Everything you need to know about plantar fasciitis

February 28, 2017

Overview

 

The plantar fascia is a thick band of connective tissue found on the plantar surface (sole) of your foot. It runs from the calcaneus (heel bone) to the proximal phalanges of the toes, and can divided into three separate portion; the medial, central and lateral bands.

 

 

 

The function of the plantar fascia is to provide static support and dynamic shock absorption to the foot. It also contributes to a windlass mechanism, that provides tension and support to the arches of the feet particularly the the propulsive phase of the gait cycle. This mechanism is explained very well in this article.

 

Plantar Fasciitis is a condition that causes pain in the plantar surface of your foot, typically on the medial portion (inside) of the foot just distal to the calcaneus. 

 

Plantar Fasciitis accounts for 8-10% of running related injuries and 80% of patients who present with heel pain. 

 

Characteristic symptoms of plantar fasciitis include;

  • An initial insidious onset of heel pain

  • Pain on walking after waking or periods of inactivity

  • Pain that reduces with moderate activity but worsens after long periods of standing or walking

 

Signs of plantar fasciitis include;

  • Tenderness around the medial calcaneal tuberosity on the plantar surface of the foot

  • Limited dorsiflexion of the ankle with the knee extended

  • Painful 'Windlass Test' (pain during extension/raising of the big toe)

  • Limp or abnormal gait

 

Epidemiology (who is affected)

 

There are a lot of different factors that can contribute to plantar fasciitis. These include;

  • Having pes planus (flat feet)

  • Having pes cavus (high arches in your feet)

  • Wearing poorly supportive shoes that (especially if changing from previous shoes that have better support)

  • Being overweight

  • Excessive weight-bearing activities or walking

  • Sudden large increases in weight-bearing activities such as a new running programme

There is a peak age of onset for plantar fasciitis between the ages of 40 and 60 years old. 

 

There is also an increased risk in patients with certain spondyloarthropathies such ankylosing spondylitis and reactive arthritis. There is also an increased risk in patients affected by rheumatoid arthritis. These conditions should maybe considered if the plantar fasciitis symptoms are bilateral (in both feet), accompanied with a history of previous enthesopathies (achilles tendinitis, lateral epicondylitis) and systemic features associated with reactive arthritis or rheumatoid arthritis.  

 

Aetiology (the cause)

 

I've already said that there are other conditions that increase the risk of plantar fasciitis such as rheumatoid arthritis and ankylosing spondylitis. For simplicity I am just going to focus on the biomechanical causes of plantar fasciitis, even though there are neurologic, infectious, neoplastic, arthritic and other systemic conditions that can prove causative. 

 

The most common cause of plantar fasciitis is believed to be biomechanical dysfunction leading to microtrauma (small tears) in the plantar fascia. These are caused by constant and repetitive strain, leading to damage either along the course, or more commonly, around the attachment of the plantar fascia to the calcaneus. 

 

An example of this is the strain placed on the foot during running. As you run, the forces placed upon the foot can reach around 2 to 3 times your bodyweight. If this is done repetitively without allowing necessary recovery time, then repetitive strain to the plantar fascia can lead to plantar fasciitis. 

 

Some believe however that the term plantar fasciitis is slightly misleading, as you can develop the condition with or without signs of inflammation. The term fasciosis seems to be a term some are potentially seeking to use instead, due to the degenerative nature of the condition. Similar to the idea for the use of the word tendinosis to describe degenerative changes in tendons, even though thats recently been updated to be described purely as tendinopathy...

 

Management and rehabilitation

 

Most people recover completely from plantar fasciitis within six months of starting conservative treatment. 

 

Initial management of plantar fasciitis includes;

  • Rest from excessive/long periods of standing or weight-bearing

  • Wear supportive shoes and avoid walking barefoot when possible

  • Insoles and heel pads can be used to provide relief by reducing the stress/stretch on the plantar fascia (NOT 'MAGNETIC' DEVICES)

  • Ice can be applied to provide symptomatic relief (10-15 minutes application

 

Self physiotherapy can also be performed to accompany the initial management period. This would has a number of different elements to it including;

  • Stretching to the gastrocnemius, soleus and plantar fascia

  • Self-myofascial release with foam roller to gastrocnemius and soleus (calf muscles)

  • 'Dynamic stretching' to plantar fascia by rolling a can, rolling pin, tennis ball or massage ball under the foot

  • Continuing with the icing under the foot

Manual therapy treatment can also help if self-physiotherapy doesn't work to improve symptoms. Manual therapy from Osteopaths, Physiotherapists and other manual therapists can work along side treatment and management advice from Podiatrists, to try and reduce symptoms. Aims of manual therapy to treat plantar fasciitis are similar to the principles of 'self-physiotherapy' that aim to reduce pain and to improve flexibility of the calf and plantar fascia, as well as keeping the foot mobile. 

 

If conservative methods fail then further treatments can be performed. These are the last line of treatments and are only ever considered if the symptoms persist for a long period of time. They include;

  • Extracorporeal Shockwave Therapy

  • Corticosteroid injection (more for short symptomatic relief)

  • Surgical release of the plantar fascia

 

‘Prehabilitation’ and prevention

 

There are many different approaches to prevention of plantar fasciitis. Continuing with stretching, self-physiotherapy and occasionally treatment from a manual therapist can help improve muscle tone and mobility of the foot and ankle.

 

Other focuses of 'prehab' can focus on;

  • Improving gluteal strength to improve the shock absorption of the lower extremity

  • Strengthening of the tibialis posterior to reduce excessive pronation that can increase the strain to the plantar fascia

  • Improving the strength and shock absorption of the gastrocnemius and soleus to reduce the strain to the plantar fascia

  • Isometric and eccentric loading to the calf and plantar fascia can improve these structures abilities to tolerate and increase in load

 

 

 

Please note that this blog post/article shouldn't be used as a replacement for seeking the appropriate medical advice. It is always best to seek medical help from a trained health care professional that can advise the next best steps for you! 

 

If you have any questions about anything, or would like to book an appointment then please call 02083047237 or message us on our Facebook page directly (link below).

 

 

Bibliography

1. Brukner, P., Khan, K., et al. (2012) Brukner & Khan’s Clinical Sports Medicine. 4th Ed. North Ryde, Australia: McGraw-Hill Education

2. Thing, J., (2012) Diagnosis and management of plantar fasciitis in primary care. Br J Gen Pract. 2012 Aug; 62(601): 443-444

3. Emedicine [Accessed 23/1/17]

4. NICE guidelines for Plantar Fasciitis [Accessed 23/1/17]

 

 

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