Plantar Fa… whatever it’s called. My Heel is Sore!!

The Plantar Fascia

The Plantar Fascia is a thick, fibrous band of connective tissue which acts to attenuate and reduce shock, and disperse force during weight-bearing (stance) and movement (walking and running gait). The fascia also provides support to maintain integrity of the medial longitudinal arch of the foot. Unlike other soft-tissue structures, the Plantar Fascia is not very elastic. It has only a limited capacity to stretch and elongate, so is prone to injury.


Plantar Fasciitis (or Fasciopathy) is one of the most common foot complaints seen by podiatrists and physiotherapists. ‘Fasciopathy’ is a generalised term describing injury to the fascia, including both acute and chronic pain. The term ‘Fasciitis’ specifically refers to acute injury, whilst ‘Fasciosis’ describes chronic injury.


Symptoms

These injuries are characterised by inflammation and pain, most commonly surrounding the fascia’s insertion point at the medial heel, but sometimes also through the arch of the foot. Fascial rupture can also occur, but is uncommon due to the strength and integrity of the Plantar Fascia.


Sufferers will usually complain of sharp, stabbing pain that is worst in the mornings and after rest or inactivity. Return to movement causes pain because the fascia cools down and tightens with rest, and then is over-stretched. Exercise and extended periods of weight-bearing or walking can also aggravate symptoms due to increased load and strain through the fascia. Pain may be tolerable during activity, but worse afterwards or with fatigue.


Why?

Plantar Fasciopathy affects both active and less-active individuals and there are many causative factors to consider. Injury develops due to excessive loading and increased traction of the Plantar Fascia at it’s insertion point at the medial plantar heel. Over-use is the most commonly cited reason for injury development. Walking and standing for extended periods of time increases load on the Plantar Fascia, so athletes need to consider both their daily activities and their training load (volume and intensity). Footwear also plays a significant role – both during exercise and day-to-day. Wearing shoes with insufficient support and cushioning will increase strain on the Plantar Fascia. Ground surface can also influence loading, with harder surfaces greatly increasing the likelihood of Injury development due to the increased requirement for shock attenuation. For these reasons, job and daily activity changes are common reasons for injury onset, but they’re often overlooked.


Age (soft tissue becomes less elastic with age and more prone to injury) and being overweight (more weight will increase strain and shock attenuation requirements), also increase injury risk. The influence of biomechanical factors should be considered in all cases, but most particularly for athletes. Excessive pronation (rolling in) is a common contributor towards injury as it increases stretch and load through the Plantar Fascia. Amongst others, tight calves and reduced 1st MPJ (big toe) range of movement increase risk. Clinical history and symptoms are usually sufficient to accurately differentiate between Plantar Fasciopathy and similar injuries. However, in some cases diagnostic imaging is necessary to determine injury severity and rule out more serious injuries such as calcaneal stress fracture.


Treatment

A simple, multi-faceted treatment approach will provide significant improvement, and resolve a majority of cases. Successful resolution requires symptomatic treatment to relieve pain and inflammation, but also should address causative factors to reduce the risk of repeat injury.


During the acute phase of injury, relative rest and offloading are essential to reduce load and strain through the Plantar Fascia. Running and other high impact exercises such as skipping and body attack/pump classes should be avoided or at least limited. Non weight-bearing and low impact activities such as swimming, water running, cycling and upper-body strength activities are great for maintaining fitness whilst moderating load. Avoiding barefoot at all times and wearing supportive, cushioned footwear (running shoes are ideal) as much as possible is highly recommended to further assist with offloading. Cryotherapy (icing) should be done religiously during the acute phase to provide pain relief and reduce inflammation, and immersion icing is most beneficial if tolerable.


Foot strapping can provide temporary pain relief and assist in load moderation, but should only be used short-term. Good strapping should provide immediate relief and can indicate the potential success of implementing more permanent in-shoe modifications or orthotics to address overloading issues for long-term benefit. Low Dye, Copelands or modified Copelands are the most commonly used strapping techniques.


Wearing a Plantar Fascia compression sleeve will provide similar benefit and can be used long-term without causing skin irritation. The compression promotes blood flow and thus promotes reduced pain and inflammation whilst also offloading the Plantar Fascia and providing support. Gentle stretching and range of movement exercises will assist in maintaining or increasing elasticity through the Plantar Fascia and should therefore reduce severity of pain symptoms. In most cases releasing muscle tension through the calves and plantar foot is also beneficial.

Stretching and soft-tissue release methods including massage, dry needling and acupuncture can also be used to provide symptomatic relief and help promote recovery. Reducing tension and tightness through the fascia is ideal, but it shouldn’t be over-stretched as strength and integrity need to be maintained.


With chronic injury there is typically less inflammation, and pain can be much more inconsistent. Chronic pain without appropriate treatment and resolution will not only prolong recovery time, but can also increase the risk of developing other injuries due to compensation during stance and gait.


Ongoing Long-term treatments should address contributing biomechanical factors and other risk factors to reduce injury risk. There is considerable research available in support of orthotics to treat Plantar Fasciopathy, however their implementation should always be part of a multi-faceted treatment approach that also includes symptomatic relief and strengthening. When properly implemented, these treatment strategies should provide considerable relief of acute symptoms within a relatively short time-frame (1-2 weeks). Unresolved pain can be debilitating and is both mentally and physically damaging because it can affect both training and quality of life.


What to Do

If you’re struggling with Plantar Fasciopathy, or foot pain that mimics these symptoms, then you should seek advice from a Podiatrist. Runners and active individuals should seek out a Podiatrist experienced in dealing with sports and running injuries, as their treatment approach will generally be much more focussed on long-term recovery and managing your injury whilst training.

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