DO YOUR FIRST FEW STEPS IN THE MORNING REALLY HURT?

DOES THE PAIN SEEM TO EASE WHEN YOU START WALKING ONLY TO WORSEN AGAIN AFTERWARDS?

HAVE YOU TRIED REST BUT IT HASN’T HELPED?

Anatomy

There is a band of tissue (aponeurosis) that is composed of 3 segments that arises from the heel bone (calcaneus) and then divide as they attach into the toes. The central segment forms the medial longitudinal arch and arises from the inside border of the foot. It is important in providing structural support to the arch of your foot to help propel you forward as you walk as well as shock absorption as your foot hits the ground.

There are also numerous nerves, muscles and tendons around this area all of which can contribute to pain but the most common causes of pain in the heel or arch of the foot is plantar fasciitis.

How do I know if I have plantar fasciitis?

  • The pain is usually gradual in onset and develops into the arch of the foot close to the heel bone. It can also be present around the heel itself.
  • It is often described as a sharp, stabbing pain during load bearing activity but as a dull ache when the foot is rested.
  • The first few steps taken in the morning are often very sore but ease after 10-20 mins of walking.
  • As you move through the day symptoms may seem better, only to worsen again at the end of the day depending on how active you have been.
  • Periods of rest or inactivity i.e. resting from running or walking may seem to help but when you return to exercise the pain can often be the same, if not worse!
  • Medication doesn’t really seem to help.
  • It gets worse with time.
  • Pain seems to ease in a slight heeled shoe or when in a structured trainer but is worse when bare foot. You may find yourself raising your heel off the floor to ease symptoms.
  • There is no visible change to the foot and area of pain but if pressed hard the site can be acutely tender.

What has caused this?

To be honest, we don’t really know, but the condition seems to develop when the tissues in the foot are put under more pressure than they are used to. This can result in a change in the micro-structure of the plantar fascia, thus causing subsequent symptoms. The common presenting factors associated with the development of the condition include:

  1. Ankle stiffness: some of us are genetically stiff through our ankles and this often causes no problem at all. But combine this with some of the other factors below and it can create the perfect recipe for plantar fasciitis. Sudden changes in ankle mobility e.g. post-surgical intervention can also change biomechanics of the foot and ankle and in doing so will alter the loads imposed on the tissues.
  2. Muscle tightness: the muscles in your calf are a continuum with the fascia in your feet. Restricted range in the calf is considered to overload the plantar fascia.
  3. Muscle weakness: this has a similar influence as described above. If the calf muscles are weak and struggle to lift the heel to help propel you forward, then the plantar fascia will be placed under increased strain.
  4. Footwear: this is a complex topic but to highlight some of the main points: one model does not fit all of us and some fashion footwear is unfortunately poorly designed to support the foot. Shoes will also break down in structure over time and all these variables will influence the amount of load your foot and lower limb is subjected to.
  5. Elevated BMI: increase weight=increased load = increased plantar fascia strain. Note plantar fasciitis will commonly develop during pregnancy.
  6. Overload/ change in routine or training pattern: I developed plantar fasciitis when I started to do sprinting and plyometric/ jumping drills as I attempted to increase my running speed. This sudden change is my training caused a slight pain in my one foot and then the other: plantar fasciitis. A sudden increase in running distance, a change of sport, or a change in the amount of walking done during the daily commute are all previous activities that have also been involved in the development of this condition.

Will it get better and how long is it going to take?

Yes! Plantar fasciitis will resolve but it can be a very troublesome condition to treat and in some cases it can take up to a year. Generally, the shorter the time you have had symptoms the easier it is to address causative factors and settle pain. Please also note that the condition can reoccur unless measures are taken to address the potential causes.

3 tips for the treatment of plantar fasciitis

  1. Taping/ heel raises: in the early stages symptoms can be really limiting. Often walking can become very sore. It is important we still load the tissues but providing some assistance or offload to the area can be very effective in helping you still function day to day. There is a form of taping that I have shared on my Instagram page that you can try yourself. Placing a heel raise in your shoe can also ease pain. These can be bought over the counter or the internet and I would normally recommend an 8mm lift.

NOTE: SUPPORTIVE FOOTWEAR IS GOING TO BE THE MOST COMFORTABLE E.G. A STRUCTURED TRAINER, NOT BALLET FLATS, FLIP FLOPS, UGG BOOTS OR CONVERSE TRAINERS.

  1. Rest is not always best: If you cease all exercise then return to the gym or running 4 weeks later then you are imposing a sudden increase in load on the fascia which was the cause in the first place. We need to find a comfortable level for you to exercise whether this is running or walking and introduce some exercises to build strength and ‘load capacity’ to the area at the same time. As you adapt and get stronger the amount you can do will progressively increase. What exercises to do and how much to do is best done by a healthcare professional.
  2. Keep strong: with every step you take when walking or running etc. your muscles are subjected to load. Strength training increases the capacity of a muscle to cope with load. If you enjoy running I recommend that your weekly training also involves at least 2 sessions of strength training focusing on muscles through the trunk and lower limb including the glutes, quadriceps, hamstrings and calf muscles. This helps take pressure off the plantar fascia.

I have had this for over a year why isn’t it going away!!!

I emphasize the point that plantar fasciitis is a difficult and very stubborn condition to treat. We have a toolbox of treatment techniques available but it can be very persistent. In most of the longstanding cases I have seen the main reasons for ongoing symptoms include treatment programmes being ceased too early, causative factors not being addressed and poor compliance with the treatment provided. There are 2 pieces of advice for those of you suffering with longstanding symptoms:

1: SOMETHING MUST CHANGE: there will be a reason for the pain developing and so something needs to change if the pain is to be resolved. You can not rely on manual treatments. If you want constant massage or taping but fail to address other factors in your lifestyle e.g. training programmes or footwear then symptoms will almost certainly persist.

2: HAVE YOU GOT THE CORRECT DIAGNOSIS? there are other structures that can account for pain in the arch or heel of your foot. Nerves, bone, joints and tendons can all generate symptoms in this area. Remember that diagnosis is key so if you seeing no change in your condition then be sure that you are treating the right problem.

SO IN SUMMARY……….

  • Plantar fasciitis tends to be a condition caused by overload. There are a number of factors that can cause this.
  • Modified activity, taping and strength training are important in treating the condition.
  • Address symptoms early for the fastest recovery.
Davina Sherwood
Specialist Musculoskeletal Physiotherapist