The suffix “-itis” means inflammation. Thus, plantar fasciitis involves the inflammation of the plantar fascia, a ligament located in the arch of the foot between the heel and the toes. Plantar fasciitis is one of the most common injuries experienced by athletes, and particularly affects runners.
- Pain in the heel and/or plantar arch (under the foot), often in the beginning of a workout or training.
- Warming up can make the pain tolerable, but it often reemerges after training.
- Pain and stiffness often occur when taking the first steps in the morning or after a long period of rest.
- The pain can eventually linger and persist throughout the day.
- A lengthening, stretching or tearing sensation under the arch of the foot or on the heel during movement.
- Some patients complain of a pin-like sensation under the heel.
The plantar fascia is a strong, fibrous tissue that absorbs physical impact, supports the arch of the foot and plays a vital role in propulsion. Conditions that cause excessive stress on the plantar fascia can result in microscopic tears, and the resulting swelling (inflammation) can cause pain. The condition occurs most frequently at the insertion site of the ligament to the heel bone, but can also arise along the entire arch of the foot. The microtears in the fascia can appear after a sudden movement or most commonly, from repeated stress over a long period of time.
Plantar fasciitis often starts as a mild condition, with the pain limited to your first steps after a night’s sleep or following a long period of rest. That’s because while you’re resting, the body attempts to repair the microtears. But when renewed pressure is placed on the ligament after a long rest, this repair work is interrupted and pain results. Many people make the mistake of ignoring the initial signs of pain and stiffness in the morning.
Poor foot mechanics are the primary cause of plantar fasciitis. Such conditions include:
- Flat feet and hyperpronation
- High arches
- Bunions (HAV) and dysfunction of the big toe
- Lack of flexibility in the calf muscles
- Joint hypermobility (excess of flexibility in the foot)
- Leg-length discrepancy
- Poor running technique
- and others
Overstretching of the plantar fascia can also be a culprit:
- improper exercise techniques
There are a number of aggravating factors:
- sports involving repeated movement or sudden changes in direction
- running on uneven or sloping terrain
- inadequate warm-up prior to physical activity
- poor flexibility (in the calves, hamstrings and lower back)
- unsuitable footwear
- being overweight
The plantar fascia is the most important ligament for supporting the plantar arch and is involved in all movements of the foot. For this reason, once the condition sets in, it tends to worsen. Pain may initially be felt only after a period of rest but may eventually persist during exercise and impact your everyday activities. The condition forces many athletes to slow down or even stop their training.
Left untreated, the problem can become chronic as the ligament thickens with fibres that are weaker and less organized, making you prone to re-injury. If the stress continues without treatment, a partial or complete tear of the plantar fascia may occur.
Over time, the excess pressure at the insertion site of the plantar fascia to the heel bone (calcaneus) can result in a bony outgrowth called a calcaneal spur (or heel spur).
Pain under the foot can also lead to unconscious changes in posture and affect athletic technique, generating referred pain in other parts of the body, like the outer heel, leg, knee, hips or back. This increases the risk of additional injuries like sprains, strains, tendinitis, etc.
There are three aspects to treating plantar fasciitis:
- Improving foot mechanics:
- Wear laced shoes with a low heel like running shoes as often as possible, even at home.
- Fit your shoes with insoles with arch support.
- Adapt the intensity of sports activities (reduce the amount, frequency and/or intensity of training)
2. Treating inflammation:
- Apply ice to the painful area 10-15 minutes every evening and throughout the day as needed. Tip: Freeze a bottle of water, then place it on the floor and massage the painful area by rolling under the foot.
3. Stretching exercises:
- Warm up your feet when you step out of bed in the morning and before physical activity. Stand firmly on your tiptoes, make circular movements, lift your foot with the toes up to stretch the calf muscle.
- Loosen up your plantar fascia by rolling a tennis ball or lacrosse ball under your foot for 5-10 minutes.
- Stretch your calves every morning and every evening. You can use a wall, step or folded towel as a prop.
View exercises: stretches for plantar fasciitis
- To identify whether poor foot alignment or posture may be at fault, a thorough biomechanical exam is essential. The exam involves a full assessment of the foot’s mechanics, including movement, posture and gait. Afterwards, a comprehensive gait analysis is conducted using pressure sensors connected to cameras.
- X-rays must be conducted to eliminate other causes of heel pain and identify the presence of a calcaneal (heel) spur or stress fracture. X-rays also make it possible to assess the alignment of the bones in the foot.
- Ultrasound is an excellent imaging technique that can be used to diagnose plantar fasciitis, establish its severity and help design a treatment plan. This radiation-free technique allows us to observe the inflamed area, measure the thickening of the fascia, assess its fibre structure and determine whether tears are present. It also allows us to rule out other conditions affecting the surrounding structures.
After making a diagnosis and identifying the specific causes of the problem, your podiatrist can help you set up an action plan, offer you a range of tools and follow up on your condition.
The most common solutions used by podiatrists include:
- Plantar orthotics
Used to treat and prevent plantar fasciitis caused by biomechanical factors, they optimize foot mechanics, prevent overstretching of the plantar fascia and much more. Find out more about general orthotics.
2. Radial shockwave therapy
This therapy uses the body’s natural capacities to restart the healing cycle. It works like a time machine when the condition becomes too chronic. The radial shockwave therapy is successful in 80-90% of chronic cases.
3. Prescription medication:
Painkillers, muscle relaxants and/or anti-inflammatory drugs are sometimes prescribed.
4. Physical therapy
- Manipulative therapy
- Neurocryotherapy and ultrasound
- Night socks, splints and walking shoes
5. Ultrasound-guided cortisone injections
When the inflammation is severe or fails to clear up, cortisone may be used to quickly “put out the fire”. Instead of administering an anti-inflammatory drug in pill form, cortisone is placed in the exact trouble spot with the guidance of ultrasound technology.
- Wear appropriate footwear.
- Wear prescribed orthotics daily to help prevent recurrence of the condition.
- Replace running shoes if they wear down or after each 800-1,000 km of use. If your shoes are more lightweight or if you have a larger body mass, you may need to replace your shoes after 500-700 km.
- Take action at the first sign of pain to prevent long-term problems (See “Treating the condition at home”).
- If overweight, consider losing weight.
- Warm up well before doing sports or other physical activities.
- After exercising, stretch your calves and the backs of your legs.
- Follow a progressive workout plan, particularly if you run.
- Do a variety of exercise types. If running, run on a variety of surfaces (grass, dirt track, etc.).
“If I feel piercing pain under the heel, it must be a calcaneal (heel) spur.”
Many people who suffer from plantar fasciitis say they feel pain directly at the heel bone, as if they were walking on a sharp point. However, the true cause of pain is the attachment of the ligament to the heel bone. Even in cases where a calcaneal (heel) spur is actually present, the ligament is the cause of pain. Therefore, there's no point in wearing a foot pad with a hole under the heel to "protect the spur”!
There are a number of other conditions that can cause symptoms similar to those of plantar fasciitis:
- Torn plantar fascia
- Infracalcaneal bursitis
- Abductor hallucis myositis
- Calcaneus stress fracture
- Plantar fascia calcification
- Plantar fibroma
- Baxter’s neuritis (irritation of a nerve under the foot)
- Radiculopathy (inflammation of the sciatic nerve or lumbar compression)
- Panniculitis (inflammation of the fatty layer under the heel)
- Tumour mass of the heel bone
- Systemic disease (rheumatoid arthritis, fibromyalgia, psoriatic arthritis, ankylosing spondylitis, etc.)