• Definition
• Causes
• Symptoms
• Facts & Statistics
• Similar Conditions
• Diagnosis
• When to Seek a Professional
• Predisposing Factors
• Progress & Duration of Condition
• Treatment/ Rehabilitation Examples
• Prevention
• References

Definition

The Plantar fascia is a band of connective fascia tissue (similar to a ligament) that runs from the toes and attaches to the heel bone. This fascia is partially responsible for holding up the arch of the foot. Plantar fasciitis is an inflammation of that connective fascia tissue that is generally an overuse or repetitive use type injury.  

Specifically, the fascia acts to support the arch that runs length wise in the foot. The fascia also acts to prevent over-pronation, which is a condition where the foot rolls too far inward and too much pressure is placed on the inside of the foot during running or walking. Finally, the fascia serves as a dynamic shock absorber for the foot and leg during each step. Each time a step is taken the heel contacts ground stretching plantar fascia and flattening the arch.  This allows foot to accommodate for irregularities in the ground and absorption of shock.

• Repetitive or excessive pulling of this fascia will cause small tears within the tissue leading to inflammation, pain and swelling. (ie similar to a rope starting to fray)
• The extra stress placed on the foot from tight fascia may eventually lead to the fascia pulling at the bone. In this case the periosteum, which is the outside lining of the bone, becomes inflamed; this condition is called periostitis
• After periods of rest (lying, sitting) the tissue repairs itself by tightening. When weight is then placed on the foot, the fascia stretches and subsequently re injured

  • This is why the pain is so intense first thing in the morning. When you sleep, the periosteum tries to re-attach itself but when you take your first couple steps in the morning, you are actually re-tearing it again
• Researchers have found degenerative changes to the collagen of the fascia without the presence of inflammation.

  • This finding is important as it helps to illustrate why not all patients receive symptom relief from their plantar fasciitis when they take anti-inflammatory medicine
• Plantar Fasciitis = Heel spur syndrome

  • This is a misnomer and it is important to note that heel spurs do not actually cause pain
  • Heel spurs will develop in response to painful situations; their response is to ease the pain
  • When a bone is stressed, its response is to conform to the stress applied
  • As the plantar fascia pulls at its attachment site, the bone begins to grow along the direction of the pull
    • This is the body’s response to help avoid the fascia from pulling off parts of the bone
  • An X-Ray will illustrate ridges that resemble spurs
  • Many patients with plantar fasciitis do not necessarily have heel spurs (15% and 25% of the general population have asymptomatic heel spurs).
  • Heel spurs play no part in the diagnosis of plantar fasciitis, and therapy for heel spurs have a no role in its treatment

Causes

The cause of plantar fasciitis is normally multi factorial and often poorly understood. The following are some possible causes of this condition:

• Tight gastrocnemius and soleus muscles
• High foot arches (pes cavus)
• Excessive pronation (feet bend outward during stance or walking), which places too much force on the inside of the foot
• Shoes without sufficient arch support or cushioning
• Obesity
• The extra weight increases the force transmitted through the foot with each step.
• Poor Biomechanics of the foot
• A combination of stiffness in the foot bones close to the heel and excessive motion of the foot bones near the toes, which causes an increase in the pull through the fascia during the phase of running where the entire foot is on the ground.
• The likelihood of this condition increases with age

  • As when you get older, you loose the elasticity in your tissues, this result in an increase in the strain that is placed on the bone at the site of the fascia attachment. The end result is inflammation of the plantar fascia

Symptoms

The symptoms for plantar fasciitis is quite typical and generally includes:

• Pain at the bottom of the heel that is worse with the first few steps in the morning
• Pain aggravated by standing on tiptoes, walking on his heels, barefoot or walking up stairs
• The pain usually occurs when the heel strikes ground, or when pushing off during running

