I think it is fair to assume that you have heard of the term “Plantar Fasciitis”. Whether you’ve heard your great Aunt Dorothy raving on about it or you’ve seen it whilst sifting through the mountains of information on Google, we’ve all stumbled across these two words at some stage. Plantar Fasciitis is estimated to affect approximately 10% of the population and is well known for the pain it causes when the sufferer first steps out of bed in the morning.
Despite it being very common, it is regularly left untreated. Although Plantar Fasciitis is the most commonly diagnosed form of plantar heel pain, it is only one of the many causes. Before we elaborate on these many causes, let’s take a closer look at the most commonly acknowledged form of heel pain and why it has been incorrectly titled for so many years. Plantar Fasciitis!
First things first… Let’s get this name right. The suffix ‘itis’ is used to indicate a presence of inflammation. Many studies using different forms of imaging and tissue biopsies have shown that in many cases of “Plantar Fasciitis” there is little to no signs of inflammation or inflammatory markers within the plantar fascia itself. So what is it that causes this stubborn pain directly under the heel if not an inflammatory reaction?
It has been found to demonstrate similar traits to tendinopathy (tendon injury), and goes through a slower ‘weakening’ process of its collagen fibres over time, but there is still work to be done in grasping a greater understanding of what is happening here. Yes, it all sounds like doom and gloom but the positive is that it is very manageable and responds really well to movement.Some other terms which can be used to describe this condition include Plantar Fasciopathy/Fasciosis or more generally just called Plantar Heel Pain.
Now, if you’re looking for a quick way to tell if this may be what’s affecting you, some common tell-tale signs include:
• Pain under the heel (more so on the inside portion of the heel)
• Usually worse in the morning and when first standing up after prolonged sitting
• It warms up as you get moving
⇒ ACTIVITY LEVELS
Those considered to be sedentary are at greater risk. This may be partially due to associated weight gain and decreased capacity of the plantar fascia/plantar muscles.
⇒ TYPE OF ACTIVITY
Repetitive weight bearing activities can contribute to heel pain if there are training errors present. For example, some runners can experience plantar heel pain if there is a rapid increase in load, change in training surface or other significant change to training. But don’t hang up the runners right away, most of these factors are easily modifiable.
⇒ WEIGHT AND BODY COMPOSITION
Due to the extra forces which are being placed through the foot and the Plantar Fascia , being overweight or gaining weight can increase your risk of developing plantar heel pain.
Everyone is born unique! As a result we all move differently and have variations in our joint/bone structure. These variations can sometimes be a contributing factor in the heel pain you’ve developed. For example an excessively “flat” foot or high arch may put you at greater risk of experiencing heel pain.
Jobs that require a lot of heavy lifting, pushing or pulling may predispose you to low back pain due to increased repetitive load placed on the back. This may be especially true if you haven’t prepared your body for those twisting and vibration type movements. However, if you’re an office worker who sits all day, this doesn’t mean you’re in the clear! Prolonged sitting is linked to back pain, diabetes, cardiovascular disease and even some cancers.
⇒ MENTAL HEALTH
It may sound funny to some because your feet are so far away from your head but mental health plays a role in plantar heel pain (and all types of pain for that matter). Depression, stress and anxiety have been found to be linked with plantar heel pain and many other types of pain. This is due to how you pain system responds to stessors in your life.
This not only fits with an increase in body weight, but also is a time in which the joints of the feet can become more flexible and begin to function in a new/different way.
Although all age groups can be affected by plantar heel pain, it seems that those over 50 years old are at a slightly greater risk of experiencing this condition.
Our feet are extremely complex structures which are designed to act like springs for our body, absorbing load and propelling us forward with every step. Within each of these springs we have 28 bones, 33 joints, 20 intrinsic muscles (inside the foot) and 13 extrinsic muscles (outside the foot), all working to keep you moving day after day.
If we include all of our muscles, tendons and ligaments, we have over 100 soft tissue structures working to move and manipulate these bones and joints within our feet. With so much complexity and so many moving parts related to the function of our feet it is easy to see how a misbehaving ‘cog in the wheel’ can potentially impact the efficient functioning of your foot.
Now, even though the plantar fascia is pinned as the “fall guy” for most presentations of plantar heel pain, it is important to look at these surrounding structures as potential contributors. But where do we start? Listed below are some other common causes of heel pain each with their own characteristics, causes and treatment strategies:
Quadratus Plantae Overload
Baxter’s Nerve Entrapment
Tarsal Tunnel Syndrome
Calcaneal Bone Oedema
Calcaneal Stress Fracture
Fat Pad Atrophy/inflammation
Partial or Complete Plantar Fascia Rupture
On occasion, plantar heel pain may even be caused by other underlying conditions such as:
Plantar heel pain can be diagnosed with a thorough assessment from a Podiatrist with experience in managing musculoskeletal conditions. You do not require a referral from your GP to book with your Podiatrist. The fantastic thing is that almost all forms of plantar heel pain can be diagnosed within the clinical setting with your chosen Podiatrist and rarely require additional imaging.
