Plantar Fasciitis: Signs, Symptoms, Causes and Treatment
Plantar fasciitis can be infamously stubborn, with some people taking many months, or sometimes years to return to pre-plantar fascia injury acitivities (like running, for instance!).
That doesn’t mean that you have to freak out if you think you might have plantar fasciitis, it simply means you should get onto it quickly.
Signs and Symptoms
The plantar fascia is a thick band of fibres that runs underneath your foot from the base of your heel to the ball of your foot, attaching onto the metatarsal heads. There are several different branches of the plantar fascia. Any part of the plantar fascia can become injured, but the most common point of injury is at the base of the heel.
Most commonly, people with plantar fasciitis will feel a stabbing pain in their heel when they take their first few steps out of bed in the morning, or after they’ve been sitting for a long time.
Pain in the arch or heel can also be felt if you’ve had a long day on your feet, or if you’ve been wearing bare feet or unsupportive shoes, especially if you’ve been standing on bare floorboards or tiles for a while.
As far as running goes, you may find it’s worse at the beginning of a run, and will disappear as you warm up, often returning again at the end of your run.
Fasciitis or Fasciosis?
In recent years, it has become apparent that many cases of plantar pain in the foot and heel have been misdiagnosed as plantar fasciitis, when in fact a more correct diagnosis would be plantar fasciosis.
The suffix “itis” (in medical terms at least) refers to inflammation. There is mounting evidence that plantar “fasciitis” is not in fact, an inflammatory condition, rather it is a degenerative process without inflammation, and should therefore be termed “plantar fasciosis”. (1)
It’s possible that the condition does start out as an inflammatory condition, but by the time treatment is sought, it has progressed to the degenerative condition plantar fasciosis. Ultrasound examination of the plantar fascia shows a thickening of the fascia in patients suffering plantar fascia pain, but it is possible this thickening is temporary, and due to the softening of the plantar fascia from fluid infiltrating the tissue. A true fasciosis, a thickening of the tissue without inflammation as a result of degenerative changes, could possibly be the next stage of the injury if the inflammatory stage is left untreated. (2)
Causes and Risk Factors
- Tight calves. Reduced range of movement in the ankle, particularly in dorsi-flexion (when you bring your toes up towards you shin) is common in patients with plantar fasciosis. (3) Tightness in your calves inhibits dorsi flexion
- Spending a lot of time on your feet, especially with bare feet and/or on hard floors such as bare floorboards and tiles
- Active in sports that place a lot of stress on your heel bone and attached tissue including running, ballet dancing and aerobics.
- Flat-footed or have high arches. Flat feet may cause poor shock absorption, which increases the stretch and strain on the plantar fascia. People with highly arched feet have tighter plantar tissue, which also leads to poor shock absorption.
- Middle-aged or older. Heel pain tends to be more common with ageing as the arch of your foot begins to sag, putting stress on the plantar fascia.
- Gender – unfortunately, women tend to be more prone to plantar injuries than men are
- Overweight. Carrying around extra kilos can break down the fatty tissue under the heel bone and cause heel pain.
- Pregnancy. The weight gain and swelling that accompany pregnancy can cause ligaments in your body – including your feet – to relax. This can lead to mechanical problems.
- On your feet a lot. Occupations that require a lot of walking or standing on hard surfaces can cause damage to the fascia.
- Wearing shoes with poor arch support or stiff soles.
Conservative, Simple and Inexpensive Treament
In 1995, researchers Fabrikant and Ly found that the longer plantar fascia symptoms are left untreated, the less effective conservative treatment is. (4)
If you think you might have plantar fasciosis, getting onto these quick and easy treatments early might save you a whole lot of grief.
In case your problem is an inflammatory condition, RICE is always a good option – Rest, Ice, Compression and Elevation. This is the first step if you’re starting to feel the type of pain described above. It’s possible it will prevent the condition from progressing further, so you may as well give it a crack. It’s simple and inexpensive.
- To ice the area, you can fill a small plastic water bottle and freeze it. Put the bottle on its side, and roll your foot over it.
- Reduce your workload considerably
- Elevate your leg when you can, but don’t leave your foot in plantar flexion (ie your foot dropping down with your toes moving away from your calves), as this can exacerbate the problem
- For compression, you can use Tubigrip a tubular, light compression bandage-available from chemists and some supermarkets. Just slip it over your foot like a sock. It should extend from the ball of your foot to above the ankle/part way up your calf.
