What is the pain in my heel? Have you heard of the condition Plantar Fasciitis?
What is the Plantar Fascia?
The Plantar fascia is a dense connective tissue, it isn’t a tendon or a ligament but it is similar to both (Boabighi et al 1993). It runs along the sole of the foot and forms a strong biomechanical link between the calcaneus (heel bone) and the toes. It is made up of medial, lateral and central bands and it is the medial band that is frequently implicated with injury (Kaya 1996). The central band is the major structural and functional component and the lateral band is actually absent in some people (Wearing 2006).
What does it do?
The Plantar fascia makes the foot become a rigid structure ideal for propulsion by using the windlass mechanism. It is very clever because if the foot was always rigid then it would not be very good at shock absorption or be able to adapt and mould to the differing surfaces of the ground. So the plantar fascia enables the foot to have the best of both worlds so it can be rigid at the right time and flexible at the right time. The plantar fascia contains more fibroblasts than tendon or ligament. Fibroblasts are cells that can build more collagen and therefore strengthen a structure and their presence means that the plantar fascia is very adaptable to loading and so it does more than just transmit force it is also an active sensory structure capable of changing its composition in response to the demands placed upon it. This is particularly important when it comes to how to treat it.
So what is the condition itself?
As ever the term plantar fasciitis is now up for debate. The more accurate term is Chronic Plantar Heel Pain (CPHP). The reason for this is that “itis” means inflammation and the trouble with this is, that inflammation is only rarely observed in CPHP. The condition is far more likely to be related to degeneration. In fact, some people have called it plantar fasciosis or plantar fasciopathy but these are a bit of a mouthful so CPHP is best and so broad that it can’t be incorrect.
How common is it?
Chronic Plantar Heel Pain (CPHP) accounts for 15% of all adult foot complaints and affects 10% of the population in general according to Rome (1997). Lopes et al (2012) found that 4.5 to 10% of all running athletes will develop it and this is mostly in distance runners, hence why it is sometimes called jogger’s heel. Nielsen et al (2013) has said that it is also a running pace not just distance related injury so the faster you run the more load you place through the Plantar Fascia.
How long does it take to resolve?
Plantar fasciitis is considered a self limiting problem, which basically means that it is fully resolvable if you get to the root causes and resolve them, however, this is easier said than done. It is generally considered that the condition will go away within a year if you can solve the issues behind it but in this study, they found that it took 159 days on average to recovery in novice runners (Nielsen et al 2014). Luffy et al (2018) states that 70% to 80% of patients with it will get better with conservative treatment. Obviously, everyone is different, individual causes and therefore solutions will vary. This is why getting properly assessed is important otherwise you will be potentially working on the wrong things. Obviously, at Hawkes Physiotherapy, we can perform a physiotherapy assessment to create a specific treatment plan for you at either of our clinics in Stoke-on-Trent and we even offer online Physiotherapy sessions too.
How do you diagnose Plantar fasciitis or Chronic Plantar Heel pain?
It is often misdiagnosed because there are many causes of pain in this area of the body, see the below list:
Other variations and conditions causing similar pain are below:
Heel spur syndrome (Bony spur growth)
Plantar fascial insertitis (inflammation where the plantar fascia inserts into the bone)
Calcaneal enthesopathy (Pathology of the bony attachment)
Subcalcaneal bursitis (Inflammation of the bursa)
Stone bruise: (Bruising to the fat pad from impact)
Calcaneal periostitis (Inflammation of the lining of the heel bone)
Neuritis: (Nerve inflammation)
Sever’s Disease (Growth plate inflammation)
S1 nerve root compression (Trapped nerve in the lower back)
Tarsal tunnel syndrome (Compression of nerves in the foot)
Achilles tendinopathy (Achilles tendonitis)
Calcaneal stress fractures (Heel bone fracture)
So diagnosis is ruling out the above conditions and looking at symptom behaviour. For example, something called first step pain is common, which is pain in the heel when you take the first few steps in the morning. Pain is usually localised over the medial tubercle, which is considered a key diagnostic sign for an accurate diagnosis. The windlass test is often used to help diagnosis but it’s accuracy to detect it is low (De Garceau et al 2003). Diagnostic ultrasound demonstrates diffuse or localised hypoechoic areas with thickening and so can be used for diagnosis. Other scans and tests can be done to rule out other differential diagnoses to help confirmation of CPHP.
As we mentioned above, pain is in the heel and the sole of the foot, often the medial (inside) part of the arch hurts the most. 70% of all cases are on one side only (Lutter 1997) and pain is elicited when weight bearing especially when walking. It is most intense when taking the first few steps after being off your feet (first step pain). Swelling is commonly found in the painful area and commonly athletes describe worse pain until warmed up and then it reduces but then often worsens again towards the end of activity (Petraglia 2017).
Causes of Chronic Plantar Heel pain:
Doing too much too soon:
In athletes, it can occur from incorrect training, mainly from too much of an increase in distance, intensity, duration or frequency of activities (Petraglia 2017). Obviously, this can be true in non athletes too, for example, somebody could change jobs from a sedentary job to one where they spend long periods on their feet.
