Plantar fasciitis is one of the most common causes of heel pain, mostly affecting people over the age of 40 and females more than men. The characteristic presentation is:
- Pain on taking the first steps in the morning, which may decrease with gentle exercise, but increases again with prolonged walking
- Pain after periods of immobility eg. working at a desk and then getting up
- Pain when stretching the sole of the foot eg. walking up stairs or walking on tiptoes
The pain is experienced at the bottom of the heel close to the origin of the plantar fascia - a thick band of connective tissue running from the heel to the phalanges (toe bones). The plantar fascia has a very important function in the biomechanics of the foot during normal gait (see figure above). This mechanism is called the windlass mechanism and works as follows:
- In the stance position the foot is flat and the arch on the inside of the foot drops (pronates), which is a vital movement to ensure that forces are adequately distributed. The plantar fascia prevents excessive pronation and maintains the foot arch.
- At the end of each step cycle, as you propel yourself forward, the big toe extends - as this happens the plantar fascia does not stretch but pulls the heel bone closer to the toes to supinate the foot (roll the foot outwards) - this provides a solid lever to push from for efficient propulsion.
What causes the pain?
A common misconception is that pain is caused by a bony spur on the bottom of the heel which can sometimes be seen on X-ray. It is however the soft tissue and not the bone spur that is responsible for the pain.
Excessive stress on the insertion of the plantar fascia due to:
- Tight calf structures, or a stiff big toe joint
- Poor footwear
- Altered lower limb biomechanics and weakness
- Sudden weight gain
- Increased exercise intensity
"Fasciitis" would indicate that the condition is inflammatory, however in chronic cases the condition is more degenerative than inflammatory, and does not respond well to anti-inflammatory medication. It may take several months to resolve.
How should I treat it?
Treatment is directed at:
- Improving soft tissue flexibility through manual soft tissue release (such as foam rolling) and stretching
- Correcting any biomechanical errors or weakness in the lower limb
- Avoiding excessive walking or running if this aggravates the pain
- Wearing shoes with cushioned heels and good arch support - orthotics (insoles) or gel heel cups may also alleviate pain in some cases
- Weight loss
If your pain does not improve with the self-management measures above, Advanced Rehabilitatiion Parkmore can help!! We offer a number of interventions to get to the bottom of your problem. These include:
1. Shockwave therapy - in chronic cases this treatment helps to take the fascia from a degenerative back to an inflammatory state, resetting the body's natural healing cascade - check out our blog history for more information. Combined with appropriate exercise and stretches it is very effective at resolving your condition
2. Isokinetic testing - we can objectively identify any imbalances in postural alignment, strength, tissue length and joint motion, and help you to correct such imbalances
3. Gait analysis - the way your lower limb moves during walking may be contributing to your pain. We use video analysis to assess your gait and guide you to correct any biomechanical errors. We can also make recommendations on the use of off the shelf or custom made orthotics
4. Manual treatment - manual soft tissue release will help to accelerate tissue length changes, as well as provide pain relief
5. Differential diagnosis - if you are not responding to self-management measures, it may be because you have a different condition! We will assess you at your first appointment to rule out other conditions such as fat pad inflammation, bone stress, nerve irritation etc.
6. Onward referral - as a last resort, and only after all conservative measures have failed, we can refer you to the best orthopaedic specialists around, however surgery is very seldom required