What is the plantar fascia?

The plantar fascia is primarily made up of type 1 collagen and is situated under the medial longitudinal arch of the foot. It attaches to both the heel and the toes.

There are three parts (medial, central and lateral), with the central part being the largest and the most commonly injured. It is the main structure that helps maintain foot posture in conjunction with the other plantar ligaments and intrinsic & extrinsic muscles of the feet.

During movement, the central part plays an important functional role by helping the arch lift during propulsion. When the arch lifts, the bones in the midfoot become more tightly packed together in readiness for pushing our body forward. Because of this important functional role, which involves repetitive tension loading of the plantar fascia, it is also a commonly injured structure. Combined with the plantar fascia having poor vascular innervation, this can also be why it is so stubborn to heal.

What is plantar fasciitis?

It is the most common cause of plantar heel pain, and 1 in 10 people can experience it in their lifetime.¹  Defined symptomatically by pain first steps in the morning and/or when getting up from non-weight bearing for long periods. The discomfort usually eases after a few steps before potentially increasing again by the end of the day, especially if you have been on your feet for long periods and/or participating in repetitive stepping exercises, i.e. walking or running activities.

It is important to understand that this condition is a degeneration of the type 1 collagen fibres (as opposed to an inflammatory condition as the name suggests and does not involve tears or micro-tears (although these can occur). The term plantar fasciopathy is hence a better term to use when describing this condition.² The term plantar fasciitis has been around for so long that it is still more commonly referred to as this.

Plantar fasciitis should also not be associated with heel spurs as being the cause of pain. Heel spurs may look “evil” on x-ray imaging and even give the appearance of sharply poking into the body. They are actually formed at a level of an intrinsic muscle (flexor digitorum brevis) which lies deeper than the plantar fascia, and it has been shown that neither the spur shape or size has a correlation with function or pain before or after treatment.³

Clinically, it is not uncommon to find large heel spurs on X-ray while investigating other areas in the foot. This patient may have never had heel pain symptoms before, nor will they necessarily end up with any. It is important to understand, however that heel spurs have been suggested as a potential risk factor for developing plantar fasciopathy⁴ – even though not by sharply poking into the body.

What are the causes of plantar fasciitis?

The exact causes of plantar fasciitis are unknown, but there are commonly identified risk factors, including intrinsic and extrinsic factors.

Some intrinsic factors include being overweight, age – older population, heel spurs, nerve entrapment, systemic disease (e.g. diabetes), biomechanical dysfunction and genetics.¹

Extrinsic often identified are sport and exercise activities (high repetition), lifestyle, foot/ankle/knee deformities and occupation.¹

What is the treatment for plantar fasciitis?

There is also, unfortunately, limited evidence for a clear treatment path despite there being a long list of interventions at our disposal.

A positive is that 90% of patients suffering from plantar fasciitis can be successfully treated without surgical intervention.¹ It is important to understand, however that regardless of treatment, research suggests that symptoms can persist in some form for 12 months or more.¹

Our Approach to treating plantar fasciitis

Working with you to create the best environment for reducing pain levels and improving quality of life as quickly as possible.

This includes working towards your sports and exercise goals, such as returning to exercise walking and/or running if you choose to.

During this process, we will also be working towards empowering you with the tools (such as strength and conditioning) to be able to reduce the risk of this condition, and similar, from coming back.

It is common to start seeing reductions in discomfort levels within the first 2-3 weeks of treatment with our Podiatrists.

It is also common to reduce overall pain levels to a manageable level over a 3-to-6-month period. In some cases, even sooner.

If your presentation is stubborn, our Podiatrists are trained to recognise this as early as possible and change the course of treatment appropriately. For example, we work closely with medical professionals – in particular Sports & Exercise Physicians – for their opinion on further investigation, management and treatment, including exploring other less common diagnoses and other potential reasons for your heightened pain levels.

Some of the common conservative care interventions we put in place include:

• Activity load management – less steps usually means less irritation. In some cases, we can keep you walking or running. If we do need to cease you from these activities then we still highly promote active rest e.g. Exercise bike, Swimming, Rowing machine, Resistance training, Pilates etc. Our podiatrists can best guide on what you can do to stay active.

