A Look at a Common Cause of Foot Pain
The Nature of the Beast
Plantar fasciitis, the most common form of heel pain, is a common pathology involving inflammation of the plantar fascia, the band of tough connective tissue that runs from the medial tubercle of the calcaneus to the ball of the foot, forming the arch (Kisner, 1996, p. 483). See the diagram below for a visual representation of this portion of the foot.
Fig. 1—Location of Plantar Fascia (Roberts, 1996)
Plantar fasciitis usually begins by insidious onset, involving prolonged overuse of the feet. Frequently found in runners, other athletes, and obese patients, plantar fasciitis usually occurs due to repetitive high-impact stressing of the plantar fascia. Such stress can lead to microtraumatic tears in the fascia; when the body’s natural inflammatory process repeatedly attempts to repair these tears, chronic pain results (Boldridge, 1997).
Two physiological characteristics can also predispose a person to plantar fascia, including extreme pes cavus (a high arch) and pronation (flatfoot). In particular, excessive pronation of the subtalar joint increases the likelihood of a tight gastrocnemius muscle, which can place excessive stress on the plantar fascia.
Typical symptoms include varying degrees of dull, sharp, or aching pain. This is usually worse in the morning, due to the feet being slightly plantarflexed during sleep, which allows the plantar fascia to shrink and tighten. The pain will lessen as the person begins to move around, but will worsen again with weight-bearing activities throughout the day (Wheeless, 1997). The area will also be tender to firm palpation and painful when the involved muscles are placed on a stretch (Kisner, 1996, p. 483). Pain may also be constant during ambulation after only a short duration of continued activity.
Several measures can be taken to prevent the onset of plantar fasciitis. One of the most important is to wear athletic shoes with good arch supports whenever performing strenuous activities that require a person to be on his or her feet for extended periods. However, if a person has excessive foot pronation, it would be wise to consider consulting a podiatrist and having orthotics fitted to his or her shoes. Also, since runners are especially likely to develop this pathology, they are advised to limit sudden increases in intensity or running distance. A good rule of thumb is to limit an increase in distance or intensity to no more than 10% per week (Boldridge, 1997). Also, stretches focusing on the gastrocnemius, hamstrings, and buttock muscles will prevent excessive pull on the area and make the fascia less likely to be overstressed. Additionally, obese patients should lose weight to take the excess pressure off, while runners should avoid running on cement and other extremely hard surfaces that increase the intensity of the impact on the foot.
Non-PT Rehabilitation for Plantar Fasciitis Patients
For those people who fall victim to plantar fasciitis, several methods of non-invasive treatment are available. One of the easiest methods is taking one of a variety of NSAIDS (non-steroidal anti-inflammatory drugs) to reduce the pain; these drugs include aspirin and ibuprofen—not Tylenol, which is ineffective at reducing inflammation.
Although difficult for many patients to accept, relative rest is also recommended to give the fascia time to recover from its inflammation. Since many people with plantar fasciitis are on their feet out of necessity, staying off their feet is highly inconvenient or even impossible. In this case, recovery may be slower and less complete than usual.
A common form of home treatment for plantar fascia involves icing the area regularly. This can be done with a bag of ice covered with a damp towel and applied as often as every hour for up to ten minutes at a time (Hayes, 1993, p. 51). This will cause vasoconstriction and reduce blood flow to the area, allowing the inflammation to decrease and promoting decreased nerve conduction velocities for reduced pain. An effective variation of this treatment is rolling the involved foot over a frozen juice can, which provides double benefit by stretching the plantar fascia and exercising involved muscles, while at the same time applying the cold treatment.
Also, a night splint can be worn while sleeping. A night splint works by keeping the foot in a relatively neutral position throughout the night, which prevents the plantar fascia from shortening. In a study performed by M. Powell, MD, 88% of the subjects received significant benefit from night splints (Wheeless, 1997).
In addition, steroids can be injected into the area in order to reduce pain. The common dosage is 0.1 to 0.2 ml of corticosteroids (Wheeless, 1997). While this is often an effective temporary solution, several harmful side effects have been reported: longitudinal stress fractures, hammertoe deformity, lateral plantar nerve pain, and even rupture of the plantar fascia.
Another method of treatment commonly utilized is custom-made orthotics for the shoes. However, for this to be effective, the patient must be compliant and wear the orthotics consistently. Additionally, it is recommended that the patient wear Birkenstocks or similarly supportive shoes or sandals around the house instead of slippers or going barefoot (Solemate).
However, one of the most effective ways to treat plantar fasciitis is active stretching and exercise as prescribed by a physical therapist. In conjunction with treatments such as cryotherapy, these activities can greatly reduce the pain and inflammation involved in plantar fasciitis. First, the plantar fascia itself, as well as the muscles which attach to the base of the heel (the gastrocnemius and soleus) need to be stretched, along with the hamstrings and gluteals. These and other techniques will be addressed in the following paragraphs.