  • Sometimes the pain may improve while running, but generally it limits length and frequency of a run
• Tenderness when the sole of the heel touched, closer to the inside of your sole
• Runner’s usually report a gradual onset, as they will not be able to relate this condition with any direct trauma or event
• Occasionally pain can also be along the inside portion of the arch or the outside of foot and it is usually described as burning/searing/piercing pain
• After rest (ie. Sitting for long periods, or sleeping), there may be a sharp pain in the heel area
• Pain is worse when running up hills
• A limp may be present when on walks or runs
• Numbness in the foot is uncommon

Facts & Statistics

• Plantar fasciitis accounts for 11-15% of doctor visits regarding foot pain
• Plantar fasciitis has been found to plague anywhere from 10-75% of runners
• 10% of the general US population will experience plantar fasciitis over their lifetime and approximately 2 million US citizens will experience this condition per year
• In the general population the incidence usually peaks in individuals aged 40-60, but is more frequent in younger individuals who participate in running activities
• Some studies have shown a higher prevalence in women but other studies refute that there is a gender difference with this condition
• In up to a 1/3 of cases, plantar fasciitis can affect both feet at the same time

Similar Conditions

There are a few conditions that have symptoms similar to plantar fasciitis which need to be ruled out by health care professional to ensure proper treatment:

• Ruptured Plantar Fascia

  • In this case, a patient will experience a sudden onset of tearing pain
  • They are usually not able to put weight through the affected foot after activity and their arch height is considerably lower than normal
• Leg length differences

  • A true leg length discrepancy is considered when one limb is ¼” or longer than the other
• Infection

  • Symptoms include a constant fever and night pain
• Cancer

  • Symptoms include deep bone pain and unremitting night pain
• Paget’s Disease

  • The lower leg usually is shaped in a bow-like fashion and there is bone pain else where in the body
• Wasting of the Fat Pad

  • More common in the elderly or runners that have been running for many years
  • Pain and tenderness at the center of the heel
• The pain is not normally present with rising in the morning
• Often wasting of the heel pad is observed
• Calcaneal stress fracture

  • Pain is usually vague and it often begins after an individual has participated in an excessive or repetitive weight bearing activity
• Tumor

  • These symptoms often do not improve with ambulation and the individual often suffers unremitting night pain
• Tarsal tunnel syndrome

  • There is often burning pain that spreads to the toes and/or up the leg
  • Often there is numbness or a pins/needles sensation
• In some cases, this condition can occur in conjunction with plantar fasciitis
• Medial plantar nerve entrapment

  • Burning pain along the inside of the foot
• Referred pain from the lumbar spine
• Heel contusion aka a bone bruise

  • Pain is usually felt along the heel after an individual spends excessive time on their feet or post trauma

Diagnosis

In most cases a detailed history and physical assessment will be sufficient to diagnose plantar fasciitis. By the time of the examination, this condition can usually been classified as chronic.

• Along with the previously reported symptoms, an assessment will usually find the following features:

  • Limited range of motion in the ankle; with greater movement lost when you try to pull your toes towards you ( i.e. Dorsiflexion)
  • In approximately 40% of plantar fasciitis cases, there is weak foot intrinsic muscles
    • Intrinsic muscles begin and end in the foot and cause movement of the toes
  • Tightness and possible weakness of gastrocnemius and soleus
  • Poor Foot biomechanics in standing and/ or ambulation
  • Flat or high arches

Diagnostic imaging plays a limited role but may be used to exclude other possible diagnoses

• A Bone scan or an X-Ray may be used to rule out stress fractures or heel spurs. These tests may show osteophyte formation or swelling in the bone marrow
• An Ultrasound or a MRI may show thickening of the plantar fascia anywhere from 2-7mm thicker than its usual 2-4mm

When to Seek a Professional

Runners should seek the advice of a professional such as a physiotherapist when they are experiencing:

