Plantar Fasciitis: How to Maximize Outcomes with Conservative Therapy

Plantar fasciitis is characterized by initial dull intermittent pain in the heel which may progress to a sharp more persistent pain particularly during weight bearing activities. Classically, it is worse in the morning with the first few steps, after prolonged sitting, and after prolonged standing or walking. Symptoms are also noted to be worse at the beginning of an athletic activity, and then may improve after warming up.

The plantar fascia is a thick fibrous material on the bottom of the foot. It is attached to the heel bone (calcaneus), then diverges forward and attaches to the underside of the toes to support the arch of the foot. 

Problems occur when a portion of this relatively inflexible fascia is repeatedly placed under tension.   Tension causes overload that produces inflammation typically at the point where the fascia attaches to the heel bone with the result being pain.

Plantar fascia pathology may also occur in the region of the middle arch or near the toes. As it is difficult to rest the foot, the problem gradually worsens as the condition is aggravated with every step. 

The inflammatory reaction that occurs at the heel bone may produce a projection of new bone called a heel spur that may be seen on x-ray. These heel spurs do not cause the initial pain nor do they cause the initial problem; they are in fact a result of the problem. 

·         Foot structure (flat/pronated feet, high arch/rigid feet)

·         Tight calf muscles

·         Poor shoe support

·         Toe running, hill running

·         Soft terrain (i.e running in sand)

·         Disproportionate body weight (obesity)

·         Sudden increase in activity level

 

Improvement for such a condition may take a prolonged period of time especially if the condition has existed for a long time. During recovery loss of excess weight, good shoe support, and activity modification will help the injury to heal. 

Rest.Use pain as your guide. If activities are increasing pain, the activity should be modified or suspended (at least temporarily).

Ice. Ice the sore area for 15-20 minutes several times a day to reduce inflammation. It is important to apply ice directly after any weight bearing activity that has historically caused you pain.   You may try rolling a frozen bottle of water under your arch or using a bag of crushed ice.

Medication. If the condition is relatively acute (developed recently), an anti-inflammatory medication may be beneficial. If the condition does not respond to more conservative measures, your doctor may chose to inject cortisone or local anesthetic directly into the tender area.

Physical Therapy. The initial objective of physical therapy is to decrease the inflammation. It will be important to teach you how to stretch the muscles of the calf as inflexibility of these muscles have a direct correlation to stress on the plantar fascia. Your treatment may additionally include a series of strengthening exercises for the muscles of the foot, and proprioceptive exercises to aid in return to previous activities.

Heel pads. A heel pad of felt, sponge, or gel may help to relieve or absorb pressure of the tender area. It may be necessary to cut a hole in the pad in region of the tender area (some pads are sold with the hole already in place). 

Shoes.  Shoes with good arch support are necessary for all weight bearing activities. Those individuals with a low arch (pronated foot) may benefit most from a motion control running shoe, whereas those with neutral and high arches may benefit from less motion control and more cushioning. 

Orthotics. Orthotics (or foot orthoses) are shoe inserts that may be recommended if necessary. These inserts support and control the foot to alleviate tension on the plantar fascia. Your doctor or physical therapist can recommend specifics.

Taping/Bracing/Splints. Taping the arch or utilizing and plantar fascia arch brace may be of some benefit as this will take some tension off the plantar fascia. Night splints worn during sleep hours provide a low load passive stretch to the Achilles tendon and plantar fasica and can be helpful in some cases.

Surgery. Surgery is rarely required for plantar fasciitis. It would be considered only if all forms of conservative treatment fail and if the pain is incapacitating after months of treatment. When needed, surgery involves removal of the bone spur and release of the plantar fascia.

 

Plantar fasciitis can be aggravated by all weight-bearing activities. Any sport/exercise/activity where the foot lands repeatedly can aggravate the problem. To maintain cardiovascular fitness during the healing process, weight-bearing activities can be temporarily replaced by non-weight bearing activities such as swimming and cycling. Weight training may be combined with physical therapy exercises to maintain leg strength and flexibility.   When recovering from plantar fasciitis, return to sports activities slowly. Utilize the treatment options above to aid in return to activity.