Plantar Fasciitis

Plantar Fasciitis (Overuse and Degenerative)

What Is Plantar Fasciitis? Types and Symptoms

Plantar fasciitis is a condition characterized by pain in the medial plantar heel. It is a chronic degenerative process involving the plantar aponeurosis, frequently at the point where it connects to the medial tubercle of the calcaneus.

Here's a breakdown of the key aspects related to plantar fasciitis:

• Definition: Plantar fasciitis is a chronic degenerative process affecting the plantar aponeurosis, often at its insertion into the medial tubercle of the calcaneus. While historically considered an inflammatory issue, current findings suggest it is primarily a degenerative mechanism. Some experts have called this condition "plantar fasciosis," implying that its etiology is a more chronic degenerative process versus acute inflammation.
• Symptoms:
  • Heel pain that is typically more intense with the first steps in the morning or after periods of prolonged standing.
  • Medial plantar heel pain while bearing weight.
  • Pain with palpation of the plantar medial aspect of the heel.
  • Pain with passive dorsiflexion of the ankles and toes.
  • Sharp, stabbing pain with palpation of the medial plantar calcaneal region.

The plantar fascia, comprised of three bands of dense connective tissue, originates at the medial tubercle of the calcaneus and extends distally to insert into the base of each proximal phalanx. The plantar fascia tenses during the terminal stance to toe-off phases of gait. This tension elevates and reinforces the medial longitudinal arch, enabling the foot to function as a rigid lever for forward propulsion.

Anatomy of the Plantar Fascia: Support and Function

The plantar fascia is a crucial structure in the foot, providing support and contributing to its biomechanics.

Here's a summary of its anatomy, support, and function, based on the sources:

• Anatomy
  • The plantar fascia consists of three bands of dense connective tissue.
  • It originates at the medial tubercle of the calcaneus (heel bone).
  • It extends distally, fanning out to insert into the base of each proximal phalanx (toe bones).
  • It runs nearly the entire length of the foot.
• Support and Function
  • The plantar fascia plays a vital role in maintaining the medial longitudinal arch of the foot.
  • It tenses during the terminal stance to toe-off phases of gait.
  • This tension elevates and reinforces the medial longitudinal arch, allowing the foot to function as a rigid lever for forward propulsion.
  • The plantar fascia deforms 9-12% on stretching during the stance phase of gait.
  • By acting as a tie-rod, the plantar fascia holds together the anterior and posterior struts when weight is loaded, allowing the bones to handle compression forces and the plantar fascia to handle tension forces.
  • It contributes to increasing the longitudinal arch (supination of the foot) as the heel rises during the metatarsal break, which helps convert the foot into a rigid lever for push-off.
  • The tightened plantar fascia at the metatarsophalangeal (MTP) joints prevents excessive toe extension, reducing stress on the MTP joints.

Causes and Risk Factors

Plantar fasciitis is often caused by a combination of factors, with overuse and biomechanical issues being significant contributors. It is estimated that 11-15% of all foot complaints requiring medical attention can be attributed to this condition.

Here's a detailed look at the causes and risk factors associated with plantar fasciitis:

• Overuse: Repetitive strain seems to cause microtearing, which induces a repair response.
  • Activities like running and prolonged standing can lead to this condition. Each year approximately 1 million office-based physician visits result in a diagnosis of plantar fasciitis.
  • Athletes are susceptible due to increased distance, intensity, or duration of activity. The addition of speed workouts, plyometrics, and hill workouts are particularly high-risk behaviors.
  • Military personnel and those with occupations requiring prolonged standing are also at risk.
• Biomechanical Factors:
  • Flat feet (pes planus) or high-arched feet (pes cavus) can increase stress on the plantar fascia.
  • Excessive foot pronation.
  • Tightness of the Achilles tendon and intrinsic foot muscles. Active dorsiflexion less than 10° beyond neutral is indicative of an equinus contracture.
  • Leg-length discrepancy, excessive lateral tibial torsion, and excessive femoral anteversion can alter running biomechanics, increasing plantar fascia stress.
• Other Risk Factors:
  • Obesity.
  • Improper footwear: avoid flip-flops and sandals.
  • Sudden increases in activity.
  • Sedentary lifestyle.
  • Age: The peak incidence occurs in persons aged between 45 and 64 years. Men, usually between ages 40 and 70, are affected more than a woman.
  • Gender: It is more common among women.

It's worth noting that plantar fasciitis is often associated with a heel spur; however, many asymptomatic individuals have bony heel spurs, whereas many patients with PF do not have a spur.

Why Physiotherapy is Essential for Recovery

Physiotherapy plays a crucial role in the non-operative management of plantar fasciitis by addressing pain reduction, tissue flexibility improvement, and gait imbalances. Conservative treatment is almost always successful, with most patients responding and improving within 9 months of physiotherapy treatment.