• Unremitting pain that persists during the night
• Very localized pain and swelling along the surface of a bone in the foot
• Pain that does not subside when activity is over (other than regularly experienced muscle pain)
• Pain that affects activity performance or inhibits normal movement (other than regularly experienced muscle pain)
• Pain after activity that has not resolved with adequate rest
• Surgery may be indicated if pain does not subside after about one year

  • Fascial release has risks, including prolonged healing time, post-op rehabilitation, and alteration to the foot's biomechanical function
• Corticosteriod injections may be indicated if conservative treatment is not effective

Predisposing Factors

In approximately 85% of plantar fasciitis cases the exact cause is unknown, however the following are a few factors that may increase the chances of a runner developing plantar fasciitis. They include:

• Limited range of motion of the foot

  • Particularly ankle-dorsiflexion, which occurs when you pull your toes toward you
  • This causes the individual to over-pronate their foot when they walk or run, meaning that they place a greater deal of pressure along the inside of their foot
• Weak foot intrinsic muscles
• Weak plantar flexor muscles (the muscles that help you point your toes)
• Walking bare foot
• Walking or running on hard surfaces
• De conditioning
• Tight gastrocnemius and soleus muscles (i.e. calf muscles)
• High foot arches (pes cavus) or flat arches (pes planus)
• A Short Achilles tendon
• Excessive pronation
• Shoes without sufficient arch support or cushioning

  • It is recommended that you change your runners every 300-500 miles
  • A change is shoes have been reported to improve plantar fasciitis symptoms in up to 14% of patients
• Excessive training, running on uneven surfaces, sudden change in running program (excessive running causes micro trauma that exceeds the body’s ability of recover)
• Obesity
• Increased time spent on feet
• Diabetes mellitus

  • This can cause weak foot muscles and change the foot structure

Progress & Duration of Condition

Plantar fasciitis can be slow to heal because the plantar fascia is easily re injured during weight bearing activities:

• In most cases it takes anywhere from 6-12 months to fully resolve
• 4-5 weeks of “relative rest” switching to activities that remove the stress caused by repetitive excessive pull of the plantar fascia on the heel
• Relative rest is very important because sufficient time is necessary for the fascia to repair itself. If the fascia is constantly re injured over and over again, healing begins at the acute stage again

Treatment/ Rehabilitation Examples

• Treatment has two focuses:

  • Decrease inflammation
  • Eliminate pre-disposing factors
• Prompt initiation of treatment and faithful adherence to the regimen can shorten the healing time
• Conservative care is generally successful in 90-95% of the cases
• Physiotherapy is helpful in conjunction with the treatments to help speed the process of healing or during the acute phase

  • The treatments that a physiotherapist can provide include
    • Ultrasound
• Electrical stimulation
• Taping
• Contrast bathing
• ROM
• Massage
• Acupuncture
• Relative rest

  • Low impact activities such as cycling, swimming, cross-trainer
• A 10-day course of Rest, Ice, Elevation, & Compression
• NSAIDs

  • The main purpose of medications is to mask the pain; by taking the medications you will not correct your plantar fasciitis
• Frozen water bottle, rolled under the heel or use local ice massage 4-5mins several times a day. Remember to use this icing technique after walking for long periods of time or after activity
• Stretches

  • Once the symptoms have been reduced, stretches to both the calf muscles and the fascia can begin
  • Calf stretches
    • Before/after running this is important to reduce pulling on the heel from tight calf complex
  • Plantar fascia stretching
    • Roll a tennis ball, golf ball or baseball under your foot for 5minutes
      • To increase pressure, while sitting place the foot of the unaffected leg on the thigh of the affected leg; this helps to increase pressure on the foot being rolled
    • Manual stretches
      • Pull the toes of the affected foot towards you (i.e. excessive ankle dorsiflexion) or with your foot on the ground, try to raise your big toe to the ceiling
      • Hold stretch for 30-60 seconds for each foot. Do 3 sets of 10
• Massage

