Plantar fasciitis: A step-by-step guide to recovery
If you haven’t had it, you will have heard about it. If you have had heel pain then you will deeply appreciate the value of comfortable walking and running.
This post will give you the science of the plantar fascia and an overview of leading treatment strategies. Plantar fasciitis is one of the most poorly described musculoskeletal conditions. Clear facts lead to better treatment and recovery.
The name is inaccurate
Let’s call it what it is, heel pain. Heel pain is most accurately described as ‘heel pain’. A correct label results in more appropriate treatment and better clinical outcomes.
The ‘…itis’ in plantar fasciitis suggests that it is predominantly inflammatory in nature. This is not true. Research shows that heel pain is associated with many biological changes within the plantar fascia and that inflammation is only one small part. Often, inflammation is not even detected in the plantar fascia of someone with pain.
The structure of the plantar fascia
Research shows that the structure of the plantar fascia has similarities to a tendon. This is important because tendons are masters at transferring load from one part of the body to another. They also recycle kinetic/movement energy. This is key to efficient walking and running. When things go wrong (pathology) the plantar fascia and Achilles tendon show similar changes.
The plantar fascia is unique
Here are a few things that the plantar fascia is known to do.
- It guides the shape of the foot during walking and running. As the toes extend during push off, the plantar fascia becomes taught and lifts the arch of the foot (helpful supination). During early foot contact, the plantar fascia is under low tension and the arch is guided toward a lower position (helpful pronation). This changes the spring and stiffness of the foot and makes for more efficient walking and running.
- The plantar fascia has many nerves which detect changes in tension (load and movement) that then send this data to the brain. This gives real time information about what is happening in the foot and helps to coordinate movement.
- The strong, predominantly collagen (type I) structure is optimised for transferring load from the ground into the rest of the body and back again. Most of the plantar fascia starts from the big heel bone known as the calcaneus. But, a portion of the plantar fascia continues around the heel and into the Achilles tendon (paratendon). This suggests a team relationship of the calf, Achilles tendon and plantar fascia.
Big review studies summarise that most treatments get mixed results. Stretching, shoe inserts (off the shelf or custom), night splints and corticosteroid injections have all shown measurable benefits in randomised controlled trials. Yet, the benefits of these treatments are not overly exciting. Long term follow up typically shows minimal sustained effect. There are flaws in much of the research too, which muddies the water with more potential for bias.
Corticosteroid injections have been reported to correlate with increased rate of plantar fascia rupture. This is a negative outcome and one that should be considered carefully.
A recent trial in Denmark found significant improvement using a high load strength training protocol. The exercise is a weighted heel raise starting with the heel below the toes. This finding matches the current research for tendon pain, where heavy strength training yields a positive outcome. The concept suggests that safely and strongly loading the plantar fascia promotes tissue recovery. It also stimulates the sensory system which is likely to help pain. Finally, strength training produces a more efficient and capable body.
Extracorporeal shock wave therapy uses a machine to stimulate the tissues. It has been researched extensively and shows generally helpful outcomes. It is a treatment worth considering as part of a recovery plan for some people.
Pain is interesting
Pain is not just about what is happening in your plantar fascia. There is bucket loads of research to show that pain is there to protect you from danger. Pain can change to be more protective. This means that pain comes on earlier and gives you a bigger buffer between pain and injury. Generally your pain system becomes more protective when you have had pain for a long time.
Learning about pain is helpful because it gives you permission to move into your pain. Movement is a potent stimulus to your tissues to become stronger, and the load information from movement can train your pain system to become less protective. Understanding pain is not always intuitive. See this link for interesting information about pain.
Fixing heel pain
If you have heel pain, you would be best off working with a physiotherapist who:
- Completes an assessment to rule out uncommon problems
- Assesses for relevant contributing factors
- Measures and gives advice on training load
- Works with you to make a plan that helps you move past the pain
- Gives you an understanding of why you have pain
- Provides treatment using the current best research
- Does not prioritise the use of temporary treatment strategies. These include massage, dry needling, ultrasound and taping. There is absolutely no research to demonstrate long term improvement using these treatments. Don’t waste your time and money.
Getting back to it (running or walking)
The only way to get good at something is to do it. If you have stopped or reduced activity because of pain, you will want to know how to get back into it. Work with your physiotherapist to plan your return to activity. Increasing effort/load bit-by-bit is a great way train your body.
The plantar fascia does lots of useful stuff. Know that the plantar fascia is strong and capable. When you have heel pain, structuring your load is key. Smartly increasing your load and activity is the way to get back to your prime.
Touch base with any questions.