Plantar Fasciopathy: Cause, symptoms and management
AUTHOR: NICOLA STIRTON, BOUNCEREHAB PHYSIOTHERAPIST STUDENT – THE UNIVERSITY OF SYDNEY
CO-AUTHORS: JACK RAYMENT, PHYSIOTHERAPIST BOUNCEREHAB
CO-AUTHORS: MATTHEW CRAIG, PHYSIOTHERAPIST BOUNCEREHAB DIRECTOR & USYD CLINICAL EDUCATOR
Plantar Fasciopathy (formally called Plantar Fasciitis) is one of the most common foot complaints physiotherapists and podiatrists see everyday. People will often come in with complaints of pain under their heel or arch of their foot when they are standing or walking. For anyone who has experienced plantar fascia pain, it is extremely uncomfortable and will often restrict their ability to participate in daily activities and exercises.
WITH THE RIGHT TREATMENT, YOU CAN GET BACK TO WHAT YOU LOVE IN NO TIME!!
So what is it?…
The plantar fascia is a thick fibrous tissue that runs all the way from the heel to the toes. Its high tensile strength forms the arch of your foot and acts as the main shock absorber. It was commonly believed that the conditions was due to inflammation, however, it is only from recent medical research that we now know that this is a degenerative condition instead. Hence why the name changed from plantar fasciitis to plantar fasciopathy, denoting a general pathology of the plantar fascia.
Unlike normal tissue that is very elastic, the plantar fascia has a very limited capacity to stretch and elongate. This is where the problem lies…when there is an increased stretch placed on the fascia, micro-tears occur leading to irritation and eventually degeneration.
The issue is an overload problem that may have biomechanical (how we move) contributing factors. These can be away from the foot, such an imbalances and mechanics of our knees, pelvis, hips, lower back and more, though it is usually from a disruption of the loading of the mid-foot which puts excessive load on the plantar fascia.
Why are certain times of the day worse for my pain?…
When you sleep the ligament has time to tighten and shorten, as result, when you wake up in the morning and take your first steps, you feel the most pain as you are increasing the stretch on the ligament for the first time in hours. The pain may decrease after a few minutes as the ligament has time to stretch however the pain usually returns by the afternoon after you have been putting weight through the foot throughout the day. Any other movements that increase the stretch of this fascia such as standing for too long or climbing stairs may irritate the ligament more and result in pain.
It is important to note that if you are experiencing foot pain at night, this may not be plantar fasciitis. Other problems it could be include arthritis or a nerve problem such as tarsal tunnel syndrome.
What are the main contributing factors:
- Poor foot biomechanics – excessive pronation when walking (feet rolling inwards)
- Flat feet or high arches
- Worn down or ill fitting shoes
- Tight calf or achilles muscles
- Occupations that require a lot of walking/standing, especially on hard surfaces
The Windlass Mechanism:
The Windlass Mechanism describes the arch of the foot as a triangle and uses this to describe what happens to the plantar fascia as weight is put through the foot. The calcaneous (heel), mid tarsal joint and metatarsals form two sides of the triangle, whereas the plantar fascia forms the third (hypotenuse), running all the way from the heel to the toes. Forces through the body travel down into the feet, pushing the two sides of the triangle down, causing the third (plantar fascia) to stretch. Therefore movements that place weight through the foot will elongate the fascia and have the potential to become injured if it’s poorly controlled or excessively loaded.
Who gets it:
Plantar Fasciosis is most common in middle-aged patients, however, younger athletes and the active population are also prone to plantar fascia pain. The way a person walks is also a great indicator as to whether the plantar fascia is the cause of pain. Let’s have a look at the biomechanics of the foot…
Below is a picture of our walking pattern and a close up of the feet biomechanics as you walk.
During normal walking, as you place your foot on the ground the outside of your heel strikes the floor first. As you travel through mid-stance (see above image) your foot rolls slightly inwards. Changes to the mechanics of how we move between these two stages of gait may be the cause of plantar fascia pain:
1. Heel strike – When your heel first touches the floor, it is here that your achilles is at its most stretched position causing it to pull on the heel and hence the plantar ligament. This can be in issue for some people depending on their activity and footwear. For example: People who usually wear flat shoes don’t have this problem as much as the calf muscles are used to being stretched with each step. On the other hand, people who are ‘toe walkers’ or women who wear often wear high heels may experience pain when placing weight through their heels. This is because their calf muscles have adapted to a shortened length and when needing to walk on a flat surface their achilles is under a greater amount of stretch, pulling at the plantar fascia and exacerbating the degenerative process.
2. Foot movement – As stated before, during controlled walking it is normal for the outside of your heel to hit the floor first, then as you transfer your weight, you roll inwards and generally push off with the padding just under your toes (more towards your big toe). During gait analysis, it is clear that people with plantar fasciosis commonly have over-pronated feet (flat footed). As a result, this rolling happens too early causing excessive force through the inside of the foot leading to a greater stretch and irritation to the plantar ligament. If you refer back to the Windlass Mechanism, the top two sides of the triangle are pushed down too far, causing the bottom side to stretch excessively.
How do i know if I over-pronate?
The physiotherapists and podiatrist at BounceREHAB will perform a gait analysis by carefully observing your feet and walking pattern. They will also be able to gain a plethora of information by looking at the soles of your shoes. The worn parts of the soles will tell you where you place most of your weight when you walk.
