You wake up in the morning smiling, as you remember your exhilarating run last night or perfect golf game yesterday. You swing your legs over the bed and on place your feet on the floor when –OWW! There is a sharp pain in your heel. Initially you think you may have stepped on something as you hobble to the bathroom. But then fear suddenly sweeps over you when you realize you may have the dreaded plantar fasciitis. You are no stranger to the rumors about how painful it is and how hard it is to get rid of.
Plantar Fasciitis or fasciosis accounts for nearly 3.6-7% of injuries in the general population and 8% of all running injuries (1,2). It has been reported that nearly one million Americans seek medical attention for plantar fasciitis a year. It is can be a stubborn and painful issue for both athletes and non-athletes a like. Approximately 40% of patients suffering from plantar fasciitis continue to have symptoms and pain two years after diagnosis (2). Much like the scenario above, plantar fasciits can present in the morning, walking barefoot or after sitting for a long period of time.
Many people describe their symptoms as sharp and painful in the heel and it can be exacerbated walking on a hard surface. Runners will frequently say it is the worst during the first 5-10 minutes of a run and after they have stopped running (3).
Although the pathology of plantar fasciitis is not entirely understood it is likely caused by microtears in the fascia on the plantar surface (bottom) of the foot. It is thought to be progressive collagen degradation at medial calcaneal tubercle where the fascia inserts (3). Frequently areas of increased or decreased vascularity; fibrosis, fascial thickening or even necrosis can be seen on ultrasound.
Causes of Plantar fasciitis:
Plantar fasciitis is multifactorial. It is often attributed to overtraining and over-pronation of the foot. Other contributing factors including higher BMI, thicker heel pad (4), increased calf tightness and increased vertical ground reaction force and load rates in the longinitudinal arch of the foot (5). Aka too much force in the arch of the foot on landing or impact.
Just because you present with heel pain doesn’t necessarily mean you have plantar fasciitis.
When determining if your symptoms are truly plantar fasciitis your physical therapist, physician or other health care professional will have to rule out other possible diagnoses. Many sports medicine physicians can now use ultrasound in their office to see what your plantar fascia looks like which can help rule in or rule out plantar fasciitis. Other health care providers may rely on pain with palpation of the heel and patients reported history.
What do you treat it?
Conservative treatment of plantar fasciitis often begins with physical therapy. Your physical therapist will likely do a combination of treatment techniques to help you improve. Many people have heard things like rolling a frozen bottle on the bottom of their foot or resting but there are several other things that can and should be done.
Stretching of the gastroc, soleus and plantar fascia has been found to improve patient outcomes with plantar fasciitis.
In a 2006 randomized controlled trial by Digiovanni et al. (6) it was found that plantar fascia specific stretching resulted in a significant improvement for all the patients that performed the plantar fascia stretching. There was a particularly high rate of improvement for those patients that initially started with Achilles stretching and moved into more specific plantar fascia stretching.
Manual therapy such as soft tissue mobilization in the foot/ankle and calf muscles can be very helpful with the pain. Trigger point dry needling can also be a helpful technique to improve tissue mobility and get rid of trigger points in the muscles that may be causing pain. Trigger points can cause referral pain, increase muscle tightness and inhibition of muscles.
In a 2011 randomized controlled trial by Renan-Ordine et al.(7) researchers found that patients receiving a combination of manual therapy and self stretching showed a greater improvement in pain than those who merely stretched.
It is important to remember that the foot and ankle to do not function alone. Hip strength can have an impact of how the foot lands during gait. Make sure you are strengthening all the muscles in the kinetic chain. Strengthening the foot, ankle, core, hips, and legs can be important to improve outcomes with plantar fasciitis.
In a 2015 randomized study by Rathleff et al, (2) researchers found that progressive eccentric strengthening of the plantar fascia combined with wearing gel inserts resulted in “superior self-reported outcome” three months after the initiation of the program compared with only plantar specific stretching. They determined that high-load strengthening may result in faster improvements in function and pain than stretching.
Taping is often used as a means of mitigating pain in the heel while walking. There are various taping techniques your physical therapist may use. Taping is by no means a long-tern solution but it can be helpful to manage pain during treatment.
