Do you dread that initial step out of bed? Is your heel pain so intense as to make you reach for the furniture and the walls on your way to the washroom?
Heel pain can occur from a variety of causes but the most common by far is Plantar Fasciitis. Fascia is connective tissue that is found throughout the body. It literally means ‘band’ in Latin. The plantar aspect of the foot is the bottom of the foot, hence plantar wart or in this case, Plantar Fascia. When you add “itis” to the end of an anatomical term you are implying disease or inflammation.
The Plantar Fascia is a band of connective tissue originating from the calcaneus (heel bone) and inserting into the tendons and the phalanges (small bones) of the toes. Its purpose is to support the long arch of the foot, and to store energy for the propulsive phase of gait.
So, the term Plantar Fasciitis implies inflammation from an injury to the fascia, at its origin (where it attaches to the calcaneus). But new evidence suggests that it is not inflammation but a degenerative change that occurs with or without inflammation. The term fasciosis is likely more accurate. Fasciosis is a chronic degenerative condition that is absent of inflammatory cells and exhibits structural changes like thickening (fibroblastic hypertrophy) and loss of blood supply (avascularity). With the loss of blood supply and reduced nutrition, it becomes difficult to heal.
Let’s stick with the term we are familiar with, for now.
Symptoms include complaints of exquisite tenderness most commonly seen on the inner aspect of your heel, just at the beginning of your arch. Typically, most patients experience debilitating pain in the morning (static dyskinesia) with the first few steps out of bed, or after prolonged sitting. Once up and moving around, the pain subsides to a tolerable level, or to none at all. The pattern repeats itself the next morning, and counter to what you might believe, it does not get better with a night’s rest
Plantar Fasciitis is usually a clinical diagnosis, with patient history, description of symptoms and physical examination being sufficient. X-ray will rule out stress fractures and may establish a calcaneal spur around its attachment to the calcaneus. Ultrasound may also be used to establish plantar fascial thickness at the injury site and the presence of tears.
How it comes about is often a mystery but paying close attention to your history and performing a thorough physical exam will help me understand the potential cause and design a proper treatment.
Our feet often withstand up to 3 times our body weight (with every step) during physical activities like running. The plantar fascia is part of the shock absorption mechanism of our arch. The Windlass mechanism (rolling up on your toes shortens the arch by tightening the plantar fascia) helps the plantar fascia store potential energy into kinetic energy for acceleration during push off.
Training errors, including overtraining (too much too soon) are among the major causes of plantar fasciitis.
Mechanical issues like tight hamstrings, calf muscles and the Achilles tendon are risk factors. Weak calf muscles and toe flexor muscles are major contributors. And while pronation is a normal motion that allows for converting contact into forward motion and impact absorption, too much pronation (overpronation) is also a major cause of strain to the tissue. So too are structural factors like pes planus (flat feet), pes cavus (high arches), leg length differences and rotational issues below the hip can lead to injury.
Aging and a thinning fat pad (atrophy) are degenerative risk factors for plantar fasciitis.
Localized sharp pain is the typical symptom. But a heel spur has also become associated with the problem, even becoming part of the label in the diagnosis. “I think you have a heel spur”. Many people with no symptoms may have heel spurs, while many patients with exquisite tenderness do not have a spur. A side view x-ray is really the best way to determine the existence of a spur. And while the spur is not the cause of the symptoms, it suggests at least 6 months of excessive stress has occurred across the plantar fascia.
Conservative treatment is usually most successful. Initially, ice should be the first line anti-inflammatory treatment. Apply the ice pack or ice massage after work, after exercise, after stretching or strengthening. Apply the ice pack, wrapped in a towel for 15-20 minutes. Ice massage by rolling the foot over a frozen water bottle or massaging the exposed ice of water frozen in a paper cup.
Rest is critical. Modify your daily activities by limiting the time on your feet, including mowing the lawn. Many of us can’t just sit down on the job, but we can alter the time we spend on our feet at home, by sitting more, walking the dog on shorter walks, and so on.
The importance of stretching before getting out of bed or up from an extended sitting period can’t be over emphasized. While we sleep our foot naturally shortens and tightens up, so that initial foot contact on the floor can potentially reinjure the fascia. Pulling your toes back to stretch the fascia before you weight bear is extremely effective at mitigating that painful first step. And using a towel as a stirrup around your foot to stretch your calf and Achilles by pulling the towel is remarkably effective.
Strengthening the smaller muscles within the foot is paramount. The intrinsic muscles that flex(claw) your toes are integral to supporting and assisting the plantar fascia. Perform the exercise pictured below every day. And an item we sell at the clinic, The Toe Pro, is a phenomenal tool for achieving great foot strength, which helps prevent metatarsal stress fractures, neuromas as well as help heal plantar fasciitis.
Physiotherapy is a complementary treatment that can help chronic, long term patients. In addition to stretching and strengthening, modalities like ultrasound and laser may be utilized.
Compression sleeves are socks that work like an athletic tape in your arch. We sell a variety of them (OS1st), including a no show version and ones containing merino wool. The Strassburg sock is also available at the clinic and helps keep the foot stretched while sleeping. Avoiding being barefoot at home is hard to do, so we sell some variations of supportive sandals, including Sole Flips, New Balance and OOFOS and slim non custom insoles from Knead for your slippers.
Foot orthotics are the gold standard when your symptoms progress beyond 6 weeks or so. Made from a plaster cast of your foot, our custom orthotics are handcrafted to fit your shoes and help you heal.
Plantar fasciitis is a self-limited injury and up to 90% of people respond with a combination of the above treatments. But people vary in body type, activity level and lifestyle. Not everything works for all people. Some people respond quickly to the most conservative treatment while others exhaust all conservative measures with limited success. There is no panacea available. But most patients eventually have satisfactory results. Managing your expectations is easier if you get as much information as you can from your footcare professional.