What is the plantar fascia?
The plantar fascia is a thick band of fascial tissue, almost like a big ligament that is embedded deep in the sole of the foot (the plantar side as we call it!). The plantar fascia attaches from the base of the heel, where it is most commonly tender, and it sticks to the tendons of the toe flexor muscles. The job that this tissue band has is to provide a structural support to the arch of the foot and prevent its collapse.
So why is it sore?
Plantar fasciitis is a very common condition and effects approximately 10 % of all adults at least once in their lifetime. The condition is slightly more common in athletes and accounts for 25 % of all foot pain. The plantar fascia can become irritated from a wide variety of reasons, however, most of the time the pain is caused in runners who ramp up training loads, running too hard and too fast and too frequently. Being overweight is another risk factor for plantar fasciitis as excessive load is passed through the tissue. We often see poor biomechanics in people which also causes excessive stretch on the tissue. Having collapsed or indeed very high arches places the tissue under stress and can lead to pain developing due to tissue stress. Foot wear is also of huge importance, especially in those with biomechanical defects. Wearing comfortable supportive footwear can go a log way in preventing and relieving plantar fasciitis.
I have heel pain but how do I know its plantar fasciitis?
Well firstly check your foot for signs of infections and trauma. Plantar fasciitis isn’t caused by either of these so you may have another source of pain such as a stepping on a foreign body or even a muscle tear. Plantar fasciitis typically gives a very reproducible pain pattern, which is pain for the first few steps of the day. Our patient’s usually say that the early morning walk is the worst time of the day and the pain usually eases off before going downstairs. The same thing happens if you sit for a long time and then stand and start to walk. People often again find this painful.
But why is it sore when I have been resting then walk?
Plantar fasciitis is an inflammatory condition. When you rest this is the optimal time for your body to repair itself and in doing so it releases chemicals during this repair process. These chemicals irritate the nerve endings and when you stand and load the tissue up the pressure on these nerve endings causes them to fire at a higher intensity, which results in this classic pain pattern. As you keep moving your body gets used to theses pain signals and realises its not under threat, so your brain tunes out of those pain perceptions.
So how can physiotherapy help my foot pain?
Physiotherapists are specially trained in the assessment and treatment of a wide variety of musculoskeletal conditions, including plantar fasciitis. We must first have a conversation about you and try find out about what your medical background and also your social background including sports history. We discuss what areas of your life the pain is disrupting, and we aim to make things easier with treatment. Based on the history we then perform a targeted physical exam of your foot and general lower limb. We have a look at you performing functional things like walking, running, squatting and hopping. We must first find out if the pain is from the plantar fascia before we then start treatment.
So how do you treat me?
We as physiotherapists look at treating plantar fasciitis in two different lights. We target both short term benefits (pain reduction) and also long-term treatment of the condition to keep the pain at bay and prevent reoccurrence of the condition. So here is what we do.
Acute short-term management
Acute management is all about pain reduction and this is the thing that most patients limp into our clinic seeking our help for. There are a number of treatment options that we do which may help your symptoms. We say may as some people find certain treatments work and find that some don’t. So here is what we can try.
Shockwave therapy
Shockwave therapy is a relatively new form of treatment that we currently offer in our clinic. What it is basically is like a mini-jack-hammer unit that we hold in our hand. The treatment “gun” has a mini bullet that an air-compressor fires into the treatment cap which creates a strong vibration, which is sent into the tissue. You can expect a mild-to-moderate discomfort during the treatment which usually reduces with tolerance during a single session. The shock pulses are directly targeted to penetrate deep into the tissue and directly on the source of the pain. Shockwave is particularly effective when there are calcium deposits within the tissue and it is believed that the shock pulses can help the body re-absorb some of these deposits and help alleviate discomfort. Shockwave is an irritant type treatment, so the body needs to rest for 24 hours following the treatment and then it is usually performed over at least 3-5 sessions spaced no more than 10 days apart for the treatment to be effective. This treatment is designed to irritate the tissue to then allow the body start healing the area and is usually performed in combination with a targeted exercise programme.
Manual therapy
Quite often our patient’s feet may have stiffness and lack of mobility in key areas. The first toe joint is a prime example of this. If the toe is stiff in an upward movement when you walk, this means the medial arch doesn’t get maximally supported as the big toe flexor tendon become a strong arch supporter when stretched. So we as physiotherapists are trained in identifying these defects and treating them with a hand on approach to free up the stuck joint and get it moving so it can do it’s job properly and restore a more natural walking pattern to the foot.
Taping
Rigid taping of the foot is another highly effective treatment that can alleviate pain immediately. The basic principle of the tape is to create an artificial plantar fascia under the foot (the tape), so that when you walk the load goes through this rigid tape and the plantar fascia gets a rest. Taping is basically a way of artificially correcting the biomechanical faults that can cause the problem in the first place, so it can be very effective and easy to perform. Unfortunately, it isn’t for everybody and some patients suffer allergies to tape which means we don’t continue with it as a treatment.