  • Gently rubbing the underside of your foot perpendicular to the orientation of the fascia (i.e. perpendicular to the direction of the toes)
• Strengthening

  • Foot intrinsic muscles
    • By strengthening these muscles, you can improve the support of the longitudinal foot arch and decrease the stress placed on the plantar fascia
      • Exercises:
        • Towel Scrunches: try to repeatedly pick up a flat towel by scrunching it with your toes and gathering it together
  • Gastroc and/or Soleus Muscles
    • Calf Raises
• Avoid spending a lot of time walking barefoot and instead walk in proper supportive shoes
• Night splints

  • These may or may not be custom made
  • The purpose is to stop the toes from pointing during sleep
  • This will provide a constant stretch to the calf and the plantar fascia
  • Night splints also maintain the foot in a neutral position and facilitate the healing process
  • Drawback: splints are cumbersome and difficult to sleep in
  • However, have a high success rate and can dramatically decrease the pain that is felt during the initial steps in the morning
  • In some cases a tensor bandage may be used as a substitute for a splint
• Taping

  • Termed Low-Dye tapping
  • This technique is used to support the arch and decrease the amount of stress on the plantar fascia
  • The tape normally put on first thing in the morning and then worn for 2 days
  • Using a Low-Dye taping technique; one study found a positive effect with 75% of the 16 patients studied
  • Done by a physiotherapist
• Orthotics

  • Usually custom made and often are designed to prevent the over-pronation of the foot
  • If excessive over-pronation is not present, a pre-fabricated device is often prescribed which, is normally less expensive than a custom othosis
  • If there is a decrease in the fat padding around the hell, often a heel cup is prescribed to help dissipate the pressure at each step
  • At present, the research to support to use of an orthotic is conflicting as some studies show support for this device, well other studies say orthotics are only as helpful as other treatments
  • In general, an orthotic is usually prescribe if there are major biomechanical faults with an individual’s foot
• Corticosteriod injections may be indicated if the conservative treatments are not effective

  • There is a risk that the fascia may rupture or the muscles may atrophy with this treatment
• Surgery is a rare last resort but is sometimes warranted when all other treatments fail.

  • When surgery is performed, it does have a high success rate
    • Surgery may be indicated if pain does not subside after about one year of treatment
    • Surgical fascia release has risks including prolonged healing time, post-op rehabilitation, and alteration to the foot's biomechanical function
• Returning to Running

  • Can only occur once the injury is completely healed
  • For our advice on returning to running after injury, click here
  • Proper periodization is critical once running is started, click here for our advice

Prevention

Prevention is clearly the best method to manage plantar fasciitis and avoid reoccurrence.

• Make sure running shoes are providing adequate arch support
• Stretching Calf muscles before/after running is essential part of prevention of plantar fasciitis

  • Holding stretch for 30-60 seconds for each left 3 sets of 10, TID
• Scheduling Relative Rest into your running program

  • Allowing a minimum of 24hours after a strenuous run for recovery
  • Gradual increase of mileage NOT exceeding 10% per week
  • Proper building of mileage scheduling rest weeks into your program
  • For an example of how to schedule (periodize) your running program click here
• Proper warm-up and cool-down

  • For an example of how to properly warm-up & cool down for runners, click here
  • Stretch to maintain muscle flexibility or correct muscle shortening
    • For our advice on stretching for runners, click here
• Running with lightweight footwear that has minimal wear & compression

  • For advice on footwear for runners, click here
  • Replace running shoes every 600-800km of running depending upon running surface and body weight
• Correct biomechanical problems in the lower extremities

  • Visit a Physiotherapist or Orthotist for orthotics if needed
• Swap regular insoles with or add a pair of shock absorbing insoles into your shoes

  • Note, this may slightly alter running biomechanics and lower extremity alignment, consult a specialty shoe store if you have questions
• Running on level, forgiving surfaces for the majority of mileage or long runs
• Avoid running on hills and uneven surfaces

References

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