Plantar fasciitis - what it is and how to treat it
Plantar fasciitis is common and is prevalent in active and sedentary individuals. People who have persistent plantar fasciitis often struggle to find good help.
What is plantar fasciitis?
Plantar fasciitis is a common overuse injury commonly presenting as inferior heel pain. It is frequently seen in runners and in menopausal women and is estimated to affect between 3 - 7% of the general population (Dunn et al; Hill et al).
The plantar fascia is a thick, fibrous structure that runs like a band/cord from the bottom of the heel through to the metatarsal heads and toes.
For sake of clarity, plantar fasciitis is an erroneous term as the name suggests that the tissue is inflamed. In a study by Lemont et al, they performed an analysis on 50 cases of heel spur surgery for chronic plantar fasciitis and they concluded:
"Histologic findings are presented to support the thesis that "plantar fasciitis" is a degenerative fasciosis without inflammation, not a fasciitis"
As it is unlikely that the plantar fascia is inflamed the terms plantar fasciosis (condition) or plantar fasciopathy (disease) are more appropriate. However, for the purposes of this article, I will continue to use the conventional term “plantar fasciitis”.
Why do I have plantar fasciitis?
The root cause is still unknown. It is probably multifactorial, but it is thought that excessive mechanical load acting on the plantar fascia has a lot to do with it. A combination of excessive tension and compression stress are thought to be the major forces responsible.
Like any tissue in the body, the plantar fascia has a certain capacity. If the loads applied are greater than the plantar fascia’s capacity, there will tend to be a higher risk of pain or injury. Or in other words, if stress is applied to the plantar fascia quicker than it can adapt, such as doing too much activity too soon (sudden spike in load), this will likely lead to overuse and pain.
Possible risk factors
- Increased ankle joint stiffness
- High Body Mass Index (BMI) > 30/kg especially in sedentary individuals
- Obesity – 80% of people who have plantar fasciitis are overweight (Riddle et al)
- Occupations that require prolonged weight-bearing activity or standing
What are the clinical features of plantar fasciitis?
- Typically presents as inferior heel pain; usually in one foot
- It is usually of insidious onset
- Pain is often worse in the morning and decreases with activity
- Periods of inactivity followed by activity will usually aggravate the heel
- As the condition worsens, pain becomes more frequent during periods of standing and weight-bearing activity
My X-ray shows that I have a heel spur
Spurs are common and are found in about 10-20% of the population (Barret et al; Moroney et al). It is not the spur that hurts but rather the plantar fascia and surrounding tissues (Osborne et al). As a result, spurs are not associated with plantar fasciitis or have anything to do with pain so there is probably no need to be concerned about them.
If it's not plantar fasciitis then what else could it be?
Plantar fasciitis is the most commonly reported cause of heel pain. Occasionally, there can be other causes of heel pain that mimic plantar fasciitis. Heel pain that is misdiagnosed ultimately leads to mismanagement so it's imperative that you have an accurate diagnosis.
Below is a list of conditions that can occur in the heel ranging from most common to unlikely:
- Plantar fasciitis
- Fat pad contusion or fat pad syndrome
- Calcaneal fracture
- Stress fracture
- Nerve entrapment
- Tarsal tunnel syndrome
- Spondyloarthropathies (inflammatory arthritis)
- Osteoid osteoma (bone tumour)
What role does the plantar fascia play in foot function?
The plantar fascia is a high-performance tissue. According to Kirby (2016), the plantar fascia has many important functions some of which include:
Stiffens the arch of the foot and reduces arch flattening
Helps stabilise the foot during propulsion
Assists the deep muscles within the calf muscle region of the lower leg
Assists the intrinsic muscles within the foot
Helps absorb and release elastic strain energy during running
How do I treat plantar fasciitis?
This is by no means a comprehensive treatment guide. If you would like a more in-depth perspective on treatment then you might want to consider going here. I will be focusing most of my attention on high-value therapeutic interventions that I have had practical experience with as a clinician and that I believe is supported by the evidence.
Unfortunately, there is no sure thing when it comes to treatment despite what you will read, watch or listen to on the internet. Every case is unique with some cases being much more challenging than others so it's often difficult to say with absolute certainty what will work.
