heel pain, foot pain, plantar fascia, inflammation, stretching, physical therapy, orthotics, shoe inserts, rest, exercise.
Plantar fasciitis is a condition that results from the degeneration of the collagen structure of the plantar fascia, a fibrous band of tissue that runs from its origin in the heel to the toes.
The plantar fascia plays an important biomechanical role in supporting the structures of the foot during use, acting as a shock absorber as the foot is loaded and becoming taut during push-off.
When the heel becomes painful, it is often referred to as plantar fasciitis or inflammation of the plantar fascia, even though it is now known that there is rarely an inflammatory state present. Instead, the cause of pain is often degenerative changes, which are age- or wear-and-tear-related changes in tissue that result in a decrease in tissue fluid content, elasticity, and resilience. These changes partly explain the painful symptoms experienced in the heel and the attached fascial structure. For this reason, it would be more accurate to refer to the condition as plantar fasciopathy or heel pain, but in this article, I will refer to it as plantar fasciitis because of its prevalence.
Typically, the pain is felt in the inside and bottom of the heel when it is loaded. This is often accompanied by discomfort in the arch of the foot, and it is common for the pain to be worse when starting to move. The first steps in the morning are often the most difficult. Starting to move again after a longer break can also prove to be difficult as the pain usually intensifies after sitting still for a while.
Epidemiology
Plantar fasciitis is the most common cause of heel pain in the adult population, and the first symptoms often appear between the ages of 40 and 60. The condition is slightly more common in runners than in the general population. The pain usually lasts more than six months, and 10-15% of the population suffers from it.
Approximately 90% of cases are successfully treated with conservative treatment, and women are slightly more affected than men.
Plantar fasciitis is the most common foot condition treated at physiotherapy clinics, and it can account for up to 40% of all patients treated at a foot therapy clinic.
Symptoms
The most typical symptoms of plantar fasciitis is pain in the heel or under the arch of the foot when taking the first steps in the morning or after prolonged sitting.
There may be tenderness around the heelbone and limited ankle flexion, or a tight feeling in the Achilles tendon. Walking may be limping, or it may be easier to stride forward while avoiding a powerful heel strike, causing more forefoot loading.
Pain is usually worse on hard surfaces when walking barefoot and when climbing stairs than when walking in soft or molded shoes. Pain is often preceded by abnormal loading, such as longer walks or runs.
Treatment
The first-line of treatment for plantar fasciitis is conservative treatment. Initially, it may be beneficial to rest the foot from activities that cause pain, but it is not advisable to stay completely inactive as this can prolong the overall duration of the pain.
To relieve pain, cold therapy or painkillers may be used. Stretching and strengthening exercises are recommended to improve the flexibility and strength of the plantar fascia, Achilles tendon, and calf muscles. Shoe inserts, orthotics, or heel cups can also help to redistribute pressure and support the arch of the foot. In severe cases, immobilization with a walking cast or boot may be necessary, but these are rarely used.
Surgery may be considered only when all conservative treatments have failed. The most common surgical procedure is plantar fascia release, which involves releasing the plantar fascia from its attachment on the heel bone.
Based on current knowledge, it appears that prolonged and high-intensity strength training is the most effective way to reduce the duration and intensity of symptoms. With appropriate strength training, it's also possible to strengthen tendon and membrane structures, allowing them to better withstand stress without becoming painful.
Secondary treatment options
If conservative treatment does not achieve the desired results within 3-6 months, secondary treatment options may be considered, such as:
Corticosteroid injections
Platelet-rich plasma therapy (PRP)
ESWT shockwave therapy
Needle treatments
Low-level laser therapy (LLLT)
Plantar fasciotomy
Surgery
Surgical treatment may be considered if less invasive treatments have failed or if the pain is severe and prolonged.
Physical therapy
Plantar fasciitis is a common cause of heel pain that can significantly impact a person's daily activities. A thorough evaluation of the underlying factors, including biomechanical abnormalities, is essential to create an effective treatment plan.
Physiotherapy is the primary treatment approach aimed at improving function and reducing perceived disability. A gradual exercise program targeting the calf muscles and Achilles tendon has been shown to be effective in reducing pain and improving function. Additionally, therapeutic exercise often focuses on reducing foot pronation and improving weight distribution during weight-bearing activities. High-load strength training has been found to be effective in reducing pain and improving function in plantar fasciitis, as it helps to strengthen tendon and fascial structures, allowing them to better withstand stress without becoming painful.
Manual therapy, including massage and mobilization, can also be beneficial in reducing pain and improving mobility, while taping or the use of orthotics can help reduce strain on the plantar fascia. Shoe advice is also an important part of treatment. When pain is at its worst, supportive and cushioned shoes with a slightly elevated heel can help reduce tension and shock on the plantar fascia during walking and other activities.
In addition to treating the physical symptoms, it is important to review the patient's disease course and the duration of symptoms, which can reduce uncertainty and anxiety. It is also important to discuss pain-reducing measures and exercises and to develop a plan that can be realistically implemented to achieve optimal outcomes.
Self care
Rest: Avoid high-impact activities and rest your feet.
Ice: Apply an ice pack to your heel for 15-20 minutes, three to four times a day. Make sure to wrap the ice pack in a towel to protect your skin.
Stretching: Perform gentle stretches for the calf muscles and plantar fascia. Stretching can help reduce pain and improve flexibility.
Strengthening: Perform exercises to strengthen the calf muscle and the sole of your feet to promote healing and blood-flow.
Footwear: Wear shoes that provide good arch support and cushioning. Avoid flat shoes and high heels.
Orthotics: Consider wearing shoe inserts or custom orthotics to provide extra support to the arches of your feet.
Massage: Use a tennis ball or a frozen water bottle to massage your foot. This can help reduce pain and inflammation.
Pain relief: Over-the-counter pain medications like ibuprofen or naproxen can help reduce pain and inflammation.
Remember, if your pain persists or becomes severe, it's important to consult a healthcare professional for further evaluation and treatment.
Summary
Plantar fasciitis is a common condition characterized by pain and tenderness in the heel and sole of the foot. It is typically caused by overuse or strain of the plantar fascia, a thick band of tissue that runs along the bottom of the foot.
The conditions first line of treatments are conservative measures such as rest, strengthening, stretching, and orthotics, but if symptoms persist, more invasive treatments such as corticosteroid injections, ESWT, or surgery may be necessary.
Physical therapy is effective in reducing pain and improving function through the use of exercises, manual therapy, taping, and shoe recommendations. A progressive exercise program that focuses on reducing pronation and improving weight distribution can be especially effective. Overall, early diagnosis and treatment can help to prevent the condition from becoming chronic and debilitating.
To obtain an individualized program, I recommend that anyone suffering from this condition contact a physiotherapist specializing in lower limb injuries.
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