What is Plantar Fasciitis?
Plantar fasciitis (pronounced “PLAN-tar fash-ee-EYE-tis”) is the most common cause of heel pain. There may be others, like nerve entrapment, but plantar fasciitis is by far the most common. The plantar fascia is a strong fibrous, flat band of tissue (ligament) that connects your heel bone to your toes. It supports the arch of your foot, so your feet don't splay out. If you strain your plantar fascia, it can become weak and mightily painful, as you may develop tiny micro tears at the heel bone, which crush and stretch and tear more as you place your foot to the ground. The most common location for plantar fascia tears is at the “origin of insertion”, which is where the plantar fascia connects to the heel bone.
Who is most likely to suffer from Plantar Fasciitis?
Anyone can develop a case of plantar fasciitis, from quite young to the elderly. Great age can bring plantar fasciitis on suddenly and not necessarily by direct injury, but many younger people get it by not paying attention to what they demand of their feet in terms of sport, work or homelife.
What causes Plantar Fasciitis?This list could be endless but things like:
- Slipping off a kerb by the roadside
- New shoes
- Rubbish/cheap/ill-fitting shoes
- Standing on a ladder rung, perhaps house painting (this needs strong soles)
- Running in the wrong shoes
- Standing on something hard, like a stone
- (sorry!) Being overweight
- Sudden increases in weight (pregnancy)
- Tennis, golf, football, rugby, sport in general
- Low arches (flat feet)
- High arches
- Lots of standing around (policemen, security guards, the armed services)
- Tight Achilles tendons or calf muscles
- Excessive pronation when walking
- People with a sedentary lifestyle
- Exercising on a different surface than you're used to
- Overuse or sudden stretching of your sole
- Dancers (ballet and/or club)
- Osteoarthritis and rheumatoid arthritis
True; without treatment plantar fasciitis can hang around for up to two years. Part of the reason is that the plantar fascia is poorly supplied with blood, and so, like tendons and ligaments, once it is damaged, it can take a long time to heal. Blood is the key here. The one single thing that can heal body tissue effectively is oxygen. The blood carries oxygen and nutrients around the body to the cells, delivering life saving and healing energies to each and every part.
But not all parts are made equal. Fascial tissue, tendon and ligament are high density tissue, compared to say, muscles, and are fed by tiny, sometimes single track, capillaries. Relaxing tissue that is torn, scarred, suffering from a decrease in elasticity and repeated injury, is difficult, meaning the tiny blood supply can't keep up with the demands of the damaged tissue which already has this decreased healing response.
In addition, you will have waste build up in the area. Dead cells, scar tissue, stagnant lymph, bad chemicals, bacteria, everything you could wish for to encourage infection and slow healing.
So what's the point?
That's a fair question. Because the fascia healing exercises that we show you how to do to their best advantage, stimulates the blood flow to the places it needs to reach, so you get more oxygen.
This stimulates the lymphatic return, so damaged cells and waste are eliminated, bacteria destroyed, and new fluids drawn in as a replacement, both at an accelerated rate to normal, and both vital to the healing process of your fascia tissue.
Do I have to do plantar fascia strengthening exercises?
NO! Your plantar fascia is not a muscle, so you are not exercising it as if it were a muscle. Strengthing exercises will not strengthen your plantar fascia, but rather damage it more and more, locking you in an ever extending cycle of irritation and pain. No, you are doing specific tissue repair exercises and treatments. Very different to pumping weights.
Why should I be concerned about plantar fasciitis?
Because plantar fasciitis is what is known as a gateway injury. Meaning, it can produce problems elsewhere. You may soon develop knee, shin or ankle problems, including pain, because it is likely you will change your gait, which throws your whole body off balance. This means your muscles have to cope with a whole new system of movement which it may not be used to. Different stresses will have existing muscles doing work, and working harder than they did before, often resulting in pain.
One of the complications of plantar fasciitis can be tarsal tunnel syndrome. A type of nerve entrapment which is similar to carpal tunnel syndrome in the hands and wrists. The tibial nerve that passes through the narrow passageway can become pinched. One common symptom is numbness along the bottom of the foot, along with pain, burning or tingling.
