Is an overuse injury involving the plantar fascia, a tough, fibrous band of tissue that supports the longitudinal arch of the foot. Very common among athletes and others who are on their feet for long periods. It can progress and lead to severe heel pain, which is the most common symptom among patients seeking treatment from podiatric practitioners. Approximately 10% of foot injuries associated with running are attributable to plantar fasciitis ( Bachbinder, 2004 ).
Because the feet support the bodyweight, and play a critical role in stability, locomotion, and propulsion, any injury to the foot is cause for concern and shouldn’t be ignored. Immediate treatment and intensive rehabilitation is required. Therefore, preventive exercises, early detection, and appropriate management are important.
Each foot ius composed of 28 bones, 33 joints, 19 muscles, occurring within 4 layers, plus a network of blood vessels, nerves, and soft tissues. The feet are supported by 56 bones, which represents 25% of the body’s skeletal system.
The arch is the most important structure of the foot, as it endures the entire bodyweight, and absorbs heaps of stress with every step. Therefore, any alteration or injury involving the arches can have a drastic effect on balance and gait. A damaged plantar fascia, especially at it’s attachment point on the heel bone, may give rise to plantar fasciitis.
Connecting the hind foot with the fore foot, the plantar fascia undergoes tension during walking, running, hopping, and jumping. The action of the plantar fascia during weight bearing is compared to a rubber band. When there is no weight on the foot and plantar fascia, the elastic band is relaxed. As weight is put on the foot and plantar fascia, the elastic band stretches out. A band that is too short results in a high arch, whereas a band that is too long results in a low arch ( flatfeet).
The foot is most susceptible to injury during mid-stance, which is when the weight of the foot is shifted from the back of the foot to the fore-foot. This is when the stance limb bears the entire bodyweight, and is therefore most prone to injury. The arch of the foot flattens to absorb the stress of ground contact, and the plantar fascia is stretched.
The next phase is propulsion, which begins once the heel is lifted. This is when the rubber band effect occurs. The plantar fascia is tightened over the plantar surface at the base of the toes, raising the arch. This allows the stance foot to become an efficient lever. Exagerated, or prolonged propulsion phase can increase the risk of plantar fascia injury.
CAUSES :
The damage incurred by the plantar fascia is mainly brought about by degenerative changes owing to over-use, or re-injury, which may occur with or without inflammation. Microtrauma and degeneration are commonly caused by prolonged or repeated over-stretching of plantar fascia due to walking, jumping, landing, and running. Weakened foot and lower leg muscles, a tight achilles tendon, or any activity in which the weight is taken on the ball of the foot can put a lot of pressure on the fascia, resulting in plantar fasciitis. Like tendons, the plantar fascia is poorly supplied with blood; therefore, once it is damaged, the healing process may be markedly slow.
Decreased healing response, in addition to decreased elasticity due to aging and repetitive tearing, puts the middle aged population especially at risk of plantar fasciitis. As we get older, the plantar fascia usually loses it’s ability to stretch. The fat pad on the heel also thins, and weakens, decreasing it’s ability to absorb the shock or pressure of walking. Excessive pressure applied on the heel damages the plantar fascia, making it vulnerable to swelling, tearing, and bruising.
Plantar fasciitis is the most common cause of heel pain. Thousands of Australians are treated for plantar fasciitis annually.
Plantar fasciitis is among the top five causes of foot injuries in professional athletes, cross-country and track runners, tennis players, basketballers, volleyballers, tennis players, and sprinters are all at risk.
Non-athletes also suffer plantar fasciitis. Approximately 10% of the population will experience plantar fasciitis at some time. It is most common among people aged 40 – 60, though runners below age 20 are also susceptible. Women are twice as susceptible than men.
Obesity, coupled with a sedentary lifestyle, high impact aerobics – especially on unsuitable surfaces, speed workouts, incline runs, and plyometrics are also implicated in plantar fascia degeneration. High risk behaviors, such as running on poorly padded surfaces, and poorly cushioned shoes, are known risk factors.
Repeated trauma, or chronic pressure on the plantar fascia can irritate local nerves, resulting in severe heel pain, commonly felt in the arch or the underside of the heel bone, and may extend to the toes.
The two best tests for plantar fasciitis is the Windlass test, in which the forefoot is passively moved towards the body, and will elicit heel pain, and either walking or standing on the foot’s lateral border. Plantar fasciitis usually affects uni-laterally. Bilateral symptoms are most likely caused by systemic arthritis.
PREVENTION :
Prevention is always better than cure. So, work on your ankle mobility – calf stretching, walking on toes with knees locked, walking on heels with knees locked, I suggest 2 x 10-15m alternating, after your primary routine is finished, will not only improve ankle mobility, but will also help minimize the microtrauma experienced during running, jumping, or landing.
– Wear good quality footwear – well fitting, good heel and arch support.
– Customized orthotics for either high arch or flatfoot.
– Lose weight, if over-weight.
– Appropriate floor padding in the workplace, if you stand for long periods.
TREATMENT :
– 6 weeks to 6 months rehab should provide full recovery.
