Plantar Fasciitis, or fasciosis, is a common and painful foot condition affecting the soft tissues in the arch of the foot. Recently there has been some exciting research on how exercises to strengthen the calf and foot muscles may assist in alleviating symptoms, alongside traditional conservative treatment methods such as footwear modification, orthotics and weight loss. Corticosteroid injections may have a role in pain relief for those that do not respond to conservative methods, but the evidence suggests that it will not provide relief beyond conservative means in most cases and is linked to increased risk of tear or rupture.
When one of our physios, Liam, brought this new evidence to us recently, my initial reaction was that it was only a short term study. However, as many of us who have suffered or are suffering from this condition know, it is the short term pain and loss of function that can be debilitating and anything to treat this conservatively should be embraced. Plus it appears that strengthening and biomechanical changes will have positive long term effects to prevent recurrence.
Let’s get some background anatomy in first, and then look at how the evidence suggests it is best managed.
What is the Plantar Fascia?
The Plantar fascia itself is a thick band of connective tissue that runs the length of the sole of the foot, from the inside border of the heel (medial tubercle of calcaneus) to the underside of the base of the toes (proximal phalanges).It lies superficial to the deep intrinsic muscles of the foot.
What does the Plantar Fascia do?
The plantar fascia has two main roles:
- Assisting in the propulsion of walking, known as the windlass echanism. When you go to push-off in walking or running, the joints at the ball of the foot (metatarsal-phalangeal or MTP joints) extend back which creates a bow-stringing stretch effect on the plantar fascia. This locks up the midfoot, giving the foot a rigid lever to push-off with. Without this, we would be trying to step off a floppy foot – not a greatly efficient way to move.
- Assisting in shock absorption of the foot in walking and running.
What is Plantar Fasciitis or Fasciosis?
It is an overload soft tissue disorder, with little or no inflammation, resembling the degenerative effects of chronic tendon damage (tendinosis) when looking under a microscope. Hence the term fasciosis is more widely and correctly used these days, as the ‘itis’ suffix denotes an inflammatory effect.
The pain is almost always at the origin site where the fascia inserts into the heel, though tender spots will be present through the fascia band in the arch. Concurrent Achilles, ankle and midfoot problems are not uncommon as all can be part of a greater biomechanical picture.
A typical presentation includes a sensation similar to walking on broken glass on the first steps in the morning or after a prolonged period of sitting – ouch!
How is it diagnosed?
Plantar fasciosis can easily be diagnosed in clinic. Ultrasound and MRI are useful to exclude other more sinister pathology if required. Heel spurs can be evident on X-Ray in those who have chronic symptoms, but it is the actual plantar fascia tightening over time that causes the heel spur not the other way around, and the pain emanates from the insertion of the plantar fascia onto the heel not the spur itself. In fact, the heel spur is often a red herring and usually clinically insignificant apart from telling us that the problem is chronic in nature (<12 months).
What are the Causes of Plantar Fasciosis?
Technically, non-optimal motor recruitment strategies in weightbearing. In lay terms, this means that the biomechanics of the foot, lower limb, hip and even lower back may be contributing to overloading the soft tissue under the foot. Examples of this include poor posture with a forward pelvic tilt bringing your body weight further onto the forefoot in standing, excessively rolling in (pronating) feet, reduced ankle mobility, weak or tight calves, increased angles at the hip or knee due to structural and/or weakness issues and uneven weight distribution through the lower limb (compensatory from previous injury, leg length discrepancies, scoliosis of lower spine etc).
Sub-optimal footwear and increased training or weightbearing loads will often trigger the condition. Common examples that we see of this are wearing thongs or flat shoes for a period of time on holidays, increased weight gain (a big factor), football/soccer boots on hard grounds early in the season & increase in walking or running training.
What is the treatment for Plantar Fasciosis?
There are two main components to the treatment: alleviation of symptoms, and addressing causative factors. Often we will need to address the causes in order to alleviate the symptoms, but sometimes the pain needs to be settled to a degree before corrective action and exercises can be introduced.
Alleviation of symptoms. Initial conservative approach includes:
- Strengthening: Relatively new evidence coming out showing that a plantar fascia specific program can have better treatment effects than a plantar specific stretching program at 3 months. There is no long term benefits to this form of treatment however it can improve foot pain and function in the short term. This research also outlines that more value should be placed on strengthening of the lower limbs in order to prevent future recurrences – be it calf strength or hip/pelvic strength. Expect this to be a feature of how physiotherapists and doctors treat plantar fasciosis going forward.
- Foot taping (Low dye): Effective for short-term relief of pain. Usually indicates that orthotics will be beneficial. Should be implemented early in the early phase of rehab.
- Stretching: Utilise a stretching program involving calf and plantar specific stretching. Shown to provide short term relief.
- Strasbourg sock: Has shown to be effective in chronic cases where first line treatment strategies have not produced desired results. We have these in clinic and they can be extremely useful for certain people.
- Orthotics: Can be used to help offload the fascia and have shown improvement in short and long term outcomes. No difference between the use of off the shelf orthotics and custom orthotics in early stages. If there is a biomechanical factor as to why the plantar fascia has occurred than a custom orthotic to address this issue will be important once the acute symptoms have settled.
- Footwear education: Footwear can be an aggravating factor for this condition. Some arch support in the shoe should be considered without being too rigid so as to irritate the plantar fascia. A well cushioned shoe is also important. Shoe selection can be a tricky balancing act for this condition so some help may be required.
- Rest from or modifying weightbearing activities, aim to reduce time on feet significantly
- Non-weightbearing exercise: go crazy in the pool, Pilates reformer, on the bike, rowing machine or even a cross-training machine.
- Cortisone injections: Limited evidence to support use and should be used as a last resort. May provide short term pain relief but has been associated with a greater risk of plantar fascia tears, particularly in more chronic cases.
- Surgery: Poor results and associated with poor short and long term outcomes.
Addressing Causative Factors, once symptoms begin to improve:
It is often a long slow road if symptoms persist beyond the initial first few weeks, but a biomechanics assessment combined with a guided exercises program, and orthotics or footwear modification, from your physiotherapist is key to a full recovery and preventing recurrence. This will likely include:
- Correcting walking and running technique: overstriding is a key and common factor
- Retraining with simple cues: e.g. walk quietly, lift knees higher, walk on the front of your heel
- Postural control: improve pelvic, lower back and hip strength in order to provide better standing and walking posture, particularly for those who are on their feet for many hours
- Single leg stability and strength – can you squat on one leg without tilting hips or levis sideways, and without the knee angling inward?
- Address weakness, tightness and stiffness issues in hips, knees and ankles – particularly ankle and Achilles tightness
- Gradual return to sports and walking or running based on strength and biomechanical capabilities
For further advice please make an appointment to see one of our physiotherapists in Olinda you can now book online or call us on 9751 0400.