At it's worst, plantar fasciitis can completely throw your hip out of alignment, which in turn will affect your back, lower and upper, and your entire posture. So not something to be taken lightly!
How did I get plantar fasciitis?
Many people that I have seen or treated don't rightly recall how they got their plantar fasciitis. Often it develops over time and one thing leads to another. Other times, it is obvious; I slipped off a step, or I trod on a marble. Often there can be some kind of change in activity levels, such as running, that occurred several weeks or months prior to the onset of the heel pain.Most spend too much time wondering and not enough time fixing. So I always go for the pro-active approach. Just work toward fixing it and monitor the situation. If it works quickly, then it was probably sudden onset. If the fascia is slow to respond, then look for contributing factors beyond the obvious, and eliminate them.
How long will it take for me to feel better?
A tough one to be sure. If you stick religeously to the program, you will see a difference in just days, improvement in a week or two, recovery in a few weeks. I can't be more specific than that, because some people will do the treatments on an hourly basis, some twice a day and some twice a week. But one thing is sure; If you do nothing, your plantar fasciitis will still be there weeks and months into the future.
Is it normal to only have pain in one foot/heel?
Yes. It is nearly always the case that one foot is weaker, more misaligned, softer, or more in the firing line, than the other. This one will go down first. Tissue, bone and muscle all work together, and the stresses on them vary from one side to the other.
Other than direct injury, the weaker side will develop plantar fasciitis first, and if you don't do something, the other foot may follow quite quickly. This is because you will protect the injured foot and make the other one do far more than it's used too. Naturally, the additional stresses and strains can develop into plantar fasciitis fairly quickly.
Some more general information that may be of interest
Plantar fasciitis (PF) is a painful inflammatory process of the plantar fascia, the connective tissue on the sole (bottom surface) of the foot. It is often caused by overuse of the plantar fascia or arch tendon of the foot. It is a very common condition and can be difficult to treat if not looked after properly. Another common term for the affliction is "policeman's heel".
Longstanding cases of plantar fasciitis often demonstrate more degenerative changes than inflammatory changes, in which case they are termed plantar fasciosis. The suffix "osis" implies a pathology of chronic degeneration without inflammation. Since tendons and ligaments do not contain blood vessels, they do not actually become inflamed. Instead, injury to the tendon is usually the result of an accumulation over time of microscopic tears at the cellular level.
The plantar fascia is a thick fibrous band of connective tissue originating on the bottom surface of the calcaneus (heel bone) and extending along the sole of the foot towards the toes. It has been reported that plantar fasciitis occurs in about 10% of the general population, with 83% of these patients being active working adults between 25 and 65 years. The peak incidence is among the general population of 40 to 60 years. Plantar fasciitis may present bilaterally in a third of the cases.
It is commonly associated with long periods of weight bearing. Among non-athletic populations, it is associated with a high body mass index.
The pain is usually felt on the underside of the heel and is often most intense with the first steps of the day. Another symptom is that the sufferer has difficulty bending the foot so that the toes are brought toward the shin (decreased dorsiflexion of the ankle). A symptom commonly recognized among sufferers of plantar fasciitis is an increased probability of knee pains, especially among runners.
Diagnosis
The diagnosis of plantar fasciitis is usually made by clinical examination alone. The clinical examination may include checking the patient’s feet and watching the patient stand and walk. The clinical examination will take under consideration a patient's medical history, physical activity, foot pain symptoms and more. The doctor may decide to use imaging studies like radiographs (X-rays), diagnostic ultrasound and MRI.
Heel bone with heel spur
An incidental finding associated with this condition is a heel spur, a small bony calcification on the calcaneus heel bone, in which case it is the underlying plantar fasciitis that produces the pain, and not the spur itself. The condition is responsible for the creation of the spur; the plantar fasciitis is not caused by the spur.
Sometimes ball-of-foot pain is mistakenly assumed to be derived from plantar fasciitis. A dull pain or numbness in the metatarsal region of the foot could instead be metatarsalgia, also called capsulitis. Some current studies suggest that plantar fasciitis is not actually inflamed plantar fascia, but merely an inflamed flexor digitorum brevis muscle (FDB) belly. Ultrasound evidence illustrates fluid within the FDB muscle belly, not the plantar fascia.
