Plantar fasciitis

Heel pain.JPGWhat causes heel pain?

Plantar fasciitis is one of the most common causes for heel pain. The plantar fascia is a fibrous tissue band that runs along the bottom of the foot. It supports the arch and provides vital shock absorption. Plantar fasciitis is an overuse injury where micro tears develop in the tissue.

This condition is relatively common and is also known as policeman’s heel. In brief, it is inflammation or wear and tear of the soft tissues. It often occurs after extended periods of walking on hard surfaces or in different shoes (flip flops for example). It is most obvious when you take your first step in the morning and after sitting for prolonged periods.

The average plantar heel pain episode lasts longer than six months and it affects up to 10-15 percent of the population. However, approximately 90 percent of cases are treated successfully with conservative care. 

What are the symptoms?

Patients with plantar fasciitis often present with:

  • severe pain in the heel on first step in the morning or after a rest period
  • pain in the heel after a long period of weight bearing activity
  • pain on palpation of the heel bone.

Diagnosis is made if a patient presents with these symptoms.

What causes plantar fasciitis?

Common causes of plantar fasciitis include:

  • high BMI
  • tight calf muscles with reduced movement at the ankle
  • high arch and low arch feet
  • runners or people who spend long periods of time standing on hard floors
  • poorly fitting shoes.

Often diabetics suffer from this condition.

How can I treat plantar fasciitis?

Take your usual choice of anti-inflammatory regularly unless you have been told you cannot take them. Follow instructions on the packet or speak to your GP or a pharmacist if you are unsure

Gently warm the sole of your foot first thing in the morning (e.g., rub the sole of your foot or put the plug in the bath while showering). At the end of the day rest your heel on a bag of ice wrapped in a damp cloth for 20-30 minutes, or try rolling an ice cold water bottle or golf under the arch of the foot.

Avoid walking on hard surfaces for over extended periods. Try and take smaller steps. Always wear soft shoes. Try and avoid walking barefoot.

Footwear – a supportive shoe that has a fastening (lace, Velcro, buckle) should be worn. There should be a thumb width from the end of your longest toe to the end of the shoe. Ideally, the shoe should have a removable insole to allow plenty of room for an orthosis or arch support.

Arch support – evidence has found that a simple arch support or orthosis is effective to treat plantar fasciitis. These can be purchased over the counter or may be prescribed by a podiatrist.

Stretching — achilles tendon and plantar fascia stretch – Before you get out of bed, loop a towel around your foot, and pull it with the knees straight, bringing your foot towards you. Hold this position for one minute. Repeat three times for each foot.

Stretch your calves after walking. Face a wall and step back. Keep your heels flat on the ground and feet together. Lean forward onto a wall keeping your knees straight until you feel tension in your calf muscle (Picture 1). Hold still for at least 30 seconds.

Repeat with the knees slightly bent (Picture 2). Hold for 30 seconds.

Stretch the sole of your foot before standing, after sitting or lying down. Firmly hold all the toes and bend them back until you feel a stretch in the arch of your foot.

Alternatively for a stronger stretch, place toes on a wall with heel on floor. Slide toes down wall to bend them back, then bend knee and put weight through the arch until a stretch is felt in the arch. Hold for 30 seconds. (Picture 3)

Image: copyright Physiotools Ltd. All rights reserved. Used with permission of Physiotools Ltd.

Plantar fascilitis.JPG

Stair stretches for the Achilles tendon and plantar fascia – Stand facing upstairs using the stair-rail for support. Your feet should be positioned so that both heels are off the end of the step, lower the heels, keeping the knees straight, until a tightening is felt in the calf. Hold for one minute before raising back to neutral. Repeat the exercise three times, twice a day.

Dynamic stretches for the plantar fascia – while seated, roll the arch of your foot over a rolling pin or a tennis ball. You should allow the foot and ankle to move in all directions as it rolls over the object. Continue the exercise for a few minutes or until there is some discomfort.

Recent evidence has suggested that soft tissue mobilisation (massage) over your calf and plantar fascia (sole of foot) could be beneficial in reducing pain and improving function when combining this with stretching exercises. Please be guided by your physiotherapist.

Certain taping techniques can help the pain experienced on the first few steps. It is helpful in more short-term flare- ups. It can be used to bridge the gap whilst waiting for foot over the counter orthotics, or as a second line of treatment custom made orthotics may be beneficial but costly. Night splinting e.g. Strasbourg sock, only tends to be helpful with other treatment strategies. However, the evidence for its effectiveness is contrasting.

There is some evidence to suggest that acupuncture can be beneficial in the treatment of heel pain. There is no evidence to support ultrasound therapy.

Extracorporeal shockwave therapy

This is a procedure whereby shockwaves are passed through the skin to the affected heel. The shockwaves are mechanical and not electrical and work by increasing blood flow to the injured area to accelerate the body’s healing process. NICE have deemed the procedure as safe but, again, report that there is limited evidence of it effectiveness. A recent review of research has suggested that it is effective for treating chronic plantar fasciitis (over three months).

If the initial treatment of improved footwear, daily stretching and use of insoles fails after 12 weeks then you could consider:

Steroid injections – evidence suggests that corticosteroid injections can reduce pain, improve function and reduce plantar fascial thickness in patients with plantar fasciitis. This effect has been shown to last for up to three months in patients. Steroid injections can risk heel pad atrophy and plantar fascial rupture. Therefore, they are only to be used in patients who have failed three-six months of conservative treatment.

How successful will my treatment be?

Most patients will have an improvement in pain and function after 12 weeks of conservative treatment. Patients who have tight calf muscles at presentation are four times more likely to respond to stretching. Patients who suffer with plantar fasciitis for a longer time (over six months) are less likely to respond to initial treatment. Therefore, patients are advised to commence treatment as quickly as possible after suffering with heel pain.

Podiatry (foot care)