So when will I be fixed?
This can be a hard question to answer because there are many factors that may speed up or delay your recovery. These include:
- Mechanism of injury
- Acute or chronic
- Activity levels
- Occupation requirements
- Contributing factors
Sometimes the underlying pathology can develop long before symptoms are experienced, in these cases it may take longer to resolve. In contrast to this, pain may come on quickly and leave just as fast. For example, people travelling to a summer environment where they will only wear thongs and walk along sand for 2 weeks may develop plantar fascia pain as a result of changes to footwear and usual walking pattern. When they get home and change back to their original footwear their pain may subside.
Like with any pain, if you leave it too long, the condition will get worse and symptoms may be harder to alleviate. Continual pulling of the ligament may result in the growth of a bony protrusion at the heel called a ‘heel spur.’ Heel Spurs can be a source of increased pain and hard often difficult to manage, so it is essential that plantar fascia pain be seen to as soon as possible.
- Activity modification
- Corticosteroid injections – performed by GP
- Orthotics to correct poor foot biomechanics
- Daily stretching program
- Anti-inflammatory and pain medication (consult your GP first)
- Shock wave therapy
- Weight loss
- Custom night splints
- Dynamic splint
What will orthotics do?…
Orthotics are a very popular form of treatment for people suffering from plantar fasciitis as they acts to correct the abnormal foot position. They aim to correct the overpronation of the foot and support the arches, releasing the tension on the ligament and allowing time to heal. It is extremely important that orthotics are individually sized and fitted in order to get the best outcome and the most comfort. Studies show (Landorf et al, 2006) that if an orthotic is fitted correctly there is a more significant pain reduction and functional capacity in the short term compared with generic orthotics. The podiatrist at BounceREHAB is able to take 3D images of your feet and custom make orthotics to best suit you. The picture below shows how orthotics support the arch and hold the foot in its correct position, reducing the strain placed on the plantar fascia.
Over time, the body will adapt to this the change in foot position and the orthotics may no longer be needed. It is, however, recommended that orthotics always be worn as it will reduce the risk of re-injury.
You might now be thinking: “well if we use orthotics, why is taping used as well”? Taping is used as more of a short term management option or for those who have only mild symptoms. It works by the same principle as orthotics do in that it supports the ligament by acting as an artificial arch. Additionally, taping can also act as a proprioceptive mechanism, whereby the pulling of tape serves as a constant reminder of the person’s foot position and walking pattern.
So what’s the verdict?
Gathering all the information from above, plantar fasciitis is a very common but also very treatable injury. When the right type of help is sought and appropriate action is taken, you can get back to participating in activities you love…PAIN FREE!!!
Check out our other blogs for more information
- Riel, H., Cotchett, M., Delahunt, E., Rathleff, M. S., Vicenzino, B., Weir, A., & Landorf, K. B. (2017). Is ‘plantar heel pain’a more appropriate term than ‘plantar fasciitis’? Time to move on.
- Owens, J. M. (2017). Diagnosis and Management of Plantar Fasciitis in Primary Care. The Journal for Nurse Practitioners, 13(5), 354-359.
- McNeill, W., & Silvester, M. (2017). Plantar heel pain. Journal of Bodywork and Movement Therapies, 21(1), 205-211.
- Razzano, C., Carbone, S., Mangone, M., Iannotta, M. R., Battaglia, A., & Santilli, V. (2017). Treatment of Chronic Plantar Fasciitis with Noninvasive Interactive Neurostimulation: A Prospective Randomized Controlled Study. The Journal of Foot and Ankle Surgery, 56(4), 768-772.
- Fraser, J. J., Corbett, R., Donner, C., & Hertel, J. (2017). Does manual therapy improve pain and function in patients with plantar fasciitis? A systematic review. Journal of Manual & Manipulative Therapy, 1-11.
- Grieve, R., & Palmer, S. (2017). Physiotherapy for plantar fasciitis: a UK-wide survey of current practice. Physiotherapy, 103(2), 193-200.
- Silvester, M. (2017). Calf stretching in correct alignment. An important consideration in plantar fasciopathies. Journal of Bodywork and Movement Therapies, 21(1), 212-215.
- Landorf. K, et al. Effectiveness of foot Orthoses to treat plantar fasciitis: A randomised trial. American Medical Association (2006) Vol 166, 1305-1310 http://www.vasylimedical.com/pdf/landorf-effectivness.pdf
- Gollwitzer et al. Clinically Relevant Effectiveness of Focused Extracorporeal Shock Wave Therapy in the Treatment of Chronic Plantar Fasciitis. The Journal of Bone and Joint Surgery (2015) Vol 97 (9), 701-708 http://www.ncbi.nlm.nih.gov/pubmed/25948515
- Bolgla. L, Malone. T. Plantar Fasciitis and the Windlass Mechanism: A Biomechanical Link to Clinical Practice. Journal of Athletic Training (2004) Vol 39 (1) 77-82 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC385265/
- Porter MD, Shadbolt B; Intralesional corticosteroid injection versus extracorporeal shock wave therapy for plantar fasciopathy. Clin J Sport Med (2005) Vol 15 (3) 119-2 http://www.ncbi.nlm.nih.gov/pubmed/15867552?dopt=Abstract