PLANTAR FASCIITIS & RUNNERS PLANTAR FASCIITIS
Plantar fasciitis (or a ‘heel spur’ or ‘heel spur syndrome’) is the most common injury that we see in our podiatry clinics. Although this doesn’t make it easy to treat!
The plantar fascia is a big strong ligament that runs from the tips of your toes under your foot and joins into the bottom of the heel bone. Injury to this ligament can be acute from a one-off strain that causes the ligament to tear under the arch or where it joins into the heel bone. More commonly the injury is cumulative with regular strain through the ligament gradually becoming greater than what the ligament can handle.
The excessive strain through the ligament happens when you are weight bearing with training, exercise, work or normal walking and sometimes there is little pain while the ligament is warm. When weight is taken off your feet (such as sleeping) there is no strain through the ligament and it contracts and tightens. When you stand up again, the strain through the tightened ligament produces the first step after rest pain.
Patients will report:
- 'Stone bruise' type pain that can become sharp and stabbing
- First step pain getting out of bed after rest that warms up
- Pain under heel or arch
Initial soft tissue injury treatments such as rest, ice, compression and elevation should always be carried out initially, however more medium to long-term treatments are normally required. Ligaments take about 8 weeks for your body to repair and it usually takes longer for this big strong ligament that you are walking on daily. This doesn’t mean that you should put up with the pain for months in the hope that it will suddenly resolve after a few months!
Treatments such as calf stretching, physiotherapy, massaging and dry needling will help promote healing and improve your recovery time. However reducing the strain through the injured ligament is critical to allow repair.
Athletes don’t like to rest and with big events looming we have to implement fast solutions.
Which treatments in which order?
This is our Clinical Treatment Pathway for active people with plantar fasciitis:
Correct footwear -> strapping tape -> specific orthotic design -> training modifications -> neuro-muscular releases -> specific strength programs -> ultrasound guided cortisone -> intermittent use of an air cast -> other low evidence treatments -> surgical release
It is very rare that we require the use of cortisone, air casts or surgical release, especially if treated early.
Stiffness of the shank, drop of the heel and the type of support all play a role in reducing strain through the plantar fascia of each individual. Matching the specific shoe design features for your foot type and current symptoms is critical and onsite running shoe store ensures the best possible outcomes. Our range of shoes that we stock in store can be found by clicking here.
Specialised strapping techniques are extremely helpful in reducing strain through the plantar fascia for short periods. Strapping your foot for more than a few weeks becomes expensive, tiresome and usually leads to skin sensitivities. This isn’t a long-term solution but here is a video link to a particularly effective technique:
Specific Orthotic Design:
Prescription orthotic design is critical to this condition and commonly missed prescription variables are listed below.
Three angles will increase the orthotic effectiveness and include tilting the heel outwards, heightening the arch and tilting the foot inwards. These orthotic angles shorten the distance the plantar fascia is stretched.
Pushing on the arch can be a problem and a groove should normally be cut into the orthotic so that the plantar fascia isn’t stretched over the arch of the orthotic causing excessive arch pressure.
Soft orthotic materials are usually more comfortable, especially with very painful cases. Find out more about Shoes Feet Gear's orthotic inserts here.
Working to release the small structures of the foot and lower leg helps to reduce the load through the fascia as well as physically releasing tension. Particular attention to the calf, soleus (lower calf), the flexors that control the toes as well as the small intrinsic muscles under the foot is beneficial. The physiotherapists and clinicians we work with can help with massage, trigger points, foam rolling, dry needling and other techniques.
Isometric exercises are excellent for providing immediate pain relief and to begin the healing and strengthening process. The plantar fascia joins into the bottom of the heel bone and wraps up the back of the heel bone to become continuous with the Achilles tendon and calf complex. This specific exercise targets the fascia and it's integration with the Achilles tendon to promote healing:
Long Term Strengthening:
Chronic cases of plantar fasciitis that last months or even years can be very difficult to treat and often recur easily. It is very important for these cases to turn on and strengthen the small muscles of the foot an ankle. Chronic pain and limping will turn off the neural signals from the brain to these muscles resulting in weakness and a loss of protection of the structures of the foot.
Reducing long runs, avoiding hills and stairs and sprint work can be helpful. Shorter recovery style runs normally minimise strain. Cycle and swim are always a great alternative for severe cases.
Ultrasound Guided Cortisone:
Cortisone weakens bone, ligament and damages the fat pads and is always avoided where possible. If the above treatments are implemented properly and the pain isn’t reducing then cortisone is normally indicated. Ultrasound confirms the injury and can be used to guide the injection to increase the accuracy of delivery. The local anaesthetic that is normally mixed with the cortisone will often give immediate relief and the above treatments still need to be followed for a minimum of 4 weeks. The cortisone will hopefully kick start the healing process and once it has worn off in 3 weeks time the pain hopefully keeps improving with the above treatments. Cortisone is rarely used more than two or three times due to the risk of damage to the soft tissue.
Intermittent Use of an Air Cast:
Soft tissue injuries do not normally do well with immobolisation. If the above treatments have failed then an air cast can be used for active periods of the day and then taken off for lighter duties. This can reduce strain further and try to promote healing. A minimum of 3 months of intermittent air cast use is normally required.
Other low evidence treatments:
Night splints – such as the Strassburg Sock hold the plantar fascia in a stretched position overnight. A huge number of studies have been carried out world wide on night splints and there is no evidence to suggest that these night splint patients heal any faster than others. Evidence does show a reduction in first step after rest pain as the plantar fascia is held in a lengthened position and doesn’t require warming up after rest.
Lithotripsy or Extracorporeal Shockwave Therapy – Shock waves of either low or high energy are delivered to the area over a series of sessions. It is thought that the micro trauma to the area stimulates a healing response. This is for patients where conservative treatments have failed for at least three months.
If non-surgical treatments have been exhausted for over 12 months then a surgical specialist may consider releasing the plantar fascia. This normally involves cutting a third of the width of the ligament away from each side of where the ligament joins into the heel. It is hoped that the ligament heals in a stronger and more lengthened position. The success rate is relatively low as far as surgical procedures go.
Plantar Fasciitis or Heel Spur Syndrome can appear mildly for a short period and resolve with relative rest. However, it usually re-appears with a vengeance if nothing is done to change the injury process. There is also a 30 percent chance of plantar fasciitis or heel spurs developing on the other foot as well.
Early treatment is the key as this heel pain can commonly become so painful that no weight is able to be put on the heel at all and it can take up to 12 months to recover. Some cases of plantar fasciitis never recover despite all treatments being utilised.
Make an appointment to see our Shoes Feet Gear podiatrists for treatment of your plantar fasciitis today.