Physical Therapy Treatment of Acute Plantar Fasciitis
After the initial evaluation of the patient, the physical therapist will probably set up a management program involving a variety of methods to address the problem. The therapist should encourage as much rest as possible; unappealing as it may seem, rest is the only way to give the fascia time to begin to heal itself. It is likely that the therapist will begin treatments by icing the ventral side of the foot, from the heel to the ball. This may be done with an ice pack, or with an ice massage applied for about five minutes. This will reduce the soreness and allow for less painful stretching and exercises. Then, the therapist may apply deep friction massage to the plantar fascia to loosen adhesions (Kisner, 1996, p. 483). Electrical stimulation may also be used to stimulate pain-free contractions of the involved muscles. Then the therapist can teach the patient how to perform active range of motion exercises within the patient’s pain tolerance. This may include active dorsiflexion, plantarflexion, inversion, and eversion of the foot. Modalities that should be avoided in the treatment of acute plantar fasciitis include anything that would increase inflammation, such as continuous ultrasound, hot packs, and all thermal modalities.
Physical Therapy Treatment of Subacute and Chronic Plantar Fasciitis
As the condition begins to improve, the therapist might order a night splint or request
orthotics to be made by a podiatrist. Other modalities can also be utilized during these later stages, including continuous ultrasound, hot packs, and iontophoresis (Pattie Naylor, M.S. P.T.—personal communication, 10/21/99). Next, stretching may begin, including stretching of the gastrocnemius, soleus, hamstrings, and gluteals. These exercises should be performed daily, about 10-20 repetitions each. However, care should be taken to avoid over-stretching, which could cause microtrauma to the fascia and lead to Achilles’ tendonitis, significantly lengthening the time necessary for rehabilitation (Roberts, 1996). And, of course, the general contraindications and precautions that apply to all stretching techniques apply in this case, such as recent fractures and osteoporosis. Directions for typical stretches, as recommended by Allison Boldridge, M.A., P.T. are given below (Boldridge, 1997):
Gastrocnemius Stretch: Stand with the heels hanging over the edge of a step; raise and lower the body using only the toes until a stretch in the calf is felt.
Soleus Stretch: Perform the same stretch as above, except keep the knees slightly bent throughout the range of motion.
Bicycle stretch: Lying on one side, keep the top leg straight and bring it towards your nose until a stretch is felt in the hamstrings. From this position, pretend you are bicycling with the same leg, keeping the hip in the same amount of flexion.
After this, daily exercises can be done to strengthen the involved muscles. These should be introduced gradually, and as always, should take into account the standard contraindications and precautions for strength training, such as acute inflammation, severe osteoporosis, and adequate recovery time after each training session. Also, the Valsalva maneuver should be avoided during all exercises by encouraging the patient to breathe or count out loud while exercising. Allison Boldridge recommends the following exercises (Boldridge, 1997):
Active metatarsal head raising: While standing, raise the balls of the feet off the ground while keeping the toes from curling. Do this for 6-7 repetitions.
Toe pushups: Sit with feet flat on the floor; raise the heels off the ground so that the toes are supporting the foot while still held flat; this is the starting position. Then raise the foot higher up, so that the weight is supported on the tips of the toes, like a ballerina. Repeat this 10-20 times.
Ankle evertor strengthening: Sit with the legs hanging free; bring the foot up and out to the side, trying to point the toes to the ceiling. Keep the rest of the leg stable; repeat 10-15 times.
Ankle invertor strengthening: Perform the same as above, except bring the foot in towards the opposite leg and up towards the ceiling.
Dorsiflexor strengthening: Sit with the legs hanging free; keeping the foot facing straight ahead, raise the toes straight up towards the ceiling. Repeat 10-15 times.
Once the above exercises have become easier, weights can be added and number of repetitions can be increased to develop further muscle strength and endurance. The stronger the muscles become, the less stress will be placed on the plantar fascia.
Treatment of Last Resort
If physical therapy is ineffective at reducing the pain and inflammation involved in plantar fasciitis, surgery may be considered. This technique is known as plantar fascia release (Wheeless, 1997). This involves making either a longitudinal or transverse incision into the plantar fascia in order to release the tension. However, since the foot is a complicated structure with many intricate features, this surgery has the possibility of actually worsening the problem if the mechanics of the foot are disturbed. This treatment is given in only 5% of all cases of plantar fasciitis (Wheeless, 1997).
We have looked at the anatomy, symptoms, prevention methods, and various treatment methods for plantar fasciitis. While many options are available to help its victims, it is obvious that plantar fasciitis can benefit greatly from physical therapy, which plays a key role in improving the patient’s health, well-being, and return to optimal function. However, as physical therapists and other health professionals inform the general public about how to prevent plantar fascia, it is hoped that the need for all forms of treatment will become more infrequent.
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(3rd ed.). Philadelphia, PA: F.A. Davis Company.
Roberts, Scott (1996). Plantar Fasciitis and Heel Spur Syndrome
Simon, Harvey, M.D. (1996). What Is Foot Pain?
Solemate. Solemate’s FAQ’s: Plantar Fasciitis (Sponsored by Bio Ped).
Wheeless, C.R. III, M.D. (1997). Plantar Fasciitis.
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