Plantar Fasciitis
1. Introduction
Plantar fasciitis, or ‘policeman’s foot’, is a common condition that causes pain in the undersurface of the heel and the arch of the foot. The plantar fascia is the ‘webbing’ of the foot and this connective tissue originates from the inside surface of the heel bone and fans across the bottom surface of the foot, connecting with the tendons which cause each individual toe to move. Most notably, this fascia inserts along the tendon (tendons attach muscle to bone) of the big toe with the purpose of supporting the arch of the foot and acting as a shock absorber for the pressure placed on the foot.
Frequently Asked Questions
- Plantar fasciitis is associated with irritation of the plantar fascia (a strong band of tissue that runs along the sole of the foot). It extends from the heel to the base of the toes and supports the arch of the foot.
- It is estimated that the condition will affect between 4%–7% in the general and older populations, respectively (2).
- This number is slightly higher in runners, with approximately 8%-10% being affected (3).
- No.
- With the right rehabilitation approach, plantar fasciitis generally recovers well and is not linked to other serious pathology.
- Between 70%–80% of people experience reduced pain with conservative treatment alone (5).
- Plantar fasciitis is a common condition in people aged between 40–60 years (1).
- Those who are deemed overweight or obese (4).
- Tightness of calf and/or foot muscles (5).
- Prolonged weight-bearing activities of daily living (standing, walking, running) (6).
- Tenderness of the heel area.
- Limited ankle range of movement.
- Tightness of the Achilles tendon (the thick band of connective tissue attaching the calf muscle to the heel bone).
- Spike in pain when you start walking after sleeping or resting.
- Difficulty in raising your toes off the floor.
- Modify your activity.
- Specific rehabilitation exercises have been shown to be one of the most effective treatments (6).
- Advice from a musculoskeletal physiotherapist will be helpful in most cases.
- Reduce overall bodyweight if deemed clinically obese or overweight.
- Most people achieve complete resolution of their symptoms within a year (7), although with the correct physiotherapy advice many will recover sooner.
We recommend consulting a musculoskeletal physiotherapist to ensure exercises are best suited to your recovery. If you are carrying out an exercise regime without consulting a healthcare professional, you do so at your own risk.
2. Signs and Symptoms
- Initial gradual onset of heel pain.
- Pain that reduces with moderate activity but worsens later during the day, or after long periods of standing or walking.
- Pain often causes a limp.
- Tenderness of the heel area.
- Limited ankle range of movement.
- Tightness of the Achilles tendon.
- Pain exacerbation when you start walking after sleeping or resting.
- Difficulty in raising your toes off the floor.
3. Causes
The exact cause of plantar fasciitis is unknown. However, it is believed to be a degenerative process where we often see collagen (substance found in connective tissue) wear and tear in which inflammation is not the main feature (8). Whilst plantar fasciitis remains the most used terminology for this condition, a more accurate name is plantar fasciopathy. When ‘itis’ is used to describe a condition, it indicates that inflammation is the main contributing factor. However, as detailed degeneration is thought to be the main contributing factor, plantar fasciopathy is a more accurate description.
Pain in the plantar fascia can develop as a result of a relatively sudden increase in load or activity whereby the plantar fascia cannot effectively adapt. Your musculoskeletal physiotherapist will be able to determine factors that may be contributing to the onset of this condition and identify patterns which may be contributing to your symptoms.
4. Risk Factors
This is not an exhaustive list. These factors could increase the likelihood of someone developing plantar fasciitis. It does not mean everyone with these risk factors will develop symptoms.
- Age – most commonly affects people aged between 40 – 60 years (1).
- Excessive foot pronation (flat feet) (5).
- High arches (5).
- Tight Achilles tendon or gastrocnemius (calf) muscle (5).
- Tight intrinsic foot muscles (5).
- Overweight or obesity (4).
- Prolonged weight-bearing activities of daily living (standing, walking, running) (6).
5. Prevalence
It is estimated that this condition will affect between 4%-7% in the general and older populations respectively (2), and occurs in approximately 8%-10% of all regular runners (3).
6. Assessment & Diagnosis
Musculoskeletal physiotherapists and other appropriately qualified healthcare professionals can provide you with a diagnosis by obtaining a detailed history of your symptoms. A series of physical tests might be performed as part of your assessment to rule out other potentially involved structures and gain a greater understanding of your physical abilities to help facilitate an accurate working diagnosis.
Your treating clinician will want to know how your condition affects you day-to-day so that treatment can be tailored to your needs and personalised goals can be established. Intermittent reassessment will ascertain if you are making progress towards your goals and will allow appropriate adjustments to your treatment to be made. Imaging studies like an MRI or ultrasound scans are usually not required to achieve a working diagnosis, but in unusual presentations, they may be warranted.
7. Self-Management
As part of the sessions with your physiotherapist, they will help you to understand your condition and what you need to do to help the recovery from your plantar fasciitis. This may include reducing the amount or type of activity, as well as other advice aimed at reducing your pain. It is important that you try and complete the exercises you are provided as regularly as possible to help with your recovery. Rehabilitation exercises are not always a quick fix, but if done consistently over weeks and months then they will, in most cases, make a significant difference. It is worth noting that true plantar fasciitis will likely take months rather than weeks to improve.
Other self-care options include:
- Resting the foot (by avoiding standing or walking for long periods) where possible.
- Wearing shoes with good arch support and cushioned heels (such as laced sports shoes).
- Avoid walking barefoot.
- Consider purchasing insoles and heel pads to insert in shoes with the aim of correcting foot pronation (flat feet).
- Losing weight if overweight or obese.
- Taking over the counter painkillers; seek advice from your local pharmacist if unsure.
- Apply an icepack (covered with a towel) to the foot for 15–20 minutes for symptomatic relief.
