Plantar Fasciitis - Revisited

Figure 1 - Plantar Fasciitis - Injury / pain site

We published a very brief article on plantar fasciitis (PF) in 2011. We felt it was time to revisit this problem with a much more comprehensive article, aiming to give more detail on how to manage this injury.

The following journal article - Diagnosis and Treatment of Plantar Fascitiis - is a great resource to refer to if you are suffering from PF. This blog post will use our own experience in treating PF and information from journal articles such as the one above.

The basics

PF typically causes heel pain in the sufferer (see figure 1) around the inside and underside aspect of the foot. This pain is most often worst in the morning, especially the first few steps of the day. Walking around will generally improve this morning discomfort after a short period.

PF can be very tricky to clear up and no single treatment method seems to be highly effective in isolation. Often a number of interventions will be needed in combination to resolve the issue. Having said that, PF is a self-limiting condition and the report above does indicate that 90% of PF injuries will resolve with 'conservative', i.e. non-surgical, treatment. This statistic is backed up by our own experiences in the clinic, with the high majority of PF cases we see clearing up without surgical intervention being required.

Risk factor and causes 

1) Low arches (or over pronation) and high arches. It does appear that anything that bio-mechanically challenges the arch and, in turn, the plantar fascia will increase the risk of injury.

2) High volume of weight bearing activity, whether this is walking, running or standing. The statistics show that, if you are on your feet a lot, you will be more likely to suffer with PF.

3) Being overweight or being obese. High body weight will increase the load on the foot and plantar fascia.

4) Tightness and/or weakness of the calf, Achilles or intrinsic muscles of the foot.

5) Poor bio-mechanics; in particular adduction and internal rotation of the knee (see this post) leading to increased pronation at the foot and off axis forces on the plantar fascia.

6) Other factors such as a sedentary life style, a sudden increase in training volume, a leg length discrepancy or landing heavily on the foot are all additional reported risk factors.

Other problems that can appear to be PF (Differential Diagnosis).

Sometimes injuries will appear to be PF but are actually something different. This often can occur with a 'self diagnosis'. For example, there may be a nerve impingement issue, such as tarsal tunnel syndrome. Below is a list of injuries that may at first appear to be PF but are actually a different injury altogether:

Click to see a larger version

Treatment options for PF

As I said before there are many treatments available for PF and in most cases it is necessary to combine more than one approach. The treatments required will differ from person to person depending on the individual's circumstances.

1) Rest (or relative rest)

The simple aim is to perform less of the activity (or activities) that are causing you pain. If walking for more than 45 minutes is causing increased pain then, do your best reduce the time that you are on your feet. Every time you irritate the injury, you are perpetuating the issue.

2) Massage, ice and stretching the plantar fascia (see picture below)

Top left: Massage the foot with a tennis ball or an even harder (and smaller) bouncy ball. This should not be painful to do, and if it is painful, reduce the pressure. Try this once a day for 5-10 minutes per application.

Top right: You can also try ice massage with a bottle that has been frozen. Again try this several time a day for 5-10 minutes per application. Beware, there is a risk of ice burn with this treatment so make sure your tissue is back to normal temperature before re-applying.

Bottom left: Ice massage is most useful in the early stages of the injury when inflammation is likely to be present. In more chronic injuries ice is still useful but only as a pain reliever.

Bottom right: Stretch the plantar fascia by pulling your toes upwards with your hand. This stretch is easier to do by crossing your ankle over the opposite knee.

1) Using a ball for self massage 2) Ice / massage with frozen bottle
3) Ice cube massage when acute 4) Stretching of the plantar fascia

3) Calf stretching

This is often the first treatment that will be given for PF. Evidence shows that PF suffers are often have very tight calves. With these stretches you should aim for 30 second holds (minimum) around 20x per day. This will give you, cumulatively, 10 minutes stretching on the problem side per day. Time the 30 seconds as it will be a lot longer then you think!

4) Taping the foot for support and proprioceptive feedback

Taping, as shown below and in the image at the top of the blog can help to 'off load' the arch of the foot and support the plantar fascia. The tape can also give additional proprioceptive feedback to the brain helping with improved positioning of the foot.

5) Non steroidal anti inflammatory drugs (NSAIDs)

NSAIDs such as Ibuprofen should always be taken under the supervision of your GP. However, topical 'gel' based applications will be most helpful in the early stages of PF. The gel based applications in this instance are arguably more effective and safer than the tablet form.

6) Night splints and orthotics

The use of night splints is the only treatment that has been shown to work effectively in isolation without the use of other treatments. The splints work by holding the calf and plantar fascia in a stretched position overnight. However, they can be uncomfortable and disturb sleep.

Orthotic devices are designed to 'off load' the plantar fascia and support the inside arch of the foot much like the taping is designed to do. For this intervention it is advisable to see a podiatrist who specialises is orthotic prescription as off the shelf orthotics can be hit and miss.

7) Corticosteroid injections

Your GP may consider this option after all other conservative treatment options have been undertaken unsuccessfully. This will often prove to be successful if there is inflammation still present at the injury site as these injections are a powerful anti-inflammatory. There are, however, risks associated with this treatment option such as rupture to the plantar fascia.

8) Plantar fasciotomy

Only a very small number of cases will require surgical intervention, this is very much a last resort.

The round up

PF can be extremely tricky to treat; it really can be a stubborn issue to resolve. With that in mind, make sure you seek advice and treatment as early as you can. This injury will often change from an inflammatory based issue to a degenerative tissue problem if left untreated. It is much easier to treat while it is still in the early inflammatory stage. 

Rotator Cuff Muscles: The basics

Rotator cuff exercises

If you have injured your shoulder in the past it is likely you will have heard of the rotator cuff muscles. You may also have been given specific exercises to strengthen them. Many people, however, have very little idea what these muscles are and what they are primarily designed to do.

The rotator cuff muscles are a group of 4 muscles with the main role of stabilising the shoulder joint. The shoulder joint (known as the glenohumeral joint) is inherently unstable. This is largely because the joint capsule is very shallow. The benefit of this shallow joint capsule is that it allows a large range of motion at the joint. This does mean that the stability at the joint is compromised. This is where the rotator cuff muscles come in. They are very small muscles that attach over the joint coming from the front, back and top of the joint. When the muscles are functioning correctly they will co-contact (firing together) to stabilise the joint through it's large range of motion.

If these muscles contact in isolation rather than co-contracting as a group they perform very specific movements. Below are the names of each individual muscle and the specific action it creates:

Supraspinatus: Abducts, or elevates, the shoulder joint.
Infraspinatus: Externally rotates the shoulder joint - or turns it outwards.
Teres Minor: Externally rotates the shoulder joint - or turns it outwards.
Subscapularis: Internally rotates the shoulder joint - or turns it inwards. The subscapularis muscle also works to depress the head of the humerus. This prevents the joint getting compressed during overhead movements.

Due to the specific actions each muscle creates, exercises to isolate and strengthen the rotator cuff muscles are often broken down into their separate actions:

Abduction (Lifting the arm away from the body) - Click here to see a series of exercises to strengthen the Supraspinatus => 5 Exercises

External Rotation (Turns the arm outwards) - Click here to see a series of exercises to strengthen the Infraspinatus and Teres Minor => 7 Exercises

Internal Rotation (Turns the arm inwards) Click here to see a series of exercises to strengthen the Subscapularis => 5 Exercises

As always with this type of blog post, it is for information only, please consult a musculoskeletal therapist before starting any of the above exercises. Rehabilitation exercises always need to be specific.