Low dye taping was found to be effective in a 2015 article written by Sanzo P et al. The article supports the use of low dye taping for unloading the foot in the acute stages of plantar fasciitis (8).
Mulligan’s taping techniques were found to be more effective in improving pain than shame taping in 2015 article by include Agrawal et el (9).
Orthotics are another intervention commonly used to treat plantar fasciitis. Many patients will subjectively feel better with the use of heel cups or orthotics. Orthotics can support the longitudinal arch of the foot suggesting they could be helpful for pain management in conjunction with other means of treatment.
In a 2015 study by Sinclair orthotics were not found to reduce plantar fascia strain in runners but they can reduce rotation in the mid-foot which ultimately may assist in pain management (10). There are several studies that support the use of orthotics in plantar fasciitis for pain management. Over the counter orthotics can be just as effective as custom orthotics (11).
Unfortunately conservative treatment as described above doesn’t always do the trick. If you are still having issues after attempting physical therapy here are several medical interventions that have been found to be helpful in treating plantar fasciitis. Each case of plantar fasciitis is different so ask your healthcare provider about the following interventions:
Shock-wave therapy (ESWT)
Plantar Fasciitis is painful and is often a tricky injury to overcome. However don't tough it out for too long - reach out to your physical therapist, massage therapist, chiropractor or MD for help. The longer you wait the more time you will spend hobbling around or sitting on your coach. Wouldn't you rather be out enjoying life?
Taunton JE et al. A retrospective case-control analysis of 2002 running injuries. Br J Sports Med 2002; 36:95–101
Rathleff MS., Mølgaard CM et al. High-load strength training improves outcome in patients with plantar fasciitis: A randomized controlled trial with 12-month follow-up. Scand J Med Sci Sports 2015: 25: e292–e300
Heiderscheit, B. (2013). The Runner: Evaluation of Common Injuries and Treatment. In C Hughes & S. Hoffman (Eds.), Orthopeadic Management of the Runner, Cyclist, and Swimmer (Section 1). APTA Home study course.
Van Leeuwen KDB., Rodgers J, Winzenberg T., van Middlekoop M. Higher body mass index is associated with plantar fasciopathy/‘plantar fasciitis’: systematic review and meta-analysis of various clinical and imaging risk factors. Br J Sports Med doi:10.1136/bjsports-2015-094695.
Pohl, MB., Hamill J., Davis IS. Biomechanical and Anatomic Factors Associated with a History of Plantar Fasciitis in Female Runners. Clin J Sport Med 2009;19:372–376
Digiovanni BF, Nawoczenski DA, et al. Plantar Fascia-Specific Stretching Exercise Improves Outcomes in Patients with Chronic Plantar Fasciitis. A Prospective Clinical Trial with Two-Year Follow-Up. J Bone Joint Surg Am, 2006 Aug; 88 (8): 1775 -1781 .
Renan-Ordine R., Alburquerque-seddin F., et al. Effectiveness of Myofascial Trigger Point Manual Therapy Combined With a Self-Stretching Protocol for the Management of Plantar Heel Pain:A Randomized Controlled Trial. J Orthop Sports Phys Ther. 2011;41:43-50.
Sanzo P., Bauer T. The Effects of Low Dye Taping on Vertical Foot Pressures in Subjects with Plantar fasciitis. International Journal of Prevention and Treatment 2015, 4(1): 1-7
Agrawal SS., Deshpande MG. Effectiveness of Mulligan’s taping for the short term management of plantar heel pain-Randomized control trial. International Journal of Biomedical and Advance Research, 2015 6(7)p. 531-536.
Sinclair, Jonathan, J. Isherwood, and P. J. Taylor. "The effects of orthotic intervention on multisegment foot kinematics and plantar fascia strain in recreational runners." Journal of applied biomechanics 31.1 (2015).
Ring K1, Otter S. Clinical efficacy and cost-effectiveness of bespoke and prefabricated foot orthoses for plantar heel pain: a prospective cohort study. Musculoskeletal Care. 2014 Mar;12(1):1-10. doi: 10.1002/msc.1053. Epub 2013 Jun 25.