Orthotics
Putting orthotics in the short-term treatment category will cause come health professionals to argue back at us strongly, but here are our reasons. There are 4 layers of muscles that help support the arch of the foot. In regular shoe wearers these muscles don’t get a chance to work properly and therefore become weak and less effective at supporting the arch. Orthotics are a passive arch support that are moulded to the shape of your feet to cover the job that these muscles are meant to do. Orthotics can therefore be a good method of relieving pain. However, the issue with orthotics is that they become a crutch! You must take them everywhere and this will have a massive impact on you because you will have to be very selective with your footwear and even your entire outfit. Sneakers with suits is currently in fashion, but for how long!!! If we choose orthotics as a treatment we usually prescribe them on a temporary basis. However, with some people, they feel they need more long-term support and this is ok. We can offer more long-term orthotic solutions.
Medications
As plantar fasciitis is an inflammatory condition, we usually recommend patient’s consult with their pharmacist or GP for some anti-inflammatory medications. These can help stem the pain and allow you to perform the corrective exercises with less discomfort and get you back on track faster. In some cases the pain is more deeply set and lingering. With these patients we often refer on to a sports medicine physician. They regularly MRI the foot with the view of confirming the diagnosis. These clinicians may or may not offer a steroid injection into the foot to reduce the inflammation and therefore allow more effective treatments take place with the pain reduces.
Cryotherapy
Cryotherapy is a very fancy word for ice therapy. We don’t perform cryotherapy in our clinic, however, we do recommend it for patients to try at home. The easiest way to try is to freeze a water bottle and then massage your foot over it in the morning and after time spent on your feet. Ice promotes deep blood flow and can also help reduce pain in the plantar fascia so why not give it a go.
Self-massage
Another thing people often finds helps a lot is to “get at the soreness” using a firm massage ball. A simple golf ball can help get stuck into the heel and may make the initial walking feel a bit better. This is usually performed in combination with other treatment to help our patients on their recovery.
Long-term recovery treatments
The long-term treatment strategies are the most important treatment of plantar fasciitis. Yes we want to get you pain-free as fast as possible, but we also don’t want you re-attending in 6 or 18 months’ time with recurring episodes of heel pain! This is what we call primary prevention in medicine and another example is stopping smoking to stop smoking related illness! So what do we do?
Exercise therapy
As we described above certain biomechanical faults can lead to the development of plantar fasciitis, most commonly the collapse of the medial arch of the foot and the reduction in activation of the 4 layers of arch supporting muscles. So we as physiotherapists try and switch these muscles back on and get you performing a home programme that you can complete yourself to improve the quality of these muscles. We also use video software to formulate your treatment plan so you can’t forget what exercises you were asked to do or how many repetitions. This is a great tool in helping you get rid of that stone in your shoe!
Weight loss coaching
Reducing body weight is something most of us could do with! As the dry January drifted past and for many whose new year gym memberships are starting to see less use, the complacency sets back in. The thing is, most of us are too hard on ourselves and try make too drastic changes too soon. But by setting small goals and trying to add exercise to your weekly routine, you can start gradually embedding those healthy choices into your daily rituals and reap the benefits of it for years to come. Cardiovascular exercise is the primary means of building a sustainable weight loss exercise routine. This includes walking, jogging, cycling, swimming rowing at a steady conversational pace for durations (30-60 minutes). Now depending on the person we may not recommend walking or running as the primary source of cardio training if their foot problem is caused by weight bearing. In these cases, we recommend getting out the two-wheeler and the helmet and don’t forget your lights and high vis gear!
The other side of weight loss training is diet skills! Now I’m not going to go off into the real nitty gritty of diet, but the basics are true. Eat less processed food. Go for whole grain options. Reduce the amount of carbs you eat as most of us eat way more than we need. Try more fruit and veg. A good tip to improve on this is to try and get at least 3 colours on your plate. Eating together with other people is a good way at promoting social connections with food and helps people make better food choices. It is also a way of seeing how other people do things. Try new things. You might find a food that you really hit it off with! Avoid fast foods and the sweet counter at the local garage!
The final impression
As you can see, plantar fasciitis is a lot more complex than just a pain in the heel and it can be trickier to deal with than just dulling the pain with medications or bringing around insoles for every pair of shoes you own. The real treatment is about changing how we move, how we rest and recover. For some the changes can be more drastic than for others but ultimately the goals are the same. We are looking at building a sustainable progressive treatment programme and try to get the pain away as fast as possible. We as physiotherapists are trained in trying to address the multi-faceted causes of your foot pain and point you in the right direction so that you can manage your pain better. Your treatment is usually a combination of the above treatments which sometimes needs changing. Many of our patients attend seeking our help but have already had treatment for heel pain and it didn’t go away. What we must do is try and improve the quality of the previous treatments or try a new treatment type. An example would be trying the relatively new treatment option of shockwave therapy and combine it with taping to rest the plantar fascia after the treatment. A recent high-level review published in the BJSM journal in 2018 found that combining medication, exercise and shockwave was the most effective treatment option for plantar fasciitis, so this avenue needs more exploring with our patients.
The most important person in treating plantar fasciitis is not the GP, Sports medicine physician, physiotherapist or the podiatrist! The person directing the treatment is you! You are the one with the pain and you are the one who must implement these changes and make amendments to what works for you and what doesn’t. So we wish you the best with your treatment journey and we as physiotherapists are always here to help you get rid of that ache in your foot!