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Plantar Fasciitis

Plantar fasciitis

Plantar fasciitis is probably the most common cause of heel pain. Symptoms come on gradually and are often worse first thing in the morning. The plantar fascia is the tissue under the foot which forms the arch.

Treatment includes rest, reducing pain and inflammation and stretching exercises. Below we explain the condition and ways to treat it including a very effective taping technique and how to use a night splint.

Symptoms

Symptoms of plantar fasciitis consist of a gradual onset of pain under the heel which may radiate forwards into the foot. There may be tenderness under the sole of the foot and on the inside of the heel when pressing in. The pain can range from being slightly uncomfortable to very painful depending on how badly it is damaged.

Pain is usually worse first in the morning because the foot has been in a relaxed position all night and the plantar fascia temporarily shortens.  After walking around this usually eases as the tissues warm up and gradually stretch out.  When the condition is present, similar periods of moving around following inactivity such as sitting for long periods can also trigger the pain.  In the early acute stages stretching the plantar fascia may also be painful.

As the injury becomes more severe the patient may experience pain all of the time, when walking or standing and may worsen with activities such as running or playing sport.

Signs

People that suffer with plantar fasciitis often present with tight calf muscles (play assessment & diagnosis video) or have very low arches of the foot (flat feet). It is not uncommon for individuals who suffer this condition to have some biomechanical issues that contribute to the problem such as 'over pronation (rolling in or flattening of the foot) or excessive supination (rolling out).

Imaging

To diagnose plantar fasciitis a doctor may recommend an ultrasound scan of the foot.  In addition to this an X-ray may be taken to see a heel spur (extra bone) where the fascia attaches, as this is often the location of pain. However, a heel spur can be present without pain and pain may be felt with no visible heel spur. The two are not always linked.

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Treatment of plantar fasciitis

Treatment usually consists of reducing painful symptoms, stretching the tight fascia and lower leg muscles, correcting any causes and a gradual return to full fitness. Often a combination of approaches is best in treating this injury.

Self help treatment

Cold therapy wrapRest & Ice - Rest until it is not painful. Apply ice or cold therapy to help reduce pain and inflammation. Cold therapy can be applied for 10 minutes every hour if the injury is particularly painful for the first 24 to 48 hours. This can be reduced to 3 times a day as symptoms ease.

Ice should not be applied directly to the skin but through a wet tea towel to avoid skin burns. Commercial gel hot and cold packs and wraps are a more convenient method of application.

Shoes - It is difficult to rest the foot so if you have to be on your feet wear comfortable training shoes. Hard or flat soled shoes are likely to make symptoms worse.

Gel heel cupsHeel pads - A silicon gel type cushioning heel pad may help with symptoms, particularly one with a soft spot directly under the heel. Long term if there are biomechanical problems with the feet this may need correcting with a firmer orthotic type insole, however in the short term relieving symptoms is the priority.

Taping - A taping technique can help support the foot relieving pain and helping it rest.

Plantar fasciitis taping

A simple roll of 2.5cm or 1 inch non stretch zinc oxide sports tape can be applied in a number of ways which all basically take the strain off the plantar fascia relieving pain and allowing it to heal. We demonstrate two simple methods of taping the foot to relieve symptoms although we recommend getting professional advice on how to apply tape effectively.

Plantar fasciitis night splintNight splint - The plantar fasciitis night splint can be a very effective way of treating the condition. The reason the foot is so painful in the morning is because the fascia tightens up over night.

As you get warmed up from walking on the foot the pain reduces. The night splint works by helping to prevent the fascia tightening up and so relieving pain.

Stretching the plantar fasciaExercises - Specific exercises can be done if pain allows, in particular stretching the fascia is an important part of treatment and prevention. Simply reducing pain and inflammation alone is unlikely to result in long term recovery. The fascia tightens up making the origin at the heel more susceptible to stress. Later on strengthening exercises may be done to help prevent the injury recurring but stretching is the priority initially.

Read more on exercises.

