Plantar fasciitis is a common source of frustration for many athletes and non-athletes alike, people can often find the condition dragging on for long periods without successful resolution. In longer conditions people can almost give up with treatment saying it is incurable see Jordan Henderson – http://www.theguardian.com/football/2015/dec/04/liverpool-jordan-henderson-heel-injury
The plantar fascia is a band of connective tissue that can be likened to that of tendon and ligament. The plantar fascia starts from its insertion under the heel and runs across the sole of the foot to the front. It is responsible for a degree of support and shock absorption of the foot during gait.
The accepted consensus was that a tensile force was being placed upon the plantar fascia causing an over stretching and a pull on the attachment point. This attachment point is located towards the inside of the heel and is often a focal point of tenderness among sufferers.
It was believed that inflammation was the key reason for the pain but more recently there has been a change of thought that it may be more likely a degeneration of tissue close to the heel bone attachment and that other forces such as sheer and compression are part of the problem along with tensile forces.
Risk factors include:
- Overtraining – Doing too much and not allowing the tissues heal adequately.
- Excessive pronation – Feet rolling in and flattening may place excess stretch on the plantar fascia.
- Poor lower limb biomechanics – Poor control and movement can cause unwanted movement at a foot level and place stress on the plantar fascia.
- Tight calf muscles – Tight calf muscles may have a relation on a tightness in the plantar fascia but they will also restrict the dorsiflexion movement at the ankle, this being a risk factor.
- Poor footwear – Excessive walking in unsupportive shoes with little cushioning.
- Overweight – Overweight individual are more at risk due to the excess weight being placed through the plantar fascia.
- Age – As we get older the fat in the heel pad degenerates along with tissues meaning they are more at risk of injury.
There are plenty of treatment options to consider so I will look at the more common options.
- Stretching – This is certainly part of any treatment that I would provide. Patients will often be asked to stretch the calves as part of the stretching routine, whilst the evidence on this isn’t too strong, stretching of the plantar fascia itself certainly has more evidence behind it and is a simple yet effective way to gain results.
- Taping – Taping is another very effective way of reducing pain. It is especially useful in helping with “first step pain” the sharp pain when you first get out of bed. Taping is a temporary measure and although it can be reapplied isn’t a permanent solution.
- Orthoses – Orthoses can certainly lay an important part of treatment. Custom foot orthoses have been shown to be effective in both the short term and long term treatment of pain (Roos et al 2006). Orthoses work well as a follow on for taping, the taping can be applied to help predict the effectiveness of orthotic treatment.
- Nightsplints – Patients have been shown to obtain a reduction in short term pain with the use of night splints, however the research suggests that in longer follow ups the results are not as good.
- Steroid injections – Some people have very positive short term effects from these injections, the considerations are that the injection of steroids into an area such as the plantar fascia increases the likelihood of a future rupture and the potential for future surgery.
- Soft tissue massage – Deep tissue massage can help provide some relief from pain, if there is an inherent tightness to the plantar fascia then massage can help.
- Extracorporeal Shock Wave Therapy – ESWT converts sound waves into shock waves with the aim of breaking down damaged tissue. It has been used to some success in various tendinopathies but the research is lacking for plantar fascial issues. The reports are that is more effective than placebo treatment.
- Footwear – Correct footwear is important in the rehabilitation programme. For the athlete the consideration would be to avoid more minimal footwear and have a shoe with a bigger drop, cushioning is another important characteristic.
Roos, E., et al (Foot orthoses for the treatment of plantar fasciitis). Foot and Ankle International. 2006 Aug; 27(8):606-11