What is Plantar Faciitis?
Plantar Fasciitis is a relatively common foot condition where the fascia (connective tissue), which spreads from the heel (on the sole of the foot) across the arch to the toes, becomes painful and stiff.
Pain is often felt in the heel area where the fascia originates from, but can also be felt under the arch of the foot. The fascia helps to prevent the bones in the middle of the foot collapsing when weight-bearing to help maintain the arch of the foot.
Contrary to popular belief this is not a chronic inflammatory condition (although there may be some inflammation present in the initial onset of the symptoms) but is a result of collagen degeneration and disorganisation from repetitive strain placed on the fascia. Collagen are the cells which form the tissue of the fascia and ideally should be ‘laid down’ in uniform lines along the direction of mechanical pull (or load) maximising the strength of the fascia when weight is placed over the foot. Pain arises when the fascia has too much stress placed on it due to excessive or uneven loads causing micro-tears, chronic degenerative changes and disorganised laying down of new collagen, leading to a loss of tensile strength. Foot pain alters the way we stand and walk which can create more pain and so it can become a viscous circle.
So what causes Plantar Fasciitis?
This is the million dollar question! The quick answer is there is usually more than one ‘cause’ and it isn’t always easy to identify and treat because often by the time individuals decide to seek help for pain it has been present for a while! Unfortunately, there is not a lot of scientific evidence to support some of the following suggestions, but each of these have been seen in those who have had plantar fasciitis so it’s reasonable to suppose that they may be a cause or a risk factor.
Heel Spurs (extra growth of bone on the heel on the sole of the foot) are often believed to be the cause of pain. However, heel spurs are found in between 10-20% of the population but not everyone who has a heel spur has heel pain. In those who do have pain it is not the bone itself which causes pain but the soft tissue around it. Surgery to remove the heel spur does not always relieve the pain and in some individuals the bone grows back!
Altered Foot Biomechanics Due To:
Excessive/Over Pronation or ‘flat feet’ is a commonly quoted cause for plantar fasciitis, believed to be due to the increased stretch placed on the fascia in weight-bearing with the loss of the foot arch.
High Foot Arch is also given as a reason for plantar fascia pain believed to be due to the fact that if the arch is stiff then the fascia also becomes too stiff and inefficient at absorbing the forces in weight-bearing.
Tight Calf Muscles may play a role in altering the way the muscles pull on the plantar fascia where the Achilles tendon (which is attached to the calf muscles) inserts into the heel.
Stiff Ankle and Foot Joints can lead to either a stiffer more rigid foot or the opposite may occur with an increase in foot mobility to compensate. Either way this will affect the mechanical load through the plantar fascia.
Other Possible Causes of Heel and Foot Pain
A Functionally rigid foot by this I mean how well your foot can cope with the challenges of uneven surfaces, such as stone to sand or going up or downhill, different footwear or the changing speed of your walk or run. A functionally rigid foot is not because of stiff joints or tight muscles so testing the structures would not reveal any problems, but when you are standing or trying to balance you may see toes/foot curling and stiffening.
The plantar nerve can cause pain in the same areas under the foot as plantar fasciitis because the nerve gives the underneath of the foot its sensation and it is in close physical proximity to the plantar fascia.
The plantar nerve needs to be able to ‘slide and glide’ during movement if this movement is affected in any way you can experience the same spread of pain into the front of the heel and the arch of the foot.
Other Factors That May Increase the Risk of Developing Plantar Fasciitis
Jobs that involve standing for long periods of time
Regular long distance walking/hiking
What is the best treatment for the pain?
Without wishing to sound vague it is very dependent upon your individual biomechanics, your work or a particular sport you might play. However, for some people, following the advice below may be all that is needed to resolve the pain. Resolving Plantar Fascia pain can be challenging and can take a ‘prolonged effort’. It is important to remember like any biomechanical pain issue a slight reduction in pain, leads to an increased tolerance to movement, which in term helps to reduce pain! So our job as physios is to break the cycle of pain to allow you to move and do the relevant exercises to reduce your pain further!
