Many people know that familiar yet agonizing pain that is plantar fasciitis. I’m talking about the heel pain you get when you first get out of bed. It's the the pain you feel when you stand up after sitting for a while. Not to mention, the nagging pain in your foot after being on your feet most of the day. It seems a lot of people end up with these horrible symptoms and begin to ask “WHY ME??”. Plantar fasciitis is certainly no fun and can be very hard to understand. Let's sit down and talk about what in blue blazes it is and why it is so stinkin’ frustrating to try to make it go away.
The plantar fascia is a giant section of connective tissue on the bottom of your foot. The bottom of our foot is referred to as the plantar aspect of the foot and the top is the dorsal aspect, hence the name. Fascia is a dense fibrous tissue that encapsulates our body. It lives under our skin but superficial to the muscles, and it plays a role in stability at various points in our body. At the foot, it is vital for helping create tension to stabilize the arch of our foot and absorb the impact of our body as we walk and take force through our foot. It starts at the base of our heel and runs forward to connect at the balls of our feet and our toes, which is why when it is really flared up it often hurts right on the heel where it starts.
Over time we can develop problems with the fascia that are essentially degeneration of the tissue. Fasciitis is a bit of a misnomer because “itis” indicates an acute inflammatory response, which plantar fasciitis is not. Nowadays it is being called things like fasciopathy or fibromatosis, which essentially means degeneration of the tissue. The plantar fascia can become irritated when there are altered mechanics in how we walk and take force through our legs. Oftentimes what happens is we develop either a more flat foot, or have a foot with a very high arch. People with high arches are typically more naturally built that way, but flat feet can result over time due to improper stability at the hip or foot, limited tibiofibular motion, or limited motion in the great toe or ankle from joint stiffness, or muscle tension. Increased tension in the calf or muscle that flexes your big toe can limit ankle motion and decrease the ability of the ankle and foot to absorb force smoothly.
All of these limitations can lead to increased stress on the plantar fascia resulting in tissue degradation, tears, and thickening.(1) According to the 2014 revision of the Heel Pain-Plantar Fasciitis Clinical Practice Guideline, people with increased fascia thickness may have more heel pain.(2) This highlights one of the changes that can occur with this condition. The fascia begins to thicken from long term irritation and essentially scarring that the body goes through when trying to heel tissue. This can also affect the fat pad on your heel, a cushion that also absorbs force when walking or running. Fascia thickness changes can cause pain in the fat pad which in turn also drives more pain from being on your feet. This is what makes plantar whatever you want to call it so difficult to manage or make disappear. It is very hard not to use your feet. Oftentimes walking can be an irritant for people, but we all have to do it and some people put in a lot of steps in a day which can drive more pain.
As stated above this condition is not an acute flare up; it is a chronic process of degrading tissue. Now before you go casket shopping for your plantar fascia, I should explain that although the tissue may be in an unhealthy place, it is not done for. There are some key things that can be done to start driving change in the tissue quality of your feet and decrease the pain signals you are receiving from it.
First off, you need to relieve tension through the calf and foot. This comes by way of plantar fascia specific stretching and stretching the gastroc and soleus muscles (your calves, that's right, there's two of them!). Another way is if you are having pain when you first get out of bed and begin to walk, you may want to try a plantar fascia night splint. I'm sure right now you are making horrible faces at the computer thinking about wearing a splint at night, but according to the clinical practice guidelines this is actually a pretty decent management tool to try out!
In addition to relieving tension, we need to restore full ankle and big toe motion. There is a lot that goes into this, and I will not be able to tell you how to directly do that through the article. Sometimes motion is limited by the aforementioned tension through the claves, but other times it is more of a joint limitation and that can be a little more hands on trying to remedy. Regardless of the cause, we need to restore as much dorsiflexion motion (ankle and toe bending up) as we can if you are lacking in that department. This will help your body be able to walk normally and not have to fall into pronation with walking or taking the stairs depending on how limited your motion currently is.
Another focus will be restoring stability to your foot and ankle. There is less direct research evidence for this but it is recommended by expert opinion, and in my experience it is beneficial. This is done by way of exercises like toe yoga, heel floats, forefoot loading, and heel raises. Oftentimes the hip needs to be addressed as well due to stability or movement limitations. Most people I meet who come in with some kind of foot pain either currently have or had hip issues at some point. Those without a history of hip dysfunction often still have poor stability in their hip or the inability to properly activate their glutes. It can be tricky figuring out how to implement these things early on when it is very painful, but ultimately this is where care needs to progress towards restoring the strength and flexibility of your plantar fascia and the hips together.
My last two recommendations that come from the clinical practice guideline are to start wearing shoes that are more comfortable and have a good heel cushion or support, and or find some kind of orthosis like a shoe insole with good support. It is recommended that if you are on your feet a lot for work you may try rotating comfortable shoes instead of wearing the same ones all the time. It is also recommended that you try an over the counter shoe insert that can provide more heel and arch support. It does not have to be anything fancy or expensive, just something that seems to fit your foot well and you find comfortable.
Wrapping all this up, plantar fasciitis can be improved! Many people get to a place where it relieves and finally lets up entirely. It is rather discouraging while it is going on, but I encourage you to try the above mentioned tools. If you are still having difficulty please come see me or another physical therapist you trust and let us help you!
References
1. Beeson P. Plantar fasciopathy: Revisiting the risk factors. Foot and Ankle Surgery. March 22, 2014. Accessed September 16, 2024. https://www.sciencedirect.com/science/article/abs/pii/S126877311400040X.
2. Robroy ML, Davenport TE, Reischl SE, et al. Heel Pain-Plantar Fasciitis: Revision 2014. Journal of Orthopedic Sports Physical Therapy. Published online 2014. doi:10-2519
