Plantar Fasciitis

Nov 10, 2019

Foot injury

Plantar fasciitis is one of the most common foot pathologies with approximately one million Americans seeking medical attention for this condition each year.

The plantar fascia is one of the most important tissues in maintaining the structural integrity of the foot. It plays a key role in supporting the medial longitudinal arch, creating tension between the proximal and distal aspects of the foot.

Plantar fasciitis has been described as an overload of the plantar fascia and is the third most common running injury with an incidence of 7.9%.

Symptoms include sharp stabbing pain in the heel or the arch of the foot. Pain is usually worse taking the first steps in the morning, when getting out of bed. The pain improves as the foot warms up. In runners the pain is felt on the push off phase of running.

Common causes of Plantar fasciitis in runners are:

  • Over-training
  • Sudden increases in training
  • Doing excessive hill work and speed work
  • Wearing overused shoes
  • Lack of flexibility.
  • Biomechanical issues of the foot such as lowered arches and excessive pronation may also contribute to Plantar Fasciitis.

Research suggests that there are many contributing factors to the injury.

The foot-leg complex takes the brunt of impact during locomotion, making it susceptible to injury. Adults take an average of 5000-7000 steps per day. This dosage increases with running because an average of 10,000 steps is taken during the course of a single, hour-long run. Even with a shorter run, ground reaction forces and joint pressures are double in magnitude compared with walking, leading to greater stress on joints and soft tissues of the foot.

Studies have shown that pronation has been implicated to an increase in incidence of plantar fasciitis because a greater than average pronation may occur as a result of foot structure or as a compensatory mechanism resulting from a lack of available ankle dorsiflexion. Other studies have said that Plantar Fasciitis is due to reduced ankle range of movement. A retrospective study revealed that only 16% of the 267 patients with plantar fasciitis were deemed to have excessive tightness in the gastrocnemius/soleus complex.

However reviews have failed to distinguish the definitive link between plantar fasciitis, pronation and calf tightness.

In a preliminary prospective study of female runners, Davis et al 2002 reported greater impact peak and loading rates in individuals with plantar fasciitis compared with healthy control subjects.

In another study by Pohl et al 2009 the authors found that female runners with Plantar fasciitis tended to load the lower extremities faster with a higher ground reaction force which subjects the plantar fascia to abnormal mechanical loading, placing the structure at greater risk of injury. The study also found that women runners with lower arch heights were also at greater risk to getting Plantar Fasciitis.

What can you do about it?

Plantar Fasciitis can be a debilitating condition that can take a long time to heal if not treated correctly. Because the Plantar Fascia tissue has poor blood supply the area does not heal as quickly as a muscle injury.

It is always best to seek advice from a medical practitioner who will be able to diagnose the condition correctly and advise on the correct path of treatment.

The initial phases of treatment include Rest and Ice. Icing the area by using a frozen bottle and rolling your foot on it. Massaging the area with a hard tennis or golf ball (Figure 1) can also stretch the Fascia but only if it can be tolerated.

Plantar Fasciitis figure 1

Figure 1

Looking at your shoes is very important. Getting rid of worn out shoes or even purchasing the correct shoes will help. A Podiatrist or a shoe specialist can give excellent advice on this. A Podiatrist can also advise on orthotics.

Arch support is important and walking around in flat shoes or flip-flops is not recommended.

Seeing a Physiotherapist or Biokineticist who can offer you advice on the correct stretching and strengthening exercises for Plantar Fasciitis is highly recommended. A Biokineticist can also evaluate your running mechanics.

The treatment may include stretching of the Gastrocnemius (Figure 2) and Soleus (Figure 3) muscles, as well as foot stretching (Figure 4).

Plantar Fasciitis figure 2  Plantar Fasciitis figure 3

Figure 2                                                                            Figure 3

Plantar Fasciitis figure 4

Figure 4

This should be followed by strengthening the intrinsic muscles of the foot. These are the smaller muscles in the foot that help to support the foot and especially the arch correctly.

Performing exercises such as Foot doming (figure 5), Big toe and little toe lifts (figure 6) and towel crunches (figure 7) can help to improve the strength in your feet.

Exercises should be completed as tolerated. If any exercises increase pain stop immediately and seek correct guidance from a medical therapist.

Plantar Fasciitis figure 5

Figure 5

Plantar Fasciitis figure 6

Figure 6

Plantar Fasciitis figure 7

Figure 7

Some Doctors and Physiotherapist also use Shockwave therapy as a modality for the treatment of Plantar Fasciitis. Shock wave therapy is a non-invasive treatment that involves creating a series of low energy acoustic wave pulsations that are directly applied to an injury through a person’s skin via a gel medium. The research is not completely conclusive as some articles suggest that using Focused shock wave has positive results as compared to Extracorporeal shock wave therapy (J Sun et al 2017, Medicine April 2017). However other studies suggest that it should be used only after non-invasive, proven measures have failed.

A runner can usually continue to participate in running while suffering from Plantar Fasciitis however you need to remember that the longer you continue to run, the longer symptoms will linger, the more damage you cause.

Runners can return to running activities once they can walk a full day without pain, especially with the initial symptoms of stepping out of bed in the morning. Once these activities are tolerated then start increasing slowly to full participation. Throughout return to running, rehabilitation exercises and stretching should continue.

Clinical Pearls

  • While sitting, roll on a ball (tennis ball, golf ball, etc) underneath the medial longitudinal to stretch the plantar fascia
  • Fill a plastic bottle with water and freeze it, roll on the frozen bottle to get the benefits of cold while also stretching the plantar fascia
  • Before getting out of bed in the morning, put on shoes with good arch supports to provide the plantar fascia support upon weight-bearing
  • Sleep with your feet off the end of the bed to allow some dorsiflexion while sleeping
  • Wear a night splint that will keep the foot in a dorsiflexed or neutral position
  • Stretching often throughout the day for a short period of time is more beneficial then stretching once a day for a long period of time
  • Do not wear high-heels or other shoes with no support (sandals) during the day

(taken from Clinical Sports Med. 2010 Jan; Rehabilitaton of Ankle and Foot Injuries in Athletes; Lisa Chinn, MS, ATC and Jay Hertel, PhD, ATC)

Prepared by the Binokinetics team at the Sports Science Institute of South Africa (SSISA)

SSISA’s Biokinetics practice has a special focus on Orthopaedic & Neurological Rehabilitation, using scientific and evidence-based exercise programmes geared to improve function, performance and quality of life. The team also offer an intensive running programme for athletes of all levels to improve their abilities. Read more about SSISA Biokinetics

Please note that information found in these articles does not constitute medical advice. If you are experiencing an injury or condition of any kind, it is always advisable to contact a medical professional for advice on your specific symptoms.

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