Here's why physiotherapy is essential for recovery:

• Reduces Inflammation and Pain:
  • Ultrasound therapy can control pain by modifying the underlying condition or through the transmission of perception. The effects may be due to stimulation of cutaneous thermal receptors or increased soft-tissue extensibility resulting from increased tissue temperature.
  • Low-intensity laser therapy can be applied to treat disease and injury.
• Improves Tissue Flexibility:
  • Stretching programs help correct functional risk factors, such as tightness of the Achilles tendon and weakness of intrinsic foot muscles. Commonly used stretches include curls or stair stretches, which focus on stretching the gastrocnemius and soleus muscles.
  • Plantar fascia-specific stretching exercises improve outcomes in patients with chronic plantar fasciitis.
• Corrects Gait Imbalances:
  • Foot orthotics are utilized to decrease abnormal foot pronation, which is thought to cause increased stress on the medial band of the plantar fascia. They can reduce strain on the plantar fascia during static loading, reduce the collapse of the medial longitudinal arch, and reduce elongation of the foot associated with pronation.
  • Taping can cause improvement in the function of the plantar fascia. Calcaneal or low-dye taping can provide short-term (7-10 days) pain relief and limit pronation.
• Additional Physical Therapy Modalities:
  • Deep myofascial massage of the plantar fascia, manually or with instrumentation, is thought to promote healing by increasing blood flow to the injured fascia, though most evidence is anecdotal.
  • Iontophoresis, which uses electrical pulses to cause absorption of topical medication into the soft tissue beneath the skin, has shown some effectiveness in treating plantar fasciitis.

A suggested treatment plan includes limiting activity, modifying footwear, and initiating a plantar fascial stretching regimen.

Prognosis: Healing Timeline for Plantar Fasciitis

The typical prognosis for plantar fasciitis involves a varying healing timeline, with most cases resolving with conservative treatment. Factors such as the chronicity of the condition and the consistency of the rehabilitation efforts influence the recovery period.

Here's what the sources say about the healing timeline for plantar fasciitis:

• Conservative Treatment Success: Approximately 85% to 90% of patients with plantar fasciitis can be successfully treated without surgery.
• Timeline for Improvement: Plantar fasciitis is a self-limiting condition that usually improves within one year regardless of treatment. Most patients respond and are better within 9 months of physiotherapy treatment.
• Acute Cases: With consistent rehabilitation, acute cases typically improve within a 3–6 month period.
• Chronic Cases: Chronic cases may require a more extended timeline, often ranging from 6–12 months or longer, necessitating a multimodal treatment approach. If symptoms have lasted more than 1 year, and the patient has been fully compliant with the multiple daily stretching routine, surgery may be required.
• Factors Influencing Recovery:
  • Compliance with treatment: Consistent adherence to rest, stretching, and other conservative measures is critical for a positive outcome.
  • Modification of risk factors: Addressing factors such as improper footwear, overuse, and biomechanical imbalances can expedite recovery.
  • Appropriate and timely intervention: Initiating treatment early and escalating care as needed can prevent the condition from becoming chronic.

It is important to note that while a majority of patients experience improvement with conservative management, a small percentage may require more invasive interventions such as extracorporeal shock wave therapy or plantar fasciotomy, particularly if symptoms persist for six months or longer.

Physiotherapy Treatment Approaches

Physiotherapy treatment approaches for plantar fasciitis aim to alleviate pain, improve flexibility, correct biomechanical imbalances, and strengthen the foot. A multimodal, evidence-based approach is recommended.

Here's a breakdown of physiotherapy treatment approaches, as described in the sources:

• Stretching and Mobility:
  • Calf stretches: Stretching the Achilles tendon, plantar fascia, and intrinsic muscles of the foot is demonstrated to improve pain. Calf stretches on a step can stretch the gastrocnemius and soleus muscles. Active dorsiflexion less than 10° beyond neutral is indicative of an equinus contracture.
  • Plantar fascia-specific stretching: A plantar fascial stretching regimen should be initiated. One exercise involves placing the ball of the foot on the base of a wall, keeping the heel on the ground, and leaning into the wall to stretch the plantar fascia for at least 2 minutes at 10-second intervals on the affected side, at least 2 times daily.
  • Towel pick-up: With the toes of the affected foot, pick up a dry paper towel, drop it, and repeat for 2 minutes once daily in the evening.
  • Ice roll: Rolling the foot over the top of a frozen water bottle for 2 minutes once daily in the evening.
  • Eccentric stretches: Exercises performed under load while the muscle is slowly lengthened, have supportive evidence in improving various tendinopathies.
• Strengthening Exercises:
  • Toe curls with a towel and marble pickups can help strengthen foot intrinsic muscles.
• Manual Therapy:
  • Counterstrain technique: The osteopathic manipulative treatment technique of counterstrain may provide immediate improvement of plantar fasciitis symptoms. The plantar fascia should be placed in a position of least resistance with passive flexion of the knee and plantar flexion of the ankle and toes, maintained for approximately 90 seconds while monitoring the tenderpoint.
  • Deep myofascial massage of the plantar fascia, either manually or with instrumentation, is thought to promote healing by increasing blood flow to the injured fascia.
• Orthotics and Taping:
  • Arch supports: Shoe inserts (e.g., silicone heel pads, felt pads, and rubber heel cups) in combination with stretching exercises can provide superior short-term improvement in heel pain compared with stretching alone. Prefabricated and custom foot orthotics can decrease rear foot pain and improve foot function.
  • Night splints: Posterior-tension night splints have also shown benefit in patients with chronic plantar fasciitis. Night splints prevent plantar fascia contracture by keeping the foot and ankle in a neutral 90-degree position.
  • Taping: Calcaneal or low-dye taping can be used to provide short-term (7-10 days) pain relief. Low dye taping of the foot has been shown to be effective in limiting pronation.

