Plantar fasciitis is a common cause of heel pain in adults. It can cause excruciating pain that can last from a few weeks to several months. This condition is characterized by pain in the heel that is worse with the first few steps in the morning. Plantar fasciitis can occur in anyone, but it is especially common in runners and those that stand for long periods of time (ie. servers or cashiers).
The plantar fascia is a thick fibrous sheet of collagen that begins at the base of your calcaneus (heel bone) and ends at the metatarsals (toes). The plantar fascia supports the longitudinal arch (inside arch) of the foot and also acts as a shock absorber while walking and running.
The term fasciitis is misleading in this condition. The ending -itis refers to an inflammatory reaction of the fascia. However, inflammation typically only occurs for the first few days into the condition. If the pain has been going on for longer than a few days, most likely it is not an inflammatory issue anymore. Most cases of plantar fasciitis are actually a degenerative disorder, which means that the collagen in the fascia fails to repair itself. The new term for plantar fascia pain is plantar fasciopathy, which includes the whole clinical spectrum of the disorder from inflammatory to degenerative.
Although the exact mechanism behind plantar fasciitis is unknown, there are a few things we do know about this condition. The risk factors for plantar fasciitis include: obesity, reduced ankle dorsiflexion (pointing your foot up), pes planus (flat feet), and prolonged weight bearing. These risk factors suggest that repetitive overloading of the plantar fascia leads to degenerative changes and pain. The good news about these risk factors is that you can modify them. By improving any or all of these risk factors can have profound effects on the condition.
The plantar fascia does not work in isolation in the foot. There are small muscles in the foot that help disburse some of the forces in the foot away from the plantar fascia. Think of these small muscles as reinforcement for the plantar fascia. Weakness of these small muscles of the foot will shift some of the force to the plantar fascia. Not only is strength important in these small muscles, but endurance of these muscles is crucial. If these muscles fatigue 10 minutes into standing or a run, then the forces on the plantar fascia will increase for the remainder of the activity. The plantar fascia also connects to the calf muscles through the Achilles tendon.. Therefore, tightness in the calves can lead to increased tightness in the plantar fascia as well.
Pronation is also commonly associated with plantar fasciopathy. Pronation is actually a normal movement of the foot, but prolonged or uncontrolled pronation is problematic. With increased pronation, there is increased stretching of the plantar fascia. Think of a rubber band anchored on the heel and the big toe. Normally there is an arch that the rubber band follows. When the foot goes into pronation, the distance between the big toe and heel increases, stretching the rubber band. Prolonged stretching or rapid stretching of the rubber band will cause the rubber band to lose its elastic properties and eventually break down.
Sometimes a heel spur is seen in this condition, which is often attributed to pain with plantar fasciitis. Before you leap to the conclusion that the heel spur is the cause of your pain, there is something you should know first. Heel spurs are present in about 15-20 percent of the asymptomatic population. Can a heel spur cause your pain? Yes it can. However, heel spurs are often a coincidental finding and usually demonstrate that there is a high amount of force going through the plantar fascia.
There are several things that you can do at home to help with plantar fasciopathy.
- The first option is to change your shoes. A shoe with a stiff midsole and a heel lift may help reduce the forces placed on the plantar fascia. The heel lift will help with restricted dorsiflexion, although you should still work on your mobility. Orthotics may also be an option to aid in controlling pronation.
- Self myofascial techniques with a lacrosse ball may also help. Create a triangle between the base of your 1st toe, 5th toe, and the calcaneus. Place the lacrosse ball on the ground and roll between those three points for 15-30 seconds a few times per day. Rolling your calves on a foam roller or a lacrosse ball will also help decrease the tightness and improve your range of motion.
- Strengthening the small muscles of the foot will also decrease the forces on the plantar fascia. Exercises such as towel crunches and picking up marbles off the ground can help strengthen these muscles.
Some cases will fail to resolve with the strategies above and will require more aggressive treatment. Soft tissue therapies such as Graston and cross friction therapy can help heal degenerated tissue by increasing blood flow into the area as well as strengthen the fascia by reorganizing the collagen. Joint mobilization can also restore the proper biomechanics in the foot and ankle joints. Surgery is rarely a consideration for plantar fasciopathy.