Plantar fasciitis can also be referred to as heel pain or heel spurs. In this blog I’m going to take a deep look at plantar fasciitis so you can understand why you have heel pain and what you need to do to help resolve it.
Plantar Fasciitis is described as pain felt on the underside of the heel and/or in the arch of the foot.
Very commonly people experience pain on walking when just out of bed. This can loosen out but come back again with walking or long periods standing. It can vary in severity and feel very sore initially affecting the distance you can walk or duration you can stand, reducing to a soreness you feel but can still walk with.
Plantar fasciitis can occur in all ages, but it is most common in middle age. It can occur in those who are not active, but also occurs frequently in athletic population accounting for 8-10% of running injuries.
What is plantar fasciitis?
The plantar fascia is a band of connective tissue connecting the heel to the toes. It helps to create the arch of the foot. With age or activity that requires a lot of standing, there is degeneration and thickening of the plantar fascia where it attaches into the heel. Pain can be experienced in the foot when small tears occur.
Plantar fascia consists of a type of collagen and is structurally more like tendon than a muscle. This means the injury won’t resolve in 2-4 weeks like a typical muscle tear. Depending on the history of injury, your age or weight etc it can take 6 months or more for it to reduce. 40% of people still experience symptoms over a year later. In 90% of cases it will resolve with physio and only 10% of people will need further intervention from a specialist.
Why does plantar fasciitis happen?
Tear and degeneration of the plantar fascia occurs when more load is placed on the plantar fascia than it had capacity to cope with. Typically, this can causes the arch to flatten putting strain on the plantar fascia leading to tears. This can be seen in the foot on the right below.
It can be due:
- Very flat feet, or feet with a high arch
- Excessive pronation which is rolling inwards of the ankle when walking or running. Such as in the picture above on the right foot.
- An increase in activity or a new activity where a lot of strain is placed on the plantar of the foot e.g. steep hike, hill runs, dancing, jumps, standing for long periods
- A change in training surface e.g. running on hard surfaces instead of grass
- Stiffness in the ankle, achilles or calf which leads to reduce range of motion at the ankle
- Risk factors also include excessive weight gain or obesity which puts can flatten the arch of the foot.
- After an injury to the leg or foot particularly where the leg or foot was immobilised for a period. This can lead to increased stiffness in the ankle or weaknesses which contribute to the onset of the injury
Biomechanics and pronation
This is really important. Poor biomechanics can be one of the factors that leads to excessive load on the plantar fascia. Excessive pronation when walking and running leads to flattening of the arch of the foot. Pronation can occur due to weakness in the gluteals, at the hips and the core. They can cause the thigh bone to turn inwards, which turns the knee inwards, which can then cause the ankle to collapse inwards a little. When working with clients we like to address any biomechanical issues we find to take the load off the plantar fascia and to try reduce the likelihood of plantar fasciitis coming back in the future.
Could your stiff back be linked to your heel pain?
In short, the answer is yes. Fascia is an interesting tissue in the body. Deep fascia surrounds the muscles, tendons, bones and nerves in continuous sheaths. This means tension in one part of the fascia in the body can lead to tension elsewhere in the body. In the picture below fascia is coloured in blue. You can see how fascia from the feet travels up the calf, into the hamstring, pelvis and either side of the spine to the base of the skull. Tightness in the lower back can lead to a pull on the fascia in the foot.
This is why a biomechanical assessment is important as it allows the therapist identify issues in the back or hip, for example, which could be leading to an issue at the foot. It is also why stretching, massage or foam rolling can be prescribed for the hip and lower back as well as the calf and foot. To read more about fascia look into the Anatomy Trains by Thomas Myers
Do heel spurs lead to pain?
Traditionally and still by some people today, heel spurs were blamed as the cause of heel pain. Heel spurs are normal, 1 in 10 people have them. They are small bony growths on the underside of the heel which can be found in people with and without plantar fasciitis. Only 5% of people with heel spurs have heel pain.
Pain can be felt in the location of the heel spur as this is where the plantar fascia will attach to the heel. There is a fat pad on the underside of the heel which degenerates with age. An increase in body weight may accelerate the rate of natural degeneration of the fat pad leading to more pressures on the heel. As people age, their steps shorten which can also lead to increased pressure on the heel. All this increases the pressure on the plantar facsia making it more likely to tear. Generally we find that presence of a heel spur does not affect recovery from plantar facsiitis. Surgery on the heel spur itself is a last resort option for someone who has tried conservative treatment.
How do you resolve plantar fasciitis?