Massage - Self massage can also be applied by rolling a frozen can or hard rubber ball under the arch of the foot. Putting a can in the freezer can combine a stretching massage effect with a pain and inflammation reducing effect of cold therapy.

See plantar fasciitis rehabilitation program for more.

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Professional treatment

What can a doctor or sports injury professional do?

Electrotherapy - Ultrasound or laser treatment may also help with symptoms. Ultrasound passes high frequency sound waves deep into the tissues to provide a micro massage effect. Laser sends a high intensity beam of light similarly into the painful areas. Extracorporeal shock wave therapy has been known to be successful.

Medication - A doctor may prescribe anti-inflammatory medication such as ibuprofen to help reduce pain and inflammation. Although symptoms and inflammation is likely to be reduced in the short term it is believed NSAID's or non steroidal anti-inflammatories are not thought to be particularly effective.

Foot massageMassage - Deep tissue sports massage techniques can reduce the tension in and stretch the plantar fascia and the calf muscles.

View foot massage demonstration video

Injection - A corticosteroid injection may be given in conjunction with other forms of treatment although some may be concerned with an increased risk of rupture and wasting away of the cushioning fat pad under the heel.

Gait analysis - An important part of prevention is to perform a gait analysis to determine any biomechanical problems with the foot which may be causing the injury. This can be corrected with orthotic inserts into the shoes.

Surgery - If symptoms do not resolve then surgery is an option, however this is more common for patients with a rigid high arch where the plantar fascia has shortened.

Read more on surgery

See rehabilitation program for more details.

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Anatomy

The Plantar Fascia or plantar aponeurosis as it is also known is a broad, thick band of tissue that runs from under the heel to the front of the foot. It comprises three segments which originate from the base of the heel bone (calcaneus bone).

The middle segment is most relevant to plantar fasciitis and forms the longitudinal arch of the foot providing support to the foot when standing and shock absorption when running.

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Causes

Plantar fasciitis is an overuse injury. Repetitive over-stretching of the plantar fascia under the foot leads to possible inflammation and thickening of the tendon. Through overuse the fascia can become inflamed and painful at its attachment to the heel bone or calcaneus. The condition is traditionally thought to be inflammation, however this is now believed to be incorrect due to the absence of actual inflammatory cells within the fascia.

The cause of pain is thought to be degeneration of the collagen fibres close to the attachment to the heel bone. This is more common in sports which involve running, dancing or jumping. Although overuse is ultimately the cause of injury, there are a number of factors which can increase the likelihood of developing it.

  • Overpronation - Runners who overpronate where their feet roll in or flatten too much are at risk because the plantar fascia is over stretched as the foot flattens.
  • High arched foot - People with pes cavus or a high arch in the foot are at risk because the foot is unable to absorb shock and adapt to the running surface.
  • Tight calf muscles - which restrict the ability of the foot to supinate or roll out and so increases the stress on the plantar fascia in the gait cycle.
  • Poor footwear - Excessive walking in footwear which does not provide adequate arch support has been attributed. Footwear for should be flat, lace-up and with good arch support and cushioning.
  • Overweight - Overweight individuals are more at risk of developing plantar fasciitis due to the excess weight impacting on the foot.
  • Previous injury - if you have suffered a plantar fascia strain or injured the underneath of your foot which fails to heal properly then this can lead on to plantar fasciitis.
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Similar injuries

Other causes of pain under the heel are:

  • Bruised heel or fat pad contusion caused by repetitive pounding or impact on the heel from running or landing from a jump.
  • Broken heel bone - a fracture of the calcaneus or heel bone caused by a sudden impact.
  • Calcaneal stress fracture - A fracture of the calcaneus, either caused by a direct trauma, or repetitive pounding resulting in a stress fracture
  • Calcaneal bursitis - Inflammation of the sack of fluid which sits under the heel
  • Tarsal tunnel syndrome - Entrapment of the plantar nerves as they pass round the outer ankle. Causes pain to radiate into the heel and arch of the foot
  • Heel spur - A heel spur is a growth of bone under the heel which can (but doesn't always) cause pain.

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