Your Podiatrist will be trained in diagnosing the condition, identifying the contributing factors and developing a clear plan with you to ensure you are on the correct road to becoming pain free. Your Podiatrist will take you through a discussion of your symptoms to better understand how your plantar heel pain impacts your life and how they can help you achieve your goals. You are then taken through a physical assessment where your Podiatrist will look at the range of motion in your joints, strength of specific muscle groups as well as movement patterns relevant to what you want to do (whether that be walking, running or dancing).
Your Podiatrist will consider all possible aspects of your life from the shoes and socks you wear to the positions you sit/stand at work, to help diagnose and treat your injury. In the unlikely event that scans or imaging are required, your Podiatrist will be able to refer you for imaging and will happily interpret and relay these results for you.
Below is a small flow chart which may help in guiding where your heel pain is stemming from, based on the nature and behaviour of your pain. Keep in mind that this information is very generalised and if you’re experiencing any similar symptoms, please check-in with your Podiatrist.
Imaging and scans can be a helpful tool used to diagnose acute injuries and things like broken bones, but can often be misleading when it comes to more chronic conditions. The reason for this is that they often identify findings which are not necessarily the cause of your pain. For example it is estimated that up to 20% of the population have non-symptomatic heel spurs (pictured above) with a poor correlation between presence of a heel spur and pain.
Despite this, heel spurs are commonly identified in imaging and are highlighted as the specific cause of many individual’s heel pain. It is more likely the surrounding structures causing the heel pain eg. plantar fasciopathy or fat pad atrophy/inflammation. So, what does this mean for you? It means that a ‘problematic’ finding on your imaging results may be nothing to worry about, and may just be an incidental finding that isn’t causing your pain.
The main takeaway is not to pain about your imaging results. Remember that these findings are most likely appropriate for your age! Your body has a great capacity to heal and recover from an injury and understanding how, and why you feel pain is an important step in your recovery.
NB: scans are important for identifying ‘red flags’ or more sinister conditions e.g. tumor.
We tend to forget about the importance of our feet, causing many people to leave their heel pain unattended for months or years. The fact that you’re reading this is a positive sign that you’re motivated to do something about your ‘plantar fasciitis’ / heel pain. Obviously the quickest path to being painfree is to pay a visit to your preferred Podiatrist for them to help you develop a treatment plan. Below are some treatment strategies which may be implemented by your Podiatrist.
As we said, the foot is a very complex beast. If we can harness the strength of all 20 intrinsic foot muscles then we have the ability to create a much more resilient base. When strengthening the foot, it is very important to strengthen all areas associated with the plantar fascia. Some of these exercises include:
Not only is it important to work these muscles hard, but if managing plantar fasciopathy there is a specific exercise which has been successfully implemented in a study by Rathleff and his colleagues to improve your recovery.
Fold a towel in half twice, then roll from one end. Stand with the ball of your foot on the flat section of the towel and your toes up on the roll. You will then slowly raise up on your toes for 3 seconds (concentric), hold at the top for 2 seconds (isometric) and slowly come down for 3 seconds (eccentric). This will be repeated for as many repetitions are required. Start with double leg & move to single leg.
Below is a proposed loading protocol over 6 weeks:
Your Podiatrist will be able to guide you through this process and tailor the weight progressions to you personally.
It all sounds a bit scary doesn’t it!? Don’t worry it’s bark is much worse than it’s bite when it comes to shock wave therapy (ESWT).
ESWT involves the application of high-energy radial pulse waves created by a hand held device. These pulses are proposed to work by travelling through the surface of the skin to accelerate the healing process by facilitating a change from a chronic condition into an acute condition. The body responds by increasing the metabolic activity at the site of pain, stimulating and accelerating the healing process. Due to the impact it has on neurotransmitters it is also said to reduce short term pain and allow increased loading on Plantar Fascia (pain modulation).
Generally shock wave therapy will be implemented initially to test the impact on your symptoms and then re-assessed for effectiveness prior to being integrated into your ongoing care over an initial period of 3-4 weeks. With this protocol it can be an effective adjunct to the various other treatment strategies which are utilised in the management of Plantar Fasciopathy / Plantar Heel Pain.