– 82% achieve full recovery within 5 months using multiple non-surgical modalities, such as rest, icing, stretching and strengthening exercises, oral intake of non-steroidal anti-inflammatory medications, cortico-steroid injections, orthotic use, weight loss, physical therapy, night splinting, and heel pads.
REST – is most important. Replace stressful activities with swimming or cycling. In severe cases crutches, casting, or immobilization in a walker boot may be considered.
ICING – 15-20 minutes, 4x daily. You can roll the bottom of your foot on a frozen cylinder for 5 minutes after activity, and before sleeping. These are made by freezing water in plastic bottles or cups. Also massage the heel by applying water frozen in styrofoam cups, in circular motions for 5-10 minutes.
SHOE MODIFICATION – ensure good shock absorbing qualities.
ORTHOTICS – to reduce over-pronation ( 90% of population ). They also increase stability in stance and gait, and provide a passive plantar fascia stretch.
NIGHT SPLINTS – dorsi-flexion night splints maintain the ankle joint in neutral, keeping the plantar fascia and achilles tendon constantly stretched, thus reducing pain and microtrauma during weight bearing in the morning.
STRETCHING EXERCISES :
– Gentle, prolonged, and pain-free stretching of the achilles tendon, plantar fascia, gastrocnemius and soleus. This is very important therapy. The plantar fascia stretches are by far the most valuable exercises in treating plantar fasciitis. Do them upon arising, before walking. Again in the middle of the day, then at night.
The following plantar fascia stretches can be done three times daily :
— Stand with your hands against the wall, with the affected leg slightly behind the other leg. Keep your heels flat on the floor. Keeping your injured leg straight, and your heels on the ground, gradually lean forward, and bend the uninjured leg until you feel a stretch in the lower part of the injured leg. Hold the position for 10 – 15 seconds, and release. Repeat the exercise 5 – 10 times.
—Sit on a well supported chair, and place the affected foot on the opposite knee. Grab the affected heel using the opposite hand, and let the other hand pull the toes back, especially the big toe. A stretch should be felt within the arch. Hold the stretch for 10 – 30 seconds, Then release. Repeat the exercise 5 – 10 times per session, or as tolerated. You can do this exercise three times a day.
—Another way to do the above exercise is to sit on the floor with the legs straight. Loop a resistance band around the foot of the leg to be stretched. Gently pull the forefoot towards the knee, and hold the stretch for 10 – 30 seconds. Repeat 5 – 10x, or as tolerated. You can push your foot against the band to strengthen the calf.
Achilles tendon stretch, hamstring stretch, stair stretch, toe stretch, and soleus stretch, are some stretching exercises that mainly work on improving the flexibility of the plantar fascia.
STRENGTHENING EXERCISES
– For the foot muscles and lower leg. Commence once the affected foot demonstrates improved flexibility during stretching exercises, without experiencing pain. A tight calf can put additional stress on the injured plantar fascia, thus slowing the healing process, so work on calf and soleus stretching.
For the plantar fascia itself, you should do ‘toe grippers’, where you pull on a towel with your toes, or pick up marbles. Wall lunges, toe walking with knees locked, and heel walking with knees locked, and toe walking with opposite ankle dorsiflexion, and toe tapping.
TOWEL STRETCH
Sit tall as you place the affected foot on a towel on the floor. Using your toes, tuck, or pull the towel towards you. Afterwards, push the towel away, also through your toes. Repeat the exercise until fatigued. As your strength improves, place a weighted object, such as a can of soda, on the other end of the towel.
MARBLE PICK – UPS
Marbles are placed next to an empty cup on the floor. Sit tall, and using your toes, pick up one marble at a time, and put it into the cup.
CONTRA-INDICATED EXERCISES :
– Avoid any exercise that hurts. Rest the foot during acute pain.
– Avoid exercising on hard or uneven surfaces.
– Avoid incline walks
– Avoid over-working the foot. This might necessitate minimizing the time spent standing up.
If a prescribed exercise causes pain, it must be stopped. Consult your therapist for a change of exercise.
KEYS TO EXERCISING
—Symptoms of plantar fasciitis are usually worse after awakening. To reduce the pain, start stretching the plantar fascia before getting out of bed. Before sitting up, flex your foot up and down 10 times. Follow this exercise with towel stretch. Put a long towel at the bedside before sleeping. Keeping your back straight, loop the towel around the top of the affected foot. Gradually pull the towel towards your body.
—After exercising, you may apply ice massage to the affected area, or you may roll a cold soda over the arch of your foot for five minutes to relieve or prevent pain. Ice pack applications for 15 – 20 minutes are also recommended.
—Massage the plantar fascia by running your thumb or fingers along the fascia. It is best to ask your therapist to teach you how to do this technique properly.
—You may ask your personal trainer or therapist to tape your plantar fascia for improved activity tolerance during exercise and weight bearing activities, as taping helps distribute the applied stress away from the fascia.
—Before exercising, do your warm-up exercises, consisting of plantar fascia and heel cord stretches for 5 – 10 minutes. After exercising, do your cool-down exercises for 5 – 10 minutes.
—Wear well-fitting and comfortable shoes, with good heel support when exercising. Choose shoes with excellent shock – absorbing qualities.