Treatment
Treatment options for plantar fasciitis include rest, massage therapy, stretching, weight loss, night splints, motion control running shoes, physical therapy, cold therapy, heat therapy, orthotics, anti-inflammatory medications, injection of corticosteroids and surgery in refractory cases. Also, in some cases, massaging of the inflamed location serves as a temporary relief.
Medical
Orthotics, i.e., foot supports, are the only non-surgical therapy to have been supported by studies rated by the Center for Evidence-Based Medicine as being of high quality. In a single-blind experiment in which patients were randomly assigned to receive off-the-shelf orthotics, personally customized orthotics, or sham (placebo) orthotics made of a soft, thin foam, patients receiving real orthotics showed statistically significant short-term improvements in functionality compared to those receiving the sham treatment.
There was no statistically significant reduction in pain, and there was no long-term effect when the patients were re-evaluated after 12 months. Off-the-shelf orthotics were found to be as effective as customized ones for acute (short term) plantar fasciitis. There is some evidence that taping may supply short-term relief, but the evidence is weaker than the evidence supporting orthotics.
Some evidence shows that stretching of the calf and plantar fascia may provide up to 2–4 months of benefit. One study has shown improvement over a four-month period with stretching. In cases of chronic plantar fasciitis, ultrasound therapy with 3 MHz for 10-15 minutes/day may be beneficial. One study has shown high success rates with a stretch of the plantar fascia, but has been criticized because it was not blinded, and contained a bias because the analysis did not use the intention to treat method. Because it is impractical to do double-blind experiments involving stretching, such studies are vulnerable to placebo effects. The Center for Evidence-Based Medicine has not rated any study of stretching as being of high quality.
Pain with the first steps of the day can be markedly reduced by stretching the plantar fascia and Achilles tendon before getting out of bed. Night splints can be used to keep the foot in a dorsi-flexed position during sleep to improve calf muscle flexibility and decrease pain on waking. These have many different designs. The type of splint has not been shown to affect outcomes.
To relieve pain and inflammation, nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin and ibuprofen are often used but are of limited benefit. Dexamethasone 0.4 % or acetic acid 5% delivered by iontophoresis combined with low Dye strapping and calf stretching has been shown to provide short term pain relief and increased function.
Local injection of corticosteroids often gives temporary or permanent relief, but may be painful, especially if not combined with a local anesthetic and injected slowly with a small-diameter needle. Recurrence rates may be lower if injection is performed under ultrasound guidance. Repeated steroid injections may result in rupture of the plantar fascia. While this may actually improve pain initially, it has deleterious long-term consequences.
Surgery
Surgery carries the risk of nerve injury, infection, rupture of the plantar fascia, and failure to improve the pain. Traditional surgical procedures, such as plantar fascia release, are a last resort, and often lead to further complications such as a lowering of the arch and pain in the supero-lateral side of the foot due to compression of the cuboid bone. This will allow decompression of the nearby FDB muscle belly that is inflamed, yet does not fix the underlying problem.
This basically allows more space for the inflamed muscle belly, thus, relieving pain/pressure. An ultrasound-guided needle fasciotomy can be used as a minimally invasive surgical intervention for plantar fasciitis. A needle is inserted into the plantar fascia and moved back and forwards to disrupt the fibrous tissue.
Extracorporeal shockwave therapy
There is contradictory evidence and recommendations for the efficacy of extracorporeal shockwave therapy (ESWT), or the use of acoustic shock waves, as treatment for plantar fasciitis. One review found that the preponderance of evidence supports the use of ESWT, but only after several months of treatment with more accepted and proven therapies have failed, as a possible alternative to surgical intervention.
However, other reviews, including one in the New England Journal of Medicine and a meta-analysis of randomized controlled studies, found that the evidence does not support its use in the treatment of plantar fasciitis, with the highest quality studies (with the least likelihood of bias) showing no evidence of efficacy. The American Academy of Orthopaedic Surgeons notes that ESWT is sometimes tried before surgery due to minimal risk involved, but due to lack of consistent results it is not commonly performed.