What is Plantar Fasciitis?
One of the most common and stubborn forms of foot pain is plantar fasciitis. On average, 2 million Americans suffer from this condition every year, and about 10% of the population will experience it within their lifetime.
The most common symptom is a sharp pain in the heel, just below the arch of the foot, especially first thing in the morning. So, what is it and why do we get it?
First, having a basic understanding of the foot anatomy is helpful to answering questions around plantar fasciitis. Let’s start with some basic anatomical terms:
- Anterior-front of body
- Posterior-back or behind the body
- Lateral-away from the centerline
- Medial-towards the centerline
- Proximal-closer to the heart
- Distal-further away from the heart
- Forefoot-includes from the toes to midfoot area
- Midfoot-includes the area of the arch of your foot
- Hindfoot-the heel area of the foot
- Abduction-the foot/ankle rotates away from midline
- Adduction-the foot/ankle rotates towards midline
- Dorsiflexion-foot bends upward
- Plantarflexion-foot bends downward
- Eversion (valgus)- weight bearing is on the inside of the foot while the “smallest toe” simultaneously points upward
- Inversion (varus)-weight bearing is on the outside of the foot while the “big toe” simultaneously points upward
- Pronation-foot movement combines all three: abduction, dorsiflexion, and eversion
- Supination-foot movement combines all three: adduction, plantarflexion, and inversion
Our feet can withstand great forces by design, but with genetics, poor shoe wear, weak muscles, etc., it can cause a mechanical breakdown. Each foot has 26 bones, 33 joints, 19 muscles, and 107 ligaments.
Bones provide structure, joints are when two bones meet, muscles are soft tissue that provides strength and movement, tendons connect muscle to bone, and ligaments connect bone to bone. A breakdown in any one of these anatomical structures may cause trouble.
In the forefoot, we have 19 bones which make up our toes (phalanges) and middle of our foot bones (metatarsal). Our toe movement comes from tendons attached to muscles within our lower leg. The major muscles involved in the movement of our toes are the Soleus and Flexor Digitorum Longus muscles which can be found in the back our lower leg.
The midfoot, or arch, has a total of 5 bones (Cuboid, Navicular, and 3 Cuneiform) which makes up the ankle. Together these five bones connect the forefoot, hindfoot, and the lower leg bones together to form the ankle. There are a lot of ligaments in this area to ensure there is not only movement but stability.
The hindfoot there are two bones (Talus and Calcaneus) which form the heel. These two bones take on the brunt of the weight bearing of our body. They can withstand great force and pressure. Besides bones, muscles, tendons and ligaments, we also have fascia tissue within our feet.
Fascia is a deep thick band of connective tissue throughout our bodies which is all interconnected, similar to a spider web. The fascia at the bottom of our feet, called plantar fascia, connects from the heel and spans to each of the proximal phalanges, or toes. With stress or wear and tear, the fascia becomes irritated and inflamed. When this happens, it is called plantar fasciitis.
Most plantar fasciitis starts off with irritation and inflammation of the tissue; however, studies have shown that over time the fascia degenerates and becomes disorganized, which means the collagen within the tissue breaks down and no longer properly aligns. Therefore, it can be stubborn to heal as the condition is not just simply inflammation.
What causes a plantar fasciitis?
Some of us are at higher risk than others of getting plantar fasciitis. A few of these risk factors include:
- Age, over 40 years’ old
- Athletes with repetitive impact (e.g. runners)
- BMI (body mass index) over 30
- Exposed to a rapid increase in weight bearing activity
- Menopausal women
- Occupations that are requiring prolonged standing (e.g. cash register attendants, teachers, factory workers, etc.)
- Poor foot mechanics (e.g. flat feet or high arches)
Beyond the risk factors, the common causes for why the fascia becomes irritated includes:
- Improper shoe wear (e.g. high heels or flat sandals)
- Poor flexibility of calf muscles and Achilles tendon
It is not all that uncommon to develop a bone spur in the heel with plantar fasciitis. Despite what some may think, bone spurs do not cause plantar fasciitis, nor do they commonly cause any pain.
Symptoms of Plantar Fasciitis
The most notable symptom is heel pain in the morning or while climbing the stairs. If you experience pain at night while sleeping, then you may have a different condition than plantar fasciitis.
Often the pain is sharp in nature and starts at the heel; however, the pain can radiate to the forefoot and midfoot areas. Most will report the most significant pain is after weight bear activities or within the first few steps in the morning.
How is plantar fasciitis diagnosed?
Plantar fasciitis is diagnosed through a physical exam by your health care provider, either your physical therapist (PT) or physician. Rarely are images like X-Rays or MRIs (magnetic resonance imaging) used. Images are only used in cases where there is suspect of another medical condition.
Your PT or physician will review your medical history and will ask questions about your activity levels. He or she will also complete a full and lower leg exam. The goal is to rule in, or out, plantar fasciitis or some other condition like a stress fracture.
Treatment of Plantar Fasciitis
The bad news is fascia, like ligaments, are very slow to heal. It takes months or longer before the fascia may calm down. The good news is there are ways to at least help speed up the recovery time.
First, rest as much as you can from the activities that flare-up the symptoms. Limit prolonged walking, standing, and running. Second, make sure you are wearing proper footwear which may also require a foot orthotic to support the structure of the foot arch. For some, heel pads can also help alleviate symptoms.
PT is highly recommended for plantar fasciitis. Due to it being such a stubborn condition, there are things your PT can do for you to help alleviate symptoms and with luck reduce the amount of time the symptoms stick around.
After a thorough evaluation, your PT will collaborate with you on establishing realistic goals and time frames to reach those goals. To start, your PT will focus on symptom managements, which can be done by customizing a fitted orthotic or night splint, educating you on proper shoe wear for good arch support, and may even tape the bottom of your foot to help support the structure of your foot.
Since plantar fasciitis is known to be a degenerative and fibrous tissue malalignment, often a PT will introduce soft tissue mobilization. This technique uses a hard tool like GRASTON®, ASYTM®, or Gua Sha tools. The goal of this technique is to reintroduce the natural healing process of the body as well as to help realign the fibrous tissue, which can be an uncomfortable technique while it is performed. However, most feel the relief of symptoms afterward.
In addition to soft tissue mobilization, your PT will introduce you to proper exercises, stretches, and gait pattern training techniques. The purpose is to stretch out the tight gastrocnemius and soleus muscles in the calf to reduce tension and tissue stress within the foot. As well, proper exercises to strengthen the foot and lower leg will also help reduce additional stress.
Gait training is a combination of awareness, orthotics, and shoe wear. Your PT will talk with you about what shoes are the best fit for your foot, which is key in helping with the recovery process. Orthotics will support the arch, whether flat or high, to reduce the stress of the fascia tissue. Finally, awareness of your gait pattern is important. If you have poor foot/heel strike, this biomechanics of the foot only prolongs healing as well as puts you at higher risk of the condition repeatedly returning.
Early intervention to plantar fasciitis is important because the sooner you address your symptoms, the more likely conservative care will work for you. As a consumer of health care, you have a choice in finding the right provider for you. Do your homework and search for a health care provider, like a physical therapist, with excellent outcomes, great customer reviews, and can provide you the care you need for a reasonable cost.
Most states have direct access to a physical therapist, meaning you can go directly to a physical therapist without a physician order. To determine if your state has direct access, please visit the American Physical Therapy Association’s website Physical Therapy Direct Access By State.
To get started with conservative care today, you can find a highly qualified PT in your area. There are many qualified PTs, so to find one near you, please click on Find A Clinic. This link will help you find a PT that has top national rankings for treating foot pain such as plantar fasciitis.