be a gradual process. If pain is felt at any time then go back a step.
• Running time should be gradually increased.
• Apply tape to the foot to support it for the first few runs, especially if orthotics are not being worn.
• Ensure the correct shoes for your type of running style or sport are worn. See our podiatrists for a personalised Footwear Assessment to determine the correct shoe.
• After every training session apply ice for about 10 minutes.
• Stretch properly before each training session and after.  Hold stretches for about 30 seconds and repeat five times.

Always Consult a Trained Professional

The information above is general in nature and is only intended to provide a summary of the subject matter covered. It is not a substitute for medical advice and you should always consult a trained professional practising in the area of sports medicine in relation to any injury. You use or rely on the information above at your own risk and no party involved in the production of this resource accepts any responsibility for the information contained within it or your use of that information.