Are you suffering from plantar fasciitis?

It’s been endured by up to 15 percent of the population, is even more common among runners and is devilishly difficult to shake. Sports physio Chris Barber explains what causes heel pain, how to treat it – and why it has so many names.

Overloading is often the root cause of heel pain but there are steps you can take to prevent it Pic: Dreamstime

The symptoms

For a large number of sufferers, the injury most commonly known as plantar fasciitis is felt as pain on the inside of the heel and/or sole of the feet. It is frequently most noticeable with the initial steps after a period of rest.

Things are often better during and immediately after activity; however, symptoms later in the day or the following morning are often worse.

For most runners, if they present with this pattern and touching the sole of their foot around the tissue that connects from the heel bone to the toes (the plantar fascia) brings pain, that is usually enough for diagnosis.

Common causes

Overloading is often at the root of the injury because the fascia’s role is to act like a spring under the foot; it absorbs shock as the foot strikes the floor when walking or running, then stores and releases the energy to help propel the body forward.

Plantar fascia is a runners’ friend because it makes our movement more efficient but, with up to four times your body weight going through your feet during running, it can suffer from wear and tear.

Unfortunately, there are a wide range of sources that can damage the area: footwear changes, increased mileage, weight gain, hormone changes (menopause) or training resumption too quickly after a virus. Others include: a tight Achilles tendon, tight calf muscles, training on unfamiliar surfaces, high arches and flat feet.

Name game

Technically, if the common symptoms added up to fasciitis it would mean there was inflammation, but studies have failed to find this sort of reaction in the tissue – damaged fascia doesn’t act like muscle in that way.

Instead, it shows a failed healing response with tendon fibres degenerating and excess fluid building up around the damage. This explains why the heel will hurt more after rest than it does when active, which is the opposite pattern with inflamed tissue.

The exception is if there has been an acute tear, such as after a heavy step down or landing from a jump, usually leaving the sufferer feeling a sharp pain.

The symptoms from such a tear would be very different to what most people feel: internal bleeding, swelling, heat and redness. Most runners with plantar fascia pain seldom remember any injury incident and the phrase I’ve heard most is: “it just came on”.

Many people call both problems plantar fasciitis because the difference requires a bit of Greek language knowledge. For what it’s worth: -itis implies inflammation, -osis (plantar fasciosis) implies degenerate tissue and this is the most accurate term for the most common form of heel pain. A third term fasciopathy is sometimes used however -pathy implies the presence of diseased tissue which isn’t the case with this condition.

Self-help

Heel pain can be slow to respond to treatment so if you have an important event coming up it’s worth getting an expert to investigate.

Otherwise, there are a few preventative measures you can take: regular foot massage (see below) with a tennis ball or foot roller, checking your running shoes are right for your foot type and gait - possibly inserting heel cups – and use of a moulded orthotic or insert if you have high arches or flat feet.

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Images and instructions below courtesy of Physiotec

Images and instructions courtesy of Physiotec

Foot massage instructions

Place the ball of your foot on a ball about 6-10 inches in front of you while balancing on your opposite foot.

Inhale as you press your foot into the ball, rolling from your medial arch (inner arch) to the front of your heel.

Apply as much pressure as you can, to the point where you feel that hurts-so-good sensation.

The ball should be placed under the inner edge of the arch of the foot on each side.

Try to do this for one minute, twice a day.

Stretching the plantar fascia

Sit with your injured foot placed across your other knee.

Pull your toes up and massage the arch of your foot, twice a day. You should aim for 10 repetitions of 10 seconds each time.

There are a couple of other things you can do to help yourself, in addition to the massaging shown in these pictures (above and below), which shouldn't impact too much on your day. These are standing calf stretches and passive ankle dorsiflexion.

To carry out the calf stretches, you should stand and place both hands on a wall, with your feet about half a metre from the wall.

Place one leg behind the other and lean your body forward without bending the back knee until you feel a stretch in your back calf. Maintain the stretch for 10 seconds and relax.

Aim for 10 of these stretches twice a day. You should try to do the same to improve your ankle dorsiflexion.

To do this, you stand in front of a wall and place the toes of the injured foot close to the wall. Attempt to touch the wall with your knee by bending at the ankle without lifting the heel off the floor.

Repeat with the foot further away from the wall until your heel begins to lift when your knee touches the wall. You may feel a stretch behind the heel/calf or a pinch in front of the ankle. Maintain the position for 10 seconds and relax.

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Staying active with low impact cross training rather than running some days and keeping an eye on your weight can also help.

Specific stretching of the plantar fascia with over-the-counter shoe inserts has been shown in randomised controlled trials to be effective, too, and a good physio can help advise you on these and move you on to other exercises if they are working.

It is worth noting that you may still be able to run with mild symptoms. A general rule of thumb with many injuries is that continuing to run and exercise is OK if you are pain free when thoroughly warmed up and not any worse the following morning.

Treatment options

If you came to me and plantar fasciosis was diagnosed I’d give you a home exercise programme initially, stretching the plantar fascia as well as the calf muscles.

Ankle strengthening may also be appropriate along with ice massage. Heel cups can help if you are not able to walk comfortably in trainers or have to wear formal shoes.

For some people, however, even with this comprehensive self-management the condition does not go away completely. Treatment options then include soft-tissue manipulation techniques to release tension in the calf and Achillles, trigger point dry needling (a more modern, scientific treatment to traditional acupuncture), periosteal needling (needling applied to where the tissue attaches to the bone), taping and shockwave therapy.

The last of these options - Shockwave therapy - might sound a bit frightening, but it’s just a treatment to improve blood circulation and promote tissue healing and regeneration. Many trials have shown positive results, and it’s certainly a good option compared to surgery.

Doctors and orthopaedic foot consultants have been known to advise having a steroid injection, and this has been shown to provide short-term relief of around a month. Over a longer term, such as three months, it is little better than a placebo and the long-term effects are uncertain so these are best avoided unless all else has failed.

My best advice is to arm yourself with the knowledge to identify potential symptoms, and get expert help early.

Chris Barber (BSc (Hons) Physiotherapy, Musculoskeletal & Sports Physiotherapist, MCSP HCPC AACP Registered Physiotherapist) has been running his own practice in South London and Kent for more than 20 years. You can reach him at Advanced Physiotherapy Centres.