• Strength and conditioning exercises – we get our protocol from evidence-based research. The main aim of the plantar fascia specific loading exercise is trying to promote type 1 collagen synthesis. It also starts to help address any calf strength deficits that may exist.

• Taping/padding – to help deload by attempting to reduce the mechanical stress.
• Manual therapy – might include a combination of massage and/or dry needling – to reduce discomfort levels and potentially reduce mechanical stress.
• Heel raises/heel pads/heel cups – to deload and accommodate.

• Correct footwear/footwear management – to help deload as regularly as possible especially in those occupations that involve being on feet for long periods.

• Night splints – to try and help reduce mechanical stress.

• Non-Custom or Custom Foot orthoses – Not as the first line of treatment as the evidence is mixed to their effectiveness. Their aim is try and further reduce the mechanical stress of the arch lengthening on every step. The decision to use will come down to the duration of the condition (acute vs chronic), the foot function type, occupation (desk-bound vs standing/walking), return to activity goals and effectiveness of functional foot taping – which is trying to achieve a similar effect but in a different way

• Shockwave therapy (Sunshine Coast clinics) – for chronic (long-standing) cases aimed at reducing pain levels and trying to promote healing.

• Laser therapy (Broadbeach, Gold Coast location) – for chronic (long-standing) cases aimed at reducing pain levels and trying to promote healing.
• Prolotherapy (Chermside, Brisbane location) – for chronic (long-standing) cases aimed at reducing pain levels and trying to promote healing.

Heel spurs when viewed on x-ray can appear sharp giving the appearance of sharply poking into the body. It is important to understand that they do not do this, nor do they cause pain.

Despite commonly held beliefs they are also not associated with the plantar fascia. According to research, they are actually formed at a level of an intrinsic muscle (flexor digitorum brevis) which lies deeper than the plantar fascia. ⁵

It has been shown that neither the spur shape or size has a correlation with function or heel pain before or after treatment. ⁵

Clinically, it is not uncommon to find large heel spurs on X-ray while investigating other areas in the foot. This patient may have never had heel pain symptoms before, nor will they necessarily end up with any. It is important to understand however that heel spurs have been suggested as a potential risk factor for developing plantar fasciopathy⁶ – even though not by sharply poking into the body.

For more information about plantar fasciitis please read

References:

1. MONTEAGUDO, M.  et al. Plantar fasciopathy: A current concepts review. EFORT Open Rev, v. 3, n. 8, p. 485-493, Aug 2018. ISSN 2058-5241 (Print) 2058-5241.
2.  PETRAGLIA, F.; RAMAZZINA, I.; COSTANTINO, C. Plantar fasciitis in athletes: diagnostic and treatment strategies. A systematic review. Muscles Ligaments Tendons J, v. 7, n. 1, p. 107-118, 2017 Jan-Mar 2017. ISSN 2240-4554. Disponível em: < https://www.ncbi.nlm.nih.gov/pubmed/28717618 >.
3. AHMAD, J.; KARIM, A.; DANIEL, J. N. Relationship and Classification of Plantar Heel Spurs in Patients With Plantar Fasciitis. Foot Ankle Int, v. 37, n. 9, p. 994-1000, Sep 2016. ISSN 1944-7876. Disponível em: < https://www.ncbi.nlm.nih.gov/pubmed/27177888 >.
4. BEESON, P. Plantar fasciopathy: revisiting the risk factors. Foot Ankle Surg, v. 20, n. 3, p. 160-5, Sep 2014. ISSN 1268-7731.
5.  AHMAD, J.; KARIM, A.; DANIEL, J. N. Relationship and Classification of Plantar Heel Spurs in Patients With Plantar Fasciitis. Foot Ankle Int, v. 37, n. 9, p. 994-1000, Sep 2016. ISSN 1944-7876. Disponível em: < https://www.ncbi.nlm.nih.gov/pubmed/27177888 >.
6. BEESON, P. Plantar fasciopathy: revisiting the risk factors. Foot Ankle Surg, v. 20, n. 3, p. 160-5, Sep 2014. ISSN 1268-7731.