Preventing Recurrence

To prevent the recurrence of plantar fasciitis, it is important to focus on consistent stretching, supportive footwear, and addressing biomechanical factors.

Here's a detailed approach to preventing plantar fasciitis recurrence based on the sources:

• Night Splints: Use posterior-tension night splints to maintain ankle dorsiflexion and toe extension, which creates a constant mild stretch on the plantar fascia, promoting healing at a functional length. Night splints prevent plantar fascia contracture by keeping the foot and ankle in a neutral 90-degree position during sleep.
• Footwear:
  • Wear shoes with adequate arch support and cushioned heels. For individuals with pes planus, a shoe with longitudinal arch support can help decrease pain associated with long periods of standing.
  • Modify footwear: avoid flip-flops and sandals.
  • Replace athletic shoes. Athletic shoes rapidly lose cushioning properties.
  • Avoid walking barefoot on hard surfaces.
• Strengthening Exercises: Strengthening programs are valuable because they can help correct functional risk factors, such as tightness of the Achilles tendon and weakness of intrinsic muscles of the foot.
• Orthotics: Foot orthotics aid in preventing overpronation of the foot and unload tensile forces on the plantar fascia.
• Stretching: Focused stretching of the Achilles tendon, plantar fascia, and intrinsic muscles of the foot has been demonstrated to improve pain.
• Address Biomechanical Factors:
  • Leg-length discrepancy, excessive lateral tibial torsion and excessive femoral anteversion can lead to an alteration of running biomechanics, which may increase plantar fascia stress.
  • Overpronation of the foot: Foot orthotics are commonly recommended for persons with plantar fasciitis to aid in preventing overpronation of the foot and to unload tensile forces on the plantar fascia.
• Lifestyle Adjustments:
  • Weight Management: Obesity is a risk factor for plantar fasciitis, maintaining a healthy weight can reduce the load on the plantar fascia.
  • Avoid Overuse: Balance activities to prevent repetitive strain on the plantar fascia.

FAQs

Here are answers to some frequently asked questions about plantar fasciitis, based on the information from the sources:

• "Can plantar fasciitis heal on its own?" Plantar fasciitis is a self-limiting condition that usually improves within one year regardless of treatment. However, the disabling heel pain may cause individuals to seek treatment from their physician. Conservative treatments can help improve symptoms.
• "Is running safe with plantar fasciitis?" Because of the high incidence in runners, plantar fasciitis is postulated to be caused by repetitive microtrauma. Athletes usually have a history of an increase in distance, intensity, or duration of activity. Running may not be safe with plantar fasciitis because sudden increases in weight bearing activity, particularly those involving running, can cause microtrauma to the plantar fascia. It is important to modify activity levels and avoid overuse to prevent repetitive strain on the plantar fascia.
• "Do heel spurs require surgery?" Subcalcaneal spurs on lateral foot radiography do not support the diagnosis of plantar fasciitis, because previous studies show that subcalcaneal spurs are also found in patients without plantar fasciitis. Surgery is only considered if all other methods fail.

Why Choose Our Vaughan Physiotherapy Clinic?

Our approach to plantar fasciitis blends evidence-based care with individualized strategies:

• Comprehensive Assessment: We evaluate foot mechanics, gait patterns, and tissue health to pinpoint the root cause of your heel pain.
• Personalized Treatment Plans: Customized to your activity level, lifestyle, and recovery goals.
• Collaborative Care: Partnering with podiatrists or orthopedic specialists for complex cases.
• Effective Home Programs: Video-guided stretches and strengthening routines to accelerate healing between visits.

Meet Our Specialized Team

Our physiotherapists have advanced training in foot biomechanics and years of experience treating plantar fasciitis. We understand how debilitating heel pain can be and are dedicated to helping you walk, run, and live without limitations.

Ready to Step Pain-Free Again?

Don’t let plantar fasciitis sideline you any longer. Contact our Vaughan clinic today:

• Phone: 905-669-1221
• Address: 398 Steeles Ave. W Unit 201, Thornhill, ON L4J 3X6
• Online Booking: Book Your Assessment

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