Plantar-fasciitis. A term that strikes fear into athletes everywhere. It's a painful injury that can sideline an individual for 6 weeks or longer and make activities of daily living difficult.
In this article, we will discuss what plantar fasciitis is, what causes it, symptoms, and treatment.
There is that term again, “itis”. It shows up in almost every diagnosis involving something wrong with the human body.
“Itis” denotes to inflammation and is often associated with a disease. As discussed previously, many musculoskeletal issues have been labeled with the term “itis”.
In recent years, research and the advanced understanding of human performance have revealed that the pathology of these conditions is more involved than just an inflammatory process.
So why the name involving “itis?
Well, it seems that initially tissue structures become inflamed under increased stress and demands but by the time the symptoms become present, the condition has progressed underway to the true dysfunction.
Plantar fasciitis is the term utilized more commonly now to reflect the degeneration nature of the condition.
Fascia is basically a connective tissue that runs throughout the entire human body.
It is everywhere. It looks like a cobweb and is extremely thin in certain places. If you are a meat-eater, you will notice a thin white material that lies between the layers of meat. That is fascia.
Fascia acts to hold everything together so basically your muscles and organs don’t bounce around and move excessively.
Think of it as a more pliable and compliant form of saran wrap. In places like the bottom of your foot, it is very thick, mostly for protective purposes from environmental elements.
Also, this region of the human body experiences a lot of daily stress considering the forces acted upon it during weight-bearing activities such as walking, standing and running.
The plantar fascia doesn’t actually contract in the same way, for example, your bicep does.
It tends to act almost like a sponge or mattress as it contracts to absorb impact forces and then releases while maintaining the appropriate tension to then distribute force.
Problems occur in the plantar fascia when the tissue is not moving the way it should be.
Some signs that you may have plantar fasciitis are:
If a therapist presses their finger hard enough into the affected spot, pain can be reproduced but this is a very forceful and localized pressure that is being administered.
The pain in the heel actually results from the pull of the plantar fascia on its origin site at the calcaneus. This is usually the pain that a person reports.
If you notice in the above X-ray image, the heel spur almost appears to hook-like.
This results in the direction of the calcification moving towards the direction of the force, which is towards the toes.
The plantar fascia originates at the heel and inserts into the toes so when it contracts the pressure results in increased stress onto the bone. It actually pulls at the heel and results in what appears in the image.
Plantar fasciitis occurs when the tissue is not contracting properly due to dysfunction in the tissue integrity.
Just like the other conditions discussed in previous articles, the integrity of the tissue is abnormal, resulting in microscopic degeneration and subsequent thickening.
This can result from the overloading of the tissue commonly occurring from running or excessive volume training.
Just like Achilles tendinopathy, the plantar fascia is susceptible to injury from:
This image is demonstrating the aggravation of the plantar fascia with the presence of a heel spur.
Achilles involvement is also noted with a Haglund’s deformity, which is a localized lesion of dysfunctional tissue in the Achilles tendon. It is not uncommon for both conditions to be hand in hand.
Plantar fascia issues can also result from lifestyle changes such as a person taking up a more sedentary lifestyle involving more time at the desk or behind the wheel for work.
The increased sitting time can result in tightening overtime of the tissue from limited neuromuscular input and use.
Even if the person engages in exercise throughout the week, the sedentary time outweighing the active time can cause issues.
Studies have revealed that individuals with deficits in foot plantar flexor muscle performance contribute to plantar fascia issues. Deficits in plantar flexor and toe flexor muscle groups can contribute towards longer recovery times with longer courses of therapy.
MRI images have also shown that individuals with plantar fascia involvement have smaller volumes in these muscle groups.
Interestingly, studies have noted that a single-leg heel raise will demonstrate insufficient results as it may result in limited execution of the movement due to pain and Achilles strain from the position of a flexed foot and toes.
Basically testing the strength of the plantar flexors in a heel rise position won’t conclude true findings in the patient’s actual strength.
Other positions will have to be used when evaluating deficits involving plantar fascia issues.
It has also been found that women are 50% more likely to experience plantar fascia due to having increased arch laxity compared to men.
Women tend to be more reliant on both intrinsic and dynamic stabilizers of the foot including the plantar fascia.
Pregnancy has also been found to alter the structure and function of the foot, contributing to an increase in joint laxity, foot length and decreased arch height.