In addition, plantar fasciitis also has a natural history - meaning that it often tends to resolve itself (most of the time). This can muddy the waters because we can never really tell if it was the actual treatment that worked or the natural history running its course which may explain why certain treatments appear to have "worked".
Of course, this isn't to say that you shouldn't treat but we have to be diligent when it comes to treatment planning. Ideally, we should be attempting to focus on treatments that produce a better result compared to no treatment.
Based on my own experience, treatment usually consists of a 2-phase approach.
Phase 1 - Reduce load and pain
Phase 2 - Improve tissue capacity and load tolerance
The goal is to unload the plantar fascia and reduce pain as quickly as possible. This can be achieved by using a combination of the following:
- Footwear modification
- Reduction in activity
- Active rest
Phase 1 may also involve other adjunct therapies to help reduce sensitivity in the heel which may involve treatments like dry needling, massage and foot mobilisations etc. However, while these passive treatments may have the ability to change the perception of pain the results are often short lasting and do not improve function or improve load tolerance.
Low-dye strapping is a very effective taping technique that I frequently use in the beginning stages of my treatment that serves two purposes:
- Reduce pain
- May help determine if orthotic therapy is clinically useful
Low-dye strapping basically supports the arch of the foot which reduces tensile stress in the plantar fascia and is usually worn for about 2-3 days.
Clients often ask if they can continue to strap the foot themselves. I often advise not to do this as it can potentially cause skin irritations and/or it may not be practical.
If you are interested in learning how to strap the foot then watch the video below:
Credit: Dr Kevin Kirby
Alternatively, here is another useful video of how to strap the foot for persistent heel pain. However, I would recommend that this modified version is applied by an experienced health professional:
Credit: Simon Bartold
Foot orthotic therapy
Foot orthoses are not a silver bullet. Plain and simple, they are a passive adjunct intervention that is used to reduce the load in the plantar fascia but not all orthoses are created equal. Some people may manage perfectly fine using a cheap over-the-counter arch support whereas others may require a device that is more customised.
At the end of the day, the difference between a good versus bad orthotic comes down to orthotic dosing. In a general sense, this means that the orthotic must possess design features that are specific to the injury which helps to reduce stress in the plantar fascia. Orthoses that lack the necessary design features have a tendency to be less effective.
Foot orthoses may be used short to medium term or occasionally for longer periods. Effectively, it will depend on the individual's needs and preferences as to how long orthoses are required. Factors which might influence when and for how long you might need to wear orthoses for include activity levels, individual biomechanical factors and comfort etc.
Once pain levels are under control the next step is to gradually apply load to plantar fascia over time so that it can make adaptations and become more resilient, thus increasing its capacity. The goal is to apply just enough load in order to allow the plantar fascia enough time to adapt. It takes time for these changes to take effect so there are no quick fixes or shortcuts.
In a study by Rathleff et al, they were able to demonstrate that high-load strength training (HLST) was an effective loading protocol that can be used to increase tissue capacity and resilience in the plantar fascia. The authors concluded that it was;
"a simple progressive exercise protocol, performed every second day, resulted in superior self-reported outcome after 3 months compared with plantar-specific stretching. High-load strength training may aid in a quicker reduction in pain and improvements in function."
If you want to see how to perform high-load strength training, here is a really good video where Physiotherapist, Brad Beer, from POGO Physio outlines how to perform the exercises and progressions:
High-load strength training consists of single leg heel raises with a towel inserted under the toes to further activate the plantar fascia.
Below is a summary of the protocol from the study:
- Perform the exercises every second day for 3 months
- Every heel rise (going up) for a count of 3 seconds
- Pause (hold) at the top for 2 seconds
- Lower the heel (going down) for a count of 3 seconds
- 3 sets x 12 repetition maximum (RM)
- After 2 weeks 4 sets x 10RM
- After 4 weeks 5 sets x 8RM
- Start at a 12 repetition maximum (RM) for three sets. 12RM is defined as the maximal amount of weight that the patient can lift 12 times through the full range of motion while maintaining proper form
- After 2 weeks, increase the load by using a backpack with books and reduce the number of repetitions to 10RM simultaneously increasing the number of sets to four
- After 4 weeks, perform 8RM and perform five sets
- If you cannot perform the required number of repetitions, start the exercises using both legs until you're strong enough to perform single leg heel raises
- Keep adding books to the backpack or add resistance (weight) as you become stronger
Please bear in mind that the above loading protocol is just a guide and may need to be tweaked to suit your individual needs under the guidance of a qualified health professional. Remember the key focus is gradual progressive load.