Many people say that heel spurs are a cause but this is not certain. What we know is that Heel spurs are very commonly found on people with chronic plantar heel pain according to Irving et al (2006) but this highlights that the spur may be an effect of the CPHP and not a cause of it but this is impossible to say.
Underloading of the structure causes weakness of the tissue, which exposes the structure making it easier to overload. This is why rest is not a great idea too.
Vascular and metabolic disturbances:
Diabetes, Peripheral vascular disease means that circulation to the plantar fascia is not optimal and this makes it more likely to become injured.
As with all things, some people have a genetic predisposition to chronic connective tissue disorders.
The enthesis (the part of the plantar fascia that is usually injured) is brittle and therefore susceptible to damage as we age. CPHP is common after 50 years old and this can be, in part, attributed to the degeneration of the fat pad and the plantar fascia itself (Petraglia 2017).
Shortened calf muscles:
12% of individuals examined in a study by Kim et al (2010), revealed a continuation of the Achilles tendon and the plantar fascia. So this means that excessive tensile forces in the calf under dorsiflexion would transmit the force into the plantar fascia. In fact, it has been found that the chance of developing CPHP actually triples if passive ankle joint dorsiflexion is less than 10 degrees according to Sahin et al (2010)!
Tight intrinsic foot muscles:
Schneider et al (2018) also found that the small muscles of the underside of the feet could potentially increase the risk.
Lutter (1997) reports that 65% of the non-sports demographic are overweight and a BMI of 25-30 doubles the chances of getting Plantar Fasciitis.
Spending a lot of time on your feet especially on hard surfaces:
The chance of developing CPHP increases by 3.6 times in weight bearing occupations (Sahin et al, 2010).
Poor footwear and abnormal biomechanics:
These foot or leg posture issues are considered potential risk factors by Petraglia (2017) for Chronic Plantar Heel pain:
Pes planus (flat feet)
Pes cavus (high arched feet)
Overpronation (Rolling in of your foot)
Leg-length discrepancy (one leg longer than the other)
Excessive lateral tibial torsion (twisting inwards of the shin bone)
Excessive femoral anteversion (Twisting of the thigh bone)
Commonly it was considered that the cause relates to your foot arch mechanics but the evidence for this is hit and miss. For example:
Wearing et al (2004) found that abnormal shape or movement of the arch is not associated with chronic plantar fasciitis, but they found that arch mechanics may influence the severity of plantar fasciitis once the condition is present.
Irving et al (2006) also found that decreased first metatarsophalangeal joint (big toe joint) extension increased the likelihood of developing the condition too.
Footwear can also be an issue to and this was found to be a risk factor in athletes who didn’t replace their shoes regularly (Petraglia 2017). This is still true in the general population too. The amount of people wearing poor footwear is amazing. I once shadowed a leading Podiatrist / Biomechanist in London and every person who came in he pointed out that their shoes were not good at all.
What are the treatments for Chronic Plantar Heel pain or Plantar Fasciitis?
CPHP can be a real challenge to treat. The reasons for this are due to the individualised nature of its causes. This means that not all people’s treatment will be the same and you need to work out why they have it and then you can tailor treatments to deal with them. That being said, here is a list of common treatments:
Rest is not the approach to take as this will make it feel better temporarily but once you return back to usual activities the problem will become overloaded again. This being said though, you don’t want to carry on regardless either. What you need to do is to work out what activities you can do and for how long without making symptoms increase and progressive build up your activities as you tolerate more.
Simple pain relief:
Plantar Fasciitis can be extremely painful and so simple pain killers are sometimes needed. Their strength depends on your individual need of course.
At present, the current N.I.C.E. guidelines recommend using ice but current thinking is now moving away from icing injuries. So I wouldn’t personally recommend this. If you want to find out more on icing of injury then check out the article below:
Strengthening or loading of the Plantar Fascia:
This is key and we will guide you specifically on this in your Physiotherapy sessions.
Rathleff et al (2015) found that strengthening and loading the Plantar fascia was an effective treatment and even better than stretching. The focus of strengthening is that you need to progressively load the Plantar fascia within its tolerance levels and build it up with exercises. Here is an example of such an approach:
Strengthening of other areas to help to improve overloading of the Plantar fascia:
For example, strengthening the plantar intrinsic muscles improves the medial longitudinal arch and improves its function according to (Mulligan et al 2013). This will help to take some load off the plantar fascia but this is not applicable in all cases.
Here is a good exercise to strengthen not just the Tibialis posterior but the intrinsic muscles of the foot:
Another commonly weak or dysfunctional muscle that can cause overloading in some people is the Gluteus Medius. Here is an example of a Gluteus Medius exercise but this is not always applicable and may be too hard for some people, therefore an easier Gluteus Medius exercise may be required instead.
Side Plank Off The Bottom Leg:
Extracorporeal Shock wave therapy (ECSWT):
This is the conversion of a sound wave into a shockwave. ESWT treatment was found to have a success rate of 98% at 1 year and only had an 8% rate of symptom recurrence (Malliaropoulos et al 2016).