Stretching and Massage
Stretch and massage the calves and foot. This will reduce strain and tension on the arch.
Calf stretch: 3 sets of straight leg and 3 sets of bent knee calf stretches, 3 times a day. Hold each stretch for about 30 seconds, with 30-60 seconds rest in between.
Specific plantar fascia stretch –this stretch was shown to be more beneficial than Achilles and calf stretching in a study of 82 subjects. (5)
Cross the leg of your affected foot over onto your other leg, so the foot is resting on your other knee. Pull your toes up towards your shin, until you feel a stretch in the sole of your foot. Massage the under surface of your foot at the same time, wherever you feel tension. Hold the stretch for 10 seconds. Repeat 10 times. These sets should be performed 3 times per day, as well as prior to any weight bearing (so first thing in the morning before you get out of bed would be a really good idea!)
Low-Dye taping (named after the inventor, Ralph Dye).
Taping can be used to take pressure off the arch of your foot. This is a simplified version of the low-Dye taping method. The straps run from the outside of the foot to the inside, and should be pulled fairly firmly, without being too tight. You need to avoid wrinkles in the tape, as your foot is likely to rub and blister. There are more complex taping methods, but for mine, you want something you can do yourself. You can see Sydney podiatrist David Fergusson demonstrating the simple low-Dye taping method in the “further information” section at the end of this article.
More Complex Treatment Options
If you find that none of the treatment options above are helping, you’d do well to see a sports physio right about now. They should be able to offer a definitive diagnosis if they are happy to either use ultrasound themselves, or refer you for scanning. Ultrasound is the most effective way to diagnose plantar fascia problems (even more so than MRI). (6)
It’s always better to know what you are dealing with. Some injuries can hang around for quite a while, and treating for the wrong injury could increase your recovery time considerably!
This sexy little number allows your plantar fascia to be stretched all night long. Because we relax when we sleep, our feet naturally point or drop down, allowing the calf muscles, Achilles tendon and plantar fascia to shorten and tighten. The splint keeps your foot at 90 degrees so you get a gentle stretch in your sleep.
The Strassburg Sock
The Strassburg Sock is another option for keeping your fascia stretched at night. The sock is just like a regular knee high sock, with a strap that runs from the toe to the top of the sock near the knee. The strap is gently tightened, bringing your toes, and your whole foot up towards your shins, stretching calves, Achilles and the plantar fascia.
Unlike a regular, hard night splint, the sock pulls your toes up as well, in a similar fashion to the plantar fascia stretch above. I’ve not looked for evidence supporting this, but it’s possible the sock offers a better outcome than the hard splint, as it gives you a more specific plantar stretch. My husband used one for a while to help in the treatment of Achilles tendonopathy. Don’t know that it helped his Achilles, but it appears to have made his toes longer! (just kidding). He did feel it offered more of a stretch to the fascia and muscles on the under surface of his foot, rather than calf and Achilles.
Orthotics can be used to support the arch whilst the plantar fascia heals, and may in fact be a good long term option.
It’s not entirely clear whether custom orthotics provide better treatment outcomes than over the counter orthotics. (7) The two advantages to the over the counter option are firstly, they are far less expensive, and secondly you can get them quickly. It could take you several weeks to get custom orthotics. If you go for the over the counter option, make sure they actually support your arch. Soft gel arch supports won’t help much. Superfeet green are a good option.
Even just wearing more supportive casual shoes can help.
Other Treatment Options
Although unproven, some runners swear by rolling their foot on a tennis ball or a golf ball – it’s a bit similar to using a foam roller to roll out your calves or ITB. You should probably ice your feet afterwards if you do try rolling out your foot, and take things gently to start.
Corticosteroid injections are fairly commonly used, but I personally wouldn’t have one myself, unless someone could prove to me without a shadow of a doubt that my condition was inflammatory. They hurt initially, but do the provide short term relief from the pain (generally 1-2 months, sometimes 3 if you are lucky). Their long term success rate is fairly low (maybe because the condition they are supposed to be treating is not inflammatory), and there is a risk of complete rupture of the fascia (8), (9)
Extracorporeal Shockwave Therapy and Platelet Rich Plasma Therapy
ESWT and PRP therpay are relatively new, but they are showing promise in treating long standing injuries. It’s a little too early to find definitive research on their effectiveness. (10). My husband tried PRP to try to heal Achilles Tendonosis, with little to no effect, but that is not to say it wouldn’t work for someone else.