One thing I have noticed is that clients can often find using a towel a bit tricky when performing the exercises, so as an alternative, I would highly recommend using this simple and effective training aid called the Fasciitis Fighter. I have been recommending this to my clients and have had some really good feedback so far.
Stretching exercises specific to the plantar fascia have also shown to be effective (Digiovanni et al). Plantar fascia-specific and Achilles tendon stretches are often employed as part of the rehabilitation program but are not the main focus of treatment. The exact mechanism as to how stretching works is still unclear.
Plantar specific stretch
- Perform the stretching program three times per day
- Hold each stretch for a count of ten and repeat it ten times
- Perform the first stretch (plantar fascia stretch) before taking the first
step in the morning followed by doing the calf stretch
- Plantar fasciitis is an overuse injury
- Excessive loads or forces may be a contributing factor
- Possible risk factors may include ankle joint stiffness, high BMI, obesity and long periods of standing
- You should make sure you have an accurate diagnosis before assuming that you have plantar fasciitis as you risk being mismanaged
- The plantar fascia has multiple important biomechanical functions that are integral to normal foot and lower limb function
- Treatment should be focused on unloading the plantar fascia initially followed by a progressive loading program in order to increase capacity
- Manual therapies can also be used as an adjunct tool to help reduce sensitivity in the heel
Barrett SL, Day SV, Pignetti TT, Egly BR. (1995). Endoscopic heel anatomy: analysis of 200 fresh frozen specimens. J Foot Ankle Surg. Jan-Feb;34(1):51–6.
Digiovanni, B. F., Nawoczenski, D. A., Lintal, M. E., Moore, E. A., Murray, J. C., Wilding, G. E., & Baumhauer, J. F. (2003). Tissue-specific plantar fascia-stretching exercise enhances outcomes in patients with chronic heel pain: a prospective, randomized study. JBJS, 85(7), 1270-1277.
Dunn JE, Link CL, Felson DT, Crincoli MG, Keysor JJ, McKinlay JB. (2004). Prevalence of foot and ankle conditions in a multiethnic community sample of older adults. Am J Epidemiol: 159: 491–498.
Hill CL, Gill TK, Menz HB, Taylor AW. (2008) Prevalence and correlates of foot pain in a population-based study: the North West Adelaide health study. J Foot Ankle Res: 1: 2.
Kirby KA. (2016). Understanding Ten Key Biomechanical Functions Of The Plantar Fascia. June 21, 2016 Volume 29 - Issue 7 - July 2016 Pages: 62-71.
Lemont H1, Ammirati KM, Usen N. (2003). Plantar fasciitis: a degenerative process (fasciosis) without inflammation. J Am Podiatr Med Assoc. 2003 May-Jun;93(3):234-7.
Moroney PJ, O'Neill BJ, Khan-Bhambro K, O'Flanagan SJ, Keogh P, Kenny PJ. (2014). The Conundrum of Calcaneal Spurs: Do They Matter? Foot Ankle Spec. Apr;7(2):95–101.
Osborne HR, Breidahl WH, Allison GT. (2006). Critical differences in lateral X-rays with and without a diagnosis of plantar fasciitis. J Sci Med Sport. Jun;9(3):231–7.
Rathleff, Michael & Mølgaard, Carsten & Fredberg, Ulrich & Kaalund, S & B. Andersen, K & T. Jensen, T & Aaskov, S & Olesen, Jens. (2014). High-load strength training improves outcome in patients with plantar fasciitis: A randomized controlled trial with 12-month follow-up: HL strength training and plantar fasciitis. Scandinavian Journal of Medicine & Science in Sports. 25. n/a-n/a. 10.1111/sms.12313.
Riddle DL, Pulisic M, Pidcoe P, Johnson RE. (2003). Risk factors for Plantar fasciitis: a matched case-control study. J Bone Joint Surg Am. May;85-A(5):872–7.
Founder & Senior Podiatrist