Dizon et al (2013) also found that moderate and high intensity ECSWT was effective in the treatment of chronic plantar fasciitis.
This evidence found manual stretching was superior to repetitive ECSWT according to Rompe et al (2010) and it would appear that ECSWT is ineffective for acute CPHP.
As weight is a major contributing factor in CPHP for those over a certain BMI, it is vital to improve this as a priority (Schneider et al 2018)
Taping was found to provide improvements in ‘first-step’ pain compared with a sham interventions after a one week (Radford et al 2006). So this could be an option to assist activity management.
Non-Steroidal anti-inflammatory drugs (NSAID’s):
Remember the condition is rarely inflamed but if you continue to overload the plantar fascia and do too much then it can inflame. In this case you could argue the use of NSAID’s, but my view is, that you shouldn’t have overloaded it in the first place to create the damage, to need the increase in inflammation, to heal the damage created. So the issue is overloading it in the first place. If you don’t overload then you don’t need NSAID’s. The only caveat is that if you are unable to manage pain and it is limiting you them you can take them for a short burst to enable this (Goff et al 2011).
Patients without previous treatments for plantar fasciitis obtain significant relief of heel pain in the short term with the use of a night splint (Beyzadeoglu et al 2007). However they don’t have any long term benefit and are often poorly tolerated as they are uncomfortable.
Myofascial Trigger point therapy:
This can help to reduce the pain in the plantar fascia in the short term but has no long term effect so can be used for pain relief to again enable the progression of the rehab.
The same argument as above with NSAID’s, they only offer short term improvement as symptoms commonly return 1 month after having the injection and there is a risk of future rupture of the Plantar fascia. This would only be done if you really needed and it would be considered a window of opportunity to enable good progressive rehab of the injury with exercises as above (Schneider et al 2018).
The aim of footwear is to reduce Plantar fascia and Achilles load, support the arch and reduce effects of the ‘windlass mechanism’.
The current N.I.C.E. Guidelines recommend to wear shoes with good arch support and cushioned heels and ideally want to be lace up or at least something to secure your foot properly in the shoe.
A heel raise has been shown to decrease Achilles load and therefore reduces plantar fascia load (Farris et al 2012). So at first wear a shoe with a reasonable heel section but this should be a gradual drop to the toe. So certainly not high heels! Over time as the pain reduces then you should ideally wean down from the heel raise with shoes that are gradually lower on the heel.
Supporting the arch:
Arch support has been shown to help to manage CPHP (Roos et al 2006). However, if you are very sensitive to touch in your arch then the arch support may not actually be tolerated especially if it is made from hard material.
The windlass mechanism:
If you can reduce the first toe extension at the MTP joint then you will minimise the strain through the plantar fascia. So a shoe with a thick rigid sole that doesn’t bend easily will help and obviously going barefoot is a bad idea!
What about barefoot minimalist trainers?
Well, the above statement tells you the answer but barefoot running tends to increase load on the calf, Achilles tendon and Plantar fascia as it creates more of a forefoot strike.
Overall comfort is king, so try different trainers and usually the one that feels the best are usually correct. Simple!
Custom foot orthoses can be effective in the short and long-term treatment for pain (Roos et al 2006). This too is backed up by Lee et al (2008) who also found foot orthoses (insoles) for plantar fasciitis appears to reduce pain & improve function. More recently a systematic review by Whittaker et al (2018) found that orthotics are helpful in the medium term. This is something that would require a biomechanical assessment to assess specifically what prescription for the orthotics is needed.
Insoles combined with exercise is even better when treating excessive pronation & chronic foot pain according to Andreasen et al (2013).
We can not only assess your biomechanics but we can also produce custom orthotics to help too. More information is available on biomechanical assessments which are available at either Stoke-on-Trent clinic below:
Stretching the plantar fascia has been shown to be superior to normal gastrocnemius and soleus stretching (Rompe 2010). As a stand-alone treatment, calf stretching appears not to be as effective as plantar fascia–specific stretching (Garrett & Neibert 2013). This being said if somebody has very tight calves and Achilles then stretching them makes sense and is also recommended in the N.I.C.E guidelines too.
Platelet-rich plasma injections:
The jury is still out on this at present and
In this study, pain reduced post injection, 88% of patients were completely satisfied, there was no negative changes to the plantar fascia afterwards and 1 year later there were no complications to having had the injection (Ragab & Othman 2012).
Dry needling provided statistically significant improvements in plantar heel pain (Cotchett et al 2014). This would most likely be a short term effect again but is a good option to get pain under control to enable rehab progressions to be made. Acupuncture is something that we offer at our both of our physio clinics in Stoke-on-Trent.
The last resort!
If all other methods have been unsuccessful then surgical release is an option. It should only be considered if conservative measures have failed after 6-12 months according to Thing et al (2018).
So there you go, everything that you need to know about Chronic Plantar Heel Pain. It can get better but would need to get to the root cause to achieve this!
The content in this blog article is provided for general information purposes only and is not meant to replace a physiotherapy or medical consultation.