Summary of Treatment
Plantar Fascia problems are notoriously difficult to treat. Generally, the longer they are left, the harder they are to treat, so there’s every reason for you to throw everything you can at it, (including the kitchen sink) from early onset.
Protection, icing and stretching are very easy treatment options you should implement quickly. You don’t have to stop all activity, but don’t persist with any activity that seems to aggravate the problem. Likewise, don’t persist with home remedies if they seem to make the problem worse, and if you’re experiencing pain for more than a couple of weeks, do see a sports physio or sports physician to get a definitive diagnosis. And lastly, be prepared to put a lot of effort into this one yourself – it’s unlikely a couple of trips to the physio, with little or no effort on your part, will fix this one!
- Ice your foot
- Wear comfortable, supportive shoes, not bare feet
- Reduce your activity
- Stretch your calves-bent knee and straight knee stretches, 3*30 seconds, 3 times/day
- Plantar fascia stretch and massage- 10*10 seconds, 3 times per day, and prior to activity
- Use low-Dye taping
- Orthotics – over the counter or custom made
- Night splint or Strassburg sock
- Roll out your plantar fascia on a tennis ball or golf ball
- See a physiotherapist or a podiatrist – ask about your condition, and question them if they tell you it’s plantar fasciitis. You’re well within your rights to mention that you’ve heard recent research showing it’s more likely to be a degenerative fasciosis than fasciitis. They may have good reason for suspecting you have an inflammatory condition, but if it was my foot, I’d certainly be asking the question. As long as the practitioner was prepared to entertain the idea it might not be inflammation, I’d most likely be ok to continue treatment with them
- Investiage extracorporeal shockwave therapy and platelet rich plasma injections if you are seeing no improvement
- Surgery is also an option
How long should you continue with conservative treatment?
That’s a question only you and your practitioner can answer. It’s common for people to exhaust all conservative treatment options over a long period of time, before looking at shockwave therapy, plasma injections, or surgery. Given the stubbornness of plantar fascia injuries, there could be a good case made for more aggressive treatment early on, however that is a decision you need to make based on your circumstances.
This video will give you a good rundown on your plantar fascia and other foot structures, and also demonstrates the specific plantar fascia stretching and massage described above. You’ll see why foot pain can be so stubborn, when you see all the layers of intrinsic muscles on the bottom of the foot. -It’s just a model, not a real live foot being cut open! It’s a bit long winded, but worth it if you’re suffering plantar fascia pain.
Note: “Skin lubricant – use any kind of oil -olive oil straight from your pantry is fine.
You can see a demonstration of a simplified version of the low Dye taping technique from Sydney podiatrist David Ferguson in this video.
- Lemont H, Ammirati KM, and Usen N. Plantar fasciitis: a degenerative process (fasciosis) without inflammation. J Am Podiatr Med Assoc, 2003. 93(3):234-7.
- Fabrikant J M, and Tae S P. Plantar Fasciitis Treatment Outcomes Study: Plantar Fascia Thickness Measureed by Ultrasound and Correlated with Patient Self Reported Improvement
- Riddle, D. L.; Pulisic, M.; Pidcoe, P.; Johnson, R. E., Risk factors for plantar fasciits: a matched case-control study. Journal of bone and Joint Surgery 2003, 85 (5), 872-877
- Fabrikant, J, Ly P. Heel pain: a treatment and outcome study. Am J Pain Management 1995;5:48-51.
- Digiovanni BF1, Nawoczenski DA, Malay DP, Graci PA, Williams TT, Wilding GE, Baumhauer JF: Plantar fascia-specific stretching exercise improves outcomes in patients with chronic plantar fasciitis. A prospective clinical trial with two-year follow-up. Bone Joint Surg Am. 2006 Aug;88(8):1775-81.
- Fabrikant and Tae; Op Cit
- Cole, C.; Seto, C.; Gazewood, J., Plantar Fasciitis: Evidence-Based Review of Diagnosis and Therapy. American Family Physician 2005, 72 (11), 2237-2242.
- Lemont, H. et al
- Ziya Tatli, Y.; Kapasi, S., The real risks of steroid injection for plantar fasciitis, with a review of conservative therapies. Current Reviews in Musculoskeletal Medicine 2009, 2 (1), 3-9