By: Kit Whiting
What is Plantar Fasciitis?
Plantar fasciitis is an inflammation of the connective tissue on the bottom surface of the foot extending from the heel toward the toes. The pain is usually characterized by extreme pain and stiffness upon initial weight bearing in the morning, with the intensity decreasing as the foot “warms up.” Typically, plantar fasciitis is caused by stress to the plantar tissue resulting from increased activity, intrinsic muscle fatigue or weakness, chronic overuse, or a repetitive pull on its origin. Occasionally, it is the result of a bony growth extending into the fascia called a calcaneal spur, or heel spur, but these are often asymptomatic. If you have recently augmented your training program, either through mileage or intensity, you may be experiencing some of these symptoms.
Plantar fasciitis can also be the result of an abnormal foot position, either pronated or supinated. A pronated foot tends to have excessive motion at the subtalar joint, which may cause overstretching of the plantar fascia. A supinated foot is more rigid, and the high, arched foot position shortens the plantar fascia, making it tight and unable to diffuse forces during loading. In both cases, orthotics may be indicated.
How do I treat Plantar Fasciitis?
There are many options currently available for runners and other athletes in the treatment of plantar fasciitis. Many of these treatments are combined in order to maximize the effectiveness of each modality.
Ice vs. heat
People often wonder whether they should be using ice or heat when self-treating at home. Ice should be used in the acute stages of an injury, or within the first two weeks of the damage. However, with chronic inflammation caused from repetitive strain and overuse, ice continues to be the modality of choice. The cold causes the capillaries to constrict, and when the cold is removed, a massive influx of blood is then shunted into the area, bringing nutrients to the tissue and flushing out toxins. Heat can still be appropriate after the acute stage of injury, particularly if one has a cold sensitivity. Heat causes capillary dilation, also allowing for increased blood flow to the tissue. During the winter, heat is preferred by many for its relaxation properties as well. An alternating program of ice/heat creates a “pumping” action into the tissue that can be very effective in the sub acute stages of injury.
Deep tissue cross-fiber friction/ Massage
Although the literature does not give much evidence for employing deep tissue massage (DTM) specifically for plantar fasciitis, DTM has been shown to have significant success in treating other fascial injuries, such as iliotibial band inflammations (ITB syndrome). Despite the painful nature of this treatment, it has been shown to be an effective way of breaking up the collagen fibers laid down as scar tissue during the inflammatory process, thereby increasing the efficacy of muscle contraction and efficiency of recovery, improving localized blood flow, preventing adhesion formation to surrounding tissues, and restructuring the fascia with a more mobile, healthy alignment.
Plantar fasciitis is sometimes an extension of tight calves and/or Achilles tendon tension. It is important that these structures be stretched without putting unnecessary strain on the plantar fascia while it remains inflamed. Ask your physical therapist about appropriate stretches for your condition. Low-dye taping techniques can be used to decrease the tension on the plantar fascia and provide a mechanical support to assist in stabilizing the foot during rehabilitation.
Plastic or fabric tension night splints put the foot into approximately 5? of dorsiflexion (flexed foot position) to create a mild stretch on the tissue while the patient is sleeping. To date, the literature has not shown them to be an effective treatment, most likely due to poor patient compliance in their wear schedule. (They’re not very comfortable!)
Ultrasound, Electrical Stimulation (Interferential current)
Ultrasound (US)and Electrical stimulation are two modalities used to increase local circulation, decrease inflammation, and in some cases, can modulate pain. US uses continuous sound waves to heat up tissue, or pulsed waves to decrease inflammation. Estim also reduces inflammation by using two medium frequency currents that cross and form a point of low frequency current. This crossed current increases blood flow to that area and creates a pulsed, low-grade muscle contraction that can fatigue an overly stimulated or spasming muscle.
Iontophoresis is a local steroid injection that is driven into the focal point of pain by using negative and positive poles of electrical current. Multiple injections are typically administered to achieve the desired results. This modality has been shown to be very effective for runners in reducing pain and focal inflammation, restoring range of motion, and improving overall function.
Custom foot orthotics have been shown to greatly enhance the biomechanical management of a pronated or supinated foot. Heel cups, wedges, metatarsal pads, arch supports, and other modifications can be added to accommodate for various misalignments. Ask your physical therapist about whether an insert or an orthotic might be helpful for you.
Electrocorporeal Shock Wave Therapy
Electrocorporeal shock wave therapy (ESWT) is a relatively new treatment for plantar fasciitis. It is recommended as a last resort before surgery, after corticosteroid injections have been tried. It uses between 0.02 mJ/mm2 and 0.08 mJ/ mm2 of energy which, in the literature, is delivered three times at various impulses ranging from 10 to 1000, depending on the study. The literature is mixed on the outcomes of ESWT, suggesting that some evidence exists for its effectiveness, but questioning the quality of the studies themselves. Other outcomes report an 88% patient satisfaction rate for individuals who underwent ESWT after 6 months of conservative treatment. New studies have recently shown more positive outcomes in certain patient populations. See your doctor for more information.
Corticosteroid injections/ Surgery
Surgery is rarely indicated in the management of plantar fasciitis. In a 1999 study by Davies et al. in Foot and Ankle International, of 43 patients who underwent surgical procedures, less than half were satisfied with the results. In all cases, surgery was a last resort when conservative treatment had failed. Some evidence exists for a series of 2-3 corticosteroid injections, although the results are suggestive of more short-term than long-term relief of symptoms. Consult your doctor or orthopedic surgeon regarding both of these procedures.
Kit Whiting is a Doctor of Physical Therapy
Living in Boulder we often search out alternative treatments before resorting to surgery, and Acupuncture has been used by some to treat and relieve these symptoms. It is the recommendation of In Motion Rehabilitation, to find out the cause of the injury first, as it results from mechanical stress. Get treatment from a physical therapist and augment that treatment with Acupuncture to help in the healing process.
Crawford, F. and Thomson, C. (2003). Interventions for treating plantar heel pain. The Cochrane Library, 1, 2004.
Davies, M.S., Weiss, G.A., Saxby, T.S. (1999). Plantar fasciitis: how successful is surgical interventions? Foot and Ankle International, 20, 803-807.
Gudeman, S. D., Eisele, S.A., Heidt, R.S., Colosimo, & A.J., Stroupe, A.L. (1997). Treatment of plantar fasciitis by iontophoresis of 0.4% dexamethasone: a randomized, double-blind, placebo-controlled study. American Journal of Sports Medicine, 25, 312-317.
Shea, M. (2003). Plantar fasciitis. Journal of Bone and Joint Surgery, 85, 576-583.
Yeung, E.W. and Yeung, S.S. (2001). Interventions for preventing lower limb soft-tissue injuries in runners. The Cochrane Library, 1, 2004.