This basically means reducing or possibly even completely stopping the sport or activity that aggravates your heel/foot pain for a period of time. How long for is the more challenging question!
Firstly, coming for advice and treatment in the first few weeks of the pain starting tends to be much easier to manage and resolve than waiting 3 months! If the pain is only mild to moderate then a week or two rest with a gradual increase in activity over the following 4-6 weeks may be enough. If the pain is severe or has been present for 6 weeks or more (without any improvement) and is affecting your ability to walk or do anything more physical on a daily basis then you may need to rest from your activity or sport until the pain is at least 50% better. Then I would suggest you build back up gradually over the same time period that you have rested for. There is little scientific evidence to support this but I have found this advice effective for a number of my own clients.
If you have tried this without trying some of the other pain relieving techniques, try combining relative rest with some of the other options below. Remember if you can walk as near normal as possible then the fascia can be gradually exposed to an increasing load (in other words you can cope with more walking, running or jumping) until the tissue can tolerate all that you throw at it!
I would advise seeing a professional massage therapist because they will be able to target the soft tissues in the leg and foot, which could be contributing to your pain symptoms. There is mixed opinion as to how effective this treatment is but there are pain relieving benefits to massage therapy and again clients of ours have found it helpful in conjunction with other exercise modification and advice.
By this I don’t mean a rigid orthotic but a support specifically for the heel to help reduce the pressure over the plantar fascia.
To ease pain, less pain means being able to cope with increasing your walking, running and jumping!
1. ‘The Listening Foot’
- Sit upright in a chair with both feet on the ground – feet are bare
- ‘Feel’ your feet on the ground, can you feel both of them the same?
- Place your hands around the top of one of your lower legs, just below the knee (this to help you sense movement)
- Your knee will remain still
- With as little effort from the muscles as possible slowly move the pressure towards the outside of your foot – keeping the toes relaxed on the ground – you should feel your lower leg rotates outwards with this movement.
- Move the pressure back across your foot in the other direction – you should feel your lower leg rotate inwards
- Make this movement as smooth and slow as possible aiming to eliminate any unnecessary tension. Repeat as often as you can in the day
- You will see that you are effectively rolling your foot creating mobility that is important for foot and leg function
Reference: ‘Stability, Sport and Performance Movement. Practical Biomechanics and Systematic Training for Movement Efficacy and Injury prevention’ 2nd Ed (2013) Joanne Elphinston
2. Balance exercise
Following on from ‘The Listening Foot’ exercise, working on improving your balance and how your foot responds to the ground when it is challenged can help to improve both stiff and ‘flat’ feet.
- Stand in bare feet and be aware of how the pressure of your feet on the ground – are they feeling the same?
- Try closing your eyes – what happens? If your feet ‘stiffen’ see if you can let them go. Do you shift more onto one leg?
- Try turning your head left, right, look up and down – what is happening at your feet?
- Try taking one arm at a time up and forwards, up and out to the side. Try holding both arms in front of you at chest height – now one arm at a time out to the side.
- The aim is to be able to do all of these with the pressure under the feet equal with minimal muscular effort in the toes and feet. Do these exercises slowly and really explore your foot response
- To make things harder, try combing eyes closed with head or arm movements. Even harder still, try standing on a balance pad / wobble board – remember to be safe and stand equipment on a non-slippery surface
3. ‘Knee to Wall’
If you have a stiff ankle (going down hill/downstairs) this can be quite effective!
- Stand in bare feet, the ‘sore’ foot is close to the wall
- Keeping the foot, knee and hip all facing forward, drop the knee cap towards the wall. Keep your heel down, toes and foot relaxed
- Hold up to 5 seconds and repeat 20 times, rest and repeat a further 2×20
- Repeat several times per day
Self Massage / Stretching
There is little evidence to say whether this works scientifically BUT I would say try using a water bottle or tennis ball as shown below and see if it helps ease your pain for a while. If it allows you to walk better and more comfortably then its worth a try. I would say you need to do it several times a day (4-6), for 2 or 3 minutes.
The bottle contains very cold water or ice – please make sure you have no sensation problems (so you can feel hot and cold) under your foot before trying this.