Treatment for plantar fasciitis consists of:
Orthoses can provide longer-term relief but many studies have been investigating the use and reliance on orthoses for extended periods of time and its effects on muscle function.
It has not been completely concluded but some studies have found that increased time in orthoses can be a contributing factor towards deficient muscle function in ankle and foot stabilizers.
Further investigation is needed into the type of foot orthoses and supports used and their exact relationship towards limiting muscle function.
The most promising treatment and prevention techniques for plantar fascia issues are neuromuscular training techniques of the ankle and foot stabilizers.
Physical therapy can be beneficial in teaching individuals how to activate and properly utilize the muscles in their foot and ankle while translating it over into functional activity.
Although considered passive methods, stretching and soft tissue mobilization is an important part of the rehabilitation process as well.
Combined with manual interventions by a therapist, restoring the normal tissue properties is important to ensure proper function during movement retraining.
Many foot specialists recommend using the towel stretch, as it tends to target the plantar fascia the best.
They also advise avoiding the heel off the edge of the step stretch as that can actually aggravate the plantar fascia even more.
Although this position may seem similar to the eccentric loading principle for Achilles tendinopathy, the eccentric loading movement is different than holding a static stretch in this position.
This type of eccentric loading for Achilles treatment would also be avoided if the patient were having plantar fascia issues at the same time.
Common and effective self soft tissue exercise of rolling the fascia on a lacrosse ball. Lacrosse balls work best due to the density and firmness.
The old method of a frozen water bottle is less commonly used as the ice has no effect and the water bottle does not penetrate deep enough into the tissue.
Neuromuscular re-education exercises with “toe yoga” where a patient learns how to active their toe flexors and extensors.
Heel raise with a ball squeeze where the patient is learning to control heel and forefoot synergy, thus activating the posterior tibialis muscle. This helps to retrain control of the arch.
Regular heel raises are good but most athletes are not standing around just pushing up onto their toes.
Once control is demonstrated with a bilateral and unilateral heel raise, especially under loads, such as weighted heel raises, progression is then appropriate.
Introducing functional movements and exercises that speak the language of the person’s sport will translate best over into performance.
Introducing single leg progressions and lunge specific movements while incorporating a heel raise are examples of good exercise options.
This will help train the plantar flexors with the rest of the lower extremity kinetic chain for the optimal function of the lower limb.
Plantar fascia issues are extremely common and have been noted by multiple studies to account for close to one million outpatient visits a year to podiatrists and physical therapists.
Although that number is extremely high, surprisingly, studies have also shown that the vast majority of people still are not seeking treatment for the condition.
This is partly attributed to the increasing inaccessibility of information and knowledge through the Internet. People tend to take treatment into their own hands.
Plantar fasciitis is a common occurring injury in many athletes, including runners and obstacle course racers so it would be no surprise that the condition is searched often online.
Although basic exercises can help, the research has shown that patients who received manual therapy interventions from a physical therapist vs. just standard passive treatments, resulted in fewer therapy sessions, faster resolution of symptoms and quicker return to function.
Barriers to treatment have been found to be the cost of healthcare in terms of price for physical therapy visits. Despite having insurance coverage, co-pay amounts can still be a financial strain.
Travel distance to clinics, accessibility to licensed physical therapists and dedication to rehab time are also limiting factors. This can be said for any condition in regards to seeking formal physical therapy but most importantly the knowledge base is the most essential.
Ensuring patients understand the condition and the importance of the treatment techniques will ensure compliance.
Knowledge is key.
Despite the vast amounts of information available through various sources, the majority of people still lack a full understanding of the condition.
Time commitment, finances, travel, and accessibility, as well as stubbornness, are all barriers towards athletes and non-athletes alike in avoiding seeking proper treatment.
There is no price on your health and fitness.
About The Author
Michael St. George, PT, DPT (@icore_stgeorge on Instagram) is a physical therapist who works for Excel Physical Therapy and Fitness which is a private practice that is based around the greater Philadelphia region and suburbs. He is FMS, SFMA, Y Balance and Motor Control Test Certified with 8 years of experience in outpatient orthopedics and sports medicine. His training consists of experience working with physicians and surgeons from the Rothman Institute and therapists in his field specializing in various manual techniques and advanced treatment procedures
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