Resolving plantar fascia requires a multi-faceted approach and patience:
- Visit your GP for advice on weight, obesity, cholesterol and diabetes as appropriate. Also let your GP know if you are having tendon pain elsewhere for example, at the knees or elbows as this may be linked to an arthritic condition which can be controlled by medication.
- Wear softer shoes such as trainers which put less pressure on the heel. Some formal work shoes can be irritating for the heel.
- If your job involves being on your feet you may need to adjust your work practices for a period of time until the pain resolves sufficiently.
- Adjust sport practices to reduce the time on your feet. Maintain cardio fitness through non weight bearing sports such as cycling or swimming.
- Research shows that a combination of insoles and stretches or strengthening exercises can improve symptoms. So attend a professional to:
- Have the foot assessed properly to determine if you need an insole with some pronation support as well as arch support. In the majority of cases off-the-shelf insoles are fine, there is no need for a customized pair. The insoles aren’t a magic fix but they can help reduce symptoms over a number of weeks by supporting the arch. This can take some pressure off where the Plantar fascia inserts into the heel and so helps to reduce the irritation a little.
- Receive a programme of stretches and strengthening exercises. This is really important. (see more about this below).
- If pronation is found, determine the root cause of the pronation for example weakness at the core or hp and start a programme to strengthen these areas.
- Have a full assessment of your flexibly and strength in other areas like the hip and back as outlined in the paragraph about fascia above. Stiffness in other areas in the path of the fascia may contribute to the injury. This often overlaps with determining the root cause of pronation
- A night splint can be helpful. This places the plantar fascia in a stretch overnight. Anecdotally, feedback from many of our clients is positive regarding the benefits they feel from the night splint.
- Many people get a short term reduction in pain from rolling the arch of their foot on a tennis ball.
There has been research into the benefit of stretching and strengthening of the plantar fascia and overall it has been shown to be beneficial.
The study below the compared wearing an insole + stretching of the plantar fascia, to wearing an insole + strengthening of the plantar fascia. After 3 months the strengthening group showed a better improvement in foot function (ideal score would be 0) than the stretching group. But after 6 months the improvements were comparable. If you would like to read more about this see the study by Rathleff and colleagues in the references below.
It is interesting to note that the score does not drop down to zero. This correlates with the findings that 40% of people still experience pain up to 12 months after onset of the pain. This may be due to people not doing exercises if they have less pain and therefore being less motivated to continue the exercise as diligently. It could also be due to a reduced rate of healing due having to spend a long time on feet during the day, increased body weight or underlying conditions such as diabetes.
Another study compared calf stretching alone versus calf + planar fascia stretching. Those that stretched both the calf + plantar fascia had better outcomes at 8 weeks than those who stretched only the calf. The picture below shows a stretch for the plantar fascia.
Exercises are an important part of recovery from plantar fascia While these studies focused on the calf and foot, exercises to correct other weakness that are leading biomechanical issues would also need to be addressed.
In summary resolving plantar fascitis involves a multifaceted approach. There is no quick solution.
Anecdotally in the clinic we find that for clients aged 40+ , and who are not involved in high impact sports like running, the best results occur with a combination of arch supports, night splints and stretching for the back and hips. They often send their friends with plantar fascitis to the clinic for arch supports and have loaned their night splint to them.
In our sporty clients we are often surprised at how weak their calf strength is. There can be good improvement in symptoms as they strengthen their calf and plantar, along with arch supports. Sometimes the calfs and plantar don’t have the capacity (or strength) to do what is asked of them in training. Bio mechanical assessments can be really important in this group to pick up other imbalances that might also be loading the plantar fascia.
- DiGiovanni BF, Nawoczenski DA, Malay DP. Plantar fascia-specific stretching exercise improves outcomes in patients with chronic plantar fasciitis. Journal of Bone and Joint Surgery: American Volume. 2006. DOI:10.2106/JBJS.E.01281
- Kirkpatrick J, Yassaie O, Mirjalili SA. The plantar calcaneal spur: a review of anatomy, histology, etiology and key associations. Journal of Anatomy. 2017. DOI: 10.1111/joa.12607
- Rathleff MS, Mølgaard CM, Fredberg U ,Kaalund S, Andersen KB, Jensen TT, Aaskov S, Olesen JL. High-load strength training improves outcome in patients with plantar fasciitis: A randomized controlled trial with 12-month follow-up. Scandinavian Journal of Medicine and Science in Sports. 2014. https://doi.org/10.1111/sms.12313
- Rathleff MS, Thorbory K. ‘Load me up, Scotty’: mechanotherapy for plantar fasciopathy (formerly known as plantar fasciitis). British Journal of Sport Medicine. 2015. http://dx.doi.org/10.1136/bjsports-2014-094562