8. Rehabilitation
Research is very clear that modifying the load that goes through the tissue is the key element that stimulates recovery. Recovery can take some time as the speed of plantar fascia regeneration is much slower than other structures in the body.
Below are three rehabilitation programmes created by our specialist physiotherapists targeted at addressing plantar fasciitis. In some instances, a one-to-one assessment is appropriate to individually tailor targeted rehabilitation. However, these programmes provide an excellent starting point as well as clearly highlighting exercise progression.
9. Plantar Fasciitis
Rehabilitation Plans
Our team of expert musculoskeletal physiotherapist have created rehabilitation plans to enable people to manage their condition. If you have any questions or concerns about a condition, we recommend you book an consultation with one of our clinicians.
What Is the Pain Scale?
The pain scale or what some physios would call the Visual Analogue Scale (VAS), is a scale that is used to try and understand the level of pain that someone is in. The scale is intended as something that you would rate yourself on a scale of 0-10 with 0 = no pain, 10 = worst pain imaginable. You can learn more about what is pain and the pain scale here.
This programme focuses on maintaining range of movement/flexibility within the foot and ankle, appropriate loading of the affected tissue and maintenance of lower limb strength and stability. We suggest you carry this out once a day for approximately 2-6 weeks as pain allows. We can work into pain during these exercises but ideally, this should not exceed any more than 5/10 on your self-perceived pain scale.
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 910
This is the next progression. More focus is given to progressive loading/strengthening of the tissue. As with the early programme some pain is to be expected but ideally, we do not want this to be any more than 4/10 on your self-perceived pain scale.
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 910
This programme is a further progression with challenging progressive loading of the affected tissue. Again, some pain is acceptable but ideally, we do not want it to exceed 4/10 on your self-perceived pain scale.
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 910
10. Return to Sport / Normal life
For patients wanting to achieve a high level of function or return to sport, we would encourage a consultation with a physiotherapist as you will likely require further progression beyond the advanced rehabilitation stage. Before returning to sport, a rehabilitation programme should incorporate plyometric-based exercises; this might include things like bounding, cutting and sprinting exercises.
As part of a multi-modal treatment approach, your musculoskeletal physiotherapist may also use a variety of other pain-relieving treatments to support symptom relief and recovery. Whilst recovering, you might benefit from a further assessment to ensure you are making progress and establish the appropriate progression of treatment. Ongoing support and advice will allow you to self-manage and prevent future reoccurrence.
11. Other Treatment Options
Podiatry referral to address significant alterations in lower limb alignment may be helpful in the short term if symptoms are severe or not responding after a few months of the aforementioned treatments.
Corticosteroid injections should only be considered as a last resort, if appropriate, and progressive conservative management has failed. Even if conservative management does not achieve a 100% improvement, careful consideration is heavily encouraged as in some cases corticosteroid injections cause more harm than good, including in rare instances plantar fascia ruptures.
Surgery should only be the last option if all other treatment attempts have been exhausted.
References
- Neufeld, S.K. (2008). Plantar fasciitis: evaluation and treatment. Journal of the American Academy of Orthopaedic Surgeons 16(6), 338-346.
- Whittaker, G.A., Munteanu, S.E., Menz, H.B., Tan, J.M., Rabusin, C.L. & Landorf, K.B. (2018). Foot orthoses for plantar heel pain: a systematic review and meta-analysis. British Journal of Sports Medicine 52(5), 322-328.
- Rasenberg, N., Riel, H., Rathleff, M.S., Bierma-Zeinstra, S.M. & van Middelkoop, M. (2018). Efficacy of foot orthoses for the treatment of plantar heel pain: a systematic review and meta-analysis. British journal of sports medicine, 52(16),1040-1046.
- Van Leeuwen, K.D.B., Rogers, J., Winzenberg, T. & van Middelkoop, M. (2016). Higher body mass index is associated with plantar fasciopathy/‘plantar fasciitis’: systematic review and meta-analysis of various clinical and imaging risk factors. British journal of sports medicine, 50(16), 972-981.
- Luffy, L., Grosel, J., Thomas, R. & So, E. (2018). Plantar fasciitis: a review of treatments. Journal of the American Academy of PAs, 31(1), 20-24.
- Schneider, H.P., Baca, J.M., Carpenter, B.B., Dayton, P.D., Fleischer, A.E. & Sachs, B.D. (2018). American college of foot and ankle surgeons clinical consensus statement: diagnosis and treatment of adult acquired infracalcaneal heel pain. The Journal of Foot and Ankle Surgery, 57(2), 370-381.
- Rathleff, M.S., Mølgaard, C.M., Fredberg, U., Kaalund, S., Andersen, K.B., Jensen, T.T., Aaskov, S.& Olesen, J.L. (2015). High‐load strength training improves outcome in patients with plantar fasciitis: A randomized controlled trial with 12‐month follow‐up. Scandinavian journal of medicine & science in sports, 25(3), 292-300.
- Becker, B.A. & Childress, M.A. (2018). Common Foot Problems: Over-the-Counter Treatments and Home Care. American Family Physician 98(5), 298-303.
- Wearing, S.C., Smeathers, J.E., Urry, S.R., Hennig, E.M. & Hills, A.P. (2006). The pathomechanics of plantar fasciitis. Sports Medicine, 36(7), 585-611.
Other Conditions in
Feet
Complex Regional Pain Syndrome
A rare condition where a person experiences persistent, severe and debilitating pain, often with a complex cause.
Adult Acquired Flatfoot
The main arch of the foot loses its height giving the appearance that the foot sits flat on the floor.
Achilles Tendinopathy
Pain, swelling and stiffness of the achilles tendon that joins the heel bone to the calf muscles.