Written by: Megan Graham, PT
With the closure of gyms and fitness centres earlier this year causing decreased access to equipment, many people have turned to walking or running as a form of socially-distanced, equipment-free exercise. Generally, any increase in activity is considered beneficial, but if performed incorrectly, a sudden increase in activity may lead to injury. This article will explore a common walking/running injury and one of the most common causes of heel pain: plantar fasciitis.
BACKGROUND
The plantar fascia is a thick connective band that originates at the calcaneous (heel bone) and extends along the bottom of the foot to insert at the base of the toes (1). The plantar fascia is important for shock absorption; in the heel strike phase of the gait cycle, the plantar fascia is relaxed, allowing for movement of the bones in the foot to decrease impact. During toe-off, the plantar fascia is tensioned, which creates a rigid base for propulsion; this is known as the windlass mechanism (1).
Image from: https://orthoinfo.aaos.org/en/diseases--conditions/plantar-fasciitis-and-bone-spurs
Injury to the plantar fascia is most commonly called “plantar fasciitis”; the suffix “itis” refers to
inflammation, which was initially thought to be the mechanism behind the heel pain. The physiology behind this type of heel pain is now thought to be the result of degeneration and thickening of the tissue, similar to the structural changes seen in tendon injuries (tendinopathy) (1,2). Essentially, too much force or load is being placed through the tissue than it can adapt to, leading to microtears in which your body responds to by changing the structure of the tissue, without the presence of inflammation. Thus, “plantar fasciopathy” is a more appropriate name for this condition (2).
A common disbelief with plantar fasciopathy is that a heel spur is responsible for the heel pain and that heel spurs cannot be treated. A heel spur is diagnosed through x-ray, and appears as a bony extension of the calcaneous. A heel spur may be present in individuals demonstrating plantar fasciopathy symptoms, but they are also present in more than 50% of people who do not display any symptoms, indicating that there is no direct correlation between a heel spur and heel pain (2). While sometimes useful to rule out other injuries, such as a stress fracture, imaging is not required to diagnose plantar fasciopathy (2).
PRESENTATION (2, 3)
Pain located on the bottom surface of the heel, sometimes into the arch of the foot
Pain presenting after prolonged rest, especially the first few steps in the AM
Pain eases with walking, but may re-present with prolonged walking
Positive windlass test (pain with lengthening of the plantar fascia)
Painful palpation at the attachment of the plantar fascia
May present with limited ankle dorsiflexion (pointing the foot upwards) range of motion
Often a history of increased load to the plantar fascia- increased walking/running volume, intensity, duration, etc
TREATMENT
Activity Modification
If there was a change in your activity that lead to the development of plantar fasciopathy, modify your activity. Temporarily decrease the amount of weight-bearing activity that you are performing. Consider cross-training with other forms of activity such as biking or swimming to maintain your cardiovascular endurance. Also, consider your training surface; the softer the surface, the less impact it has on your body. Be sure to have an appropriate gradual training plan before returning to your activity.
Footwear
Examine your footwear. Wear properly fitting, supportive walking or running shoes. Consider wearing shoes indoors, and even putting your shoes on before stepping out of bed to decrease morning pain. Track your mileage; running shoes should be replaced every ~600km due to decreased shock absorption ability (4).
Tape
Low-dye taping applied to the foot can provide immediate relief from heel pain and is intended for short-term use. Success with taping may indicate that orthotics would be a suitable alternative (4).
Orthotics
Prefabricated and custom orthotics supporting the medial longitudinal arch have been shown to
improve heel pain and foot function for up to 1 year. Many studies have found no difference between prefabricated and custom orthotics in reducing pain (2,3).
Exercise
Specific stretching of the plantar fascia and calf muscles (gastrocnemuius/soleous) is effective in reducing heel pain (2, 3). Performing high-load and progressive strength training in the form of single-leg heel raises with a towel under the toes may result in greater self-reported outcomes at 3 months than compared to stretching only (5).
Manual therapy
Joint and soft-tissue mobilizations can be used to treat restrictions in range of motion, which can
improve the function of the lower extremity and decrease heel pain (3).
For more information about plantar fasciopathy or assistance in managing your condition, contact your physiotherapist.
REFERENCES
1. Cutts, S., Obi, N., Pasapula, C., & Chan, W. (2012). Plantar fasciitis. The Annals of The Royal
College of Surgeons of England, 94(8), 539-542.
2. Monteagudo, M., de Albornoz, P. M., Gutierrez, B., Tabuenca, J., & Álvarez, I. (2018). Plantar
fasciopathy: a current concepts review. EFORT open reviews, 3(8), 485-493.
3. Martin, R. L., Davenport, T. E., Reischl, S. F., McPoil, T. G., Matheson, J. W., Wukich, D. K., ... & Davis, I. (2014). Heel pain—plantar fasciitis: revision 2014. Journal of Orthopaedic & Sports Physical Therapy, 44(11), A1-A33.
4. Johnston, C. A. M., Taunton, J. E., Lloyd-Smith, D. R., & McKenzie, D. C. (2003). Preventing
running injuries. Practical approach for family doctors. Canadian Family Physician, 49(9), 1101-
1109.
5. Rathleff, M. S., Mølgaard, C. M., Fredberg, U., Kaalund, S., Andersen, K. B., Jensen, T. T., ... &
Olesen, J. L. (2015). High‐load strength training improves outcome in patients with plantar
fasciitis: A randomized controlled trial with 12‐month follow‐up. Scandinavian journal of
medicine & science in sports, 25(3), e292-e300.