If you fall into the under active basket, then your heel pain is likely caused by extended periods of weight bearing rather than excessive repetitive load. Finding ways to reduce your overall weight bearing, or load on the plantar fascia will be the first step for you. If you are relatively sedentary and you feel that body weight may be a factor, then working to decrease this will have a positive impact on your recovery.
Initially you will have to be smart with your activity by considering the types of activity which aggravate your symptoms, but an active recovery is very important (i.e. rest is not the solution). If you are an active person or have recently increased your activity / load, then some activity modification may be required for you to change the load on the plantar fascia. It is best to have a chat to a health professional about your overall load and how this may be contributing. They will help identify any training errors in your weekly load and modify these to keep you remain active throughout your recovery.
Barefoot, thongs, slides, canvas shoes, minimalist shoes, super cushioned runners, high heels, business shoes – they all impact your feet in a different way and depending on what is causing your pain, your shoes the ability to positively or negatively impact your recovery. As a general rule, going from a high heel shoe 40 hours per week to running in a flat minimalist shoe with a 0mm drop (height of the heel in relation to forefoot), probably isn’t the best combination for you.
Instead of trying to navigate the footwear minefield book a visit with your preferred Podiatrist to find out the best option for your body and your lifestyle. But remember comfort is the number one priority, so if you’re not comfortable, don’t buy it!
Sit on a chair with your affected foot crossed over your opposite knee. Using your hands you will pull the toes backward to stretch to bottom side of your foot. This is generally most effective when completing 10 repetitions of 10 second holds.
Standing facing a wall, you will lean your body weight toward the wall (with your hands against the wall). You will have one foot forward and one foot back. The back leg should be straight with the heel planted on the ground (you should feel the stretch at the top part of the calf). This can be modified to stretch the bottom part of the calf by bending the back knee.
These have varying levels of effectiveness depending on each individual’s contributing factors. I personally find the Plantar Fascia specific stretch and massage to be helpful with symptom reduction in the early stages of recovery.
The theory behind the use of foot orthotics for the management of plantar heel pain is that they may reduce peak pressures placed on the bottom of your foot. This is said to potentially reduce the load placed through your Plantar Fascia when walking and running (much more research needs to be done in this area). As with many of the treatment options available for plantar heel pain / plantar fasciopathy, the use of foot orthotics has some conflicting evidence for/against it.
Foot orthotics should never be a stand alone treatment when trying to manage plantar fasciopathy / plantar heel pain, and should only be considered on a case-by-case basis. For those of you with a foot type which may benefit from an orthotic, they can form one part of a much larger management plan and should not be treated as a silver bullet.
I know you keep hearing it everywhere you go, but sleep is SO important. Sleep is the time where our bodies refresh themselves and complete natural healing for the day. Getting less than 6 hours sleep is said to increase risk of overuse injuries as well as slow down recovery and healing rates.
Steroid injections are often used for Plantar Fascia pain and inflammation, as they can have the ability to give quick pain relief. It is a commonly used treatment option which can be administered by your GP, making it an easily accessible, fast acting intervention.
Having said that, there are some potential downsides to the use of cortisone injections for Plantar Fasciopathy / plantar heel pain. The effects are generally short lasting (4-12 weeks) and are often administered as a standalone treatment, meaning a long-term solution will not be achieved. This means that if your “pain-free window” isn’t used to implement other treatment strategies (such as strengthening) then you are risking the pain returning.
In addition to this, (although low) there have been some links made between the use of cortisone injections and Plantar Fascia rupture, meaning all risks need to be weighed up before use.
Your Podiatrist should be working closely with you to help guide you through the minefield of information that’s out there regarding plantar heel pain. They should be implementing a holistic management plan with a number of the above treatment options to help you get back to living pain free.
This implementation of multiple strategies and getting them to work effectively together is one way we utilise the 10% rule here at Upwell Health Collective. Each individual treatment option will not necessarily be effective as a standalone treatment, but when combined into a specific, holistic and individualised plan you will see much faster and long lasting positive outcomes.
The absolute best treatment for any pain is prevention. Education around load management is key to ensuring we reduce the risk of developing plantar heel pain. This applies to those who are new to exercise and those seasoned athletes who may be changing the amount of load in their programs. Ensuring active runners are mixing up their load with different types of exercise and supplementing this with good strength training every week is important. Educating factory and hospitality workers (those on their feet a lot) in choosing appropriate footwear and developing strategies for the extended periods of time they have to spend on their feet is equally important.
Being active and maintaining a healthy weight with good nutrition and exercise will assist many individuals in preventing plantar heel pain and a number of other load related injuries. If you are looking for assistance in any of these areas, there are many passionate health professionals including Physiotherapists, Exercise Physiologists, Dietitians & Podiatrists who would love to help you achieve your goals and get back to living a pain-free, happy life.
We are always here to help you!
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