Heel pain is a common and often disabling condition that frequently presents to podiatrists. It is estimated to affect 10% of runners and occurs in a similar proportion of the general public. It presents in a range of population groups including but not limited to those who are inactive, those that participate in high-level sport and people with varying foot types. Plantar heel pain can be a frustrating condition to manage, and evidence has yet to give us a clear treatment protocol to follow.
It is important for your podiatrist to determine the source of your heel pain as there are a number of structures that can be involved. There is a range of treatment options, both conservative and non-conservative. Podiatry (the study of disorders of the foot & ankle) determines what is the most appropriate option for the individual patient.
What is Heel Pain?
Plantar heel pain is a term used to describe a painful plantar / bottom aspect of your heel bone. There are a number of potential structures or differential diagnoses that must be considered when assessing a patient’s painful heel. Some of these include:
- Plantar fascia involvement (focus of this blog post)
- Calcaneal (heel) bone stress
- Fat pad contusion
- Nerve entrapment
The focus of this blog post is on Plantar Fasciitis. You will often see it referred to as Plantar Enthesopathy or Plantar Faciosis. These terms pertain to pathology of the plantar fascia. It is thought to be the most common source of plantar heel pain.
What causes Plantar Fasciitis?
Despite being one of the most common foot pathologies, the exact cause of Plantar Fasciitis is largely unknown. The plantar fascia is a thick connective tissue that runs from the base of the heel, and fans out to attach distally at the base of the toes. It has three parts, a thick central component, and a medial and lateral component. It plays a key role in shock absorption, supporting the arch of your foot and allowing you to progress through gait. Unlike muscular tissue, the plantar fascia doesn’t contain many elastic properties and as a result, it often doesn’t respond well to excessive stretch or load. Plantar Fasciitis is thought to be a condition which often appears in response to change in load beyond what someone is used to, resulting in degenerative changes in the plantar fascia.
Some of the common associations with plantar fasciitis:
- People who have jobs requiring long periods of time on feet;
- Varying foot types; both neutral, flatter foot type, or high arch foot types;
- If you have suddenly increased your activity;
- People who are overweight;
- Women who are pregnant;
- Wearing shoes that don’t fit your feet well or if your shoes are totally worn out;
- If you have tight calf or restricted ankle joint range or stiff big toe joint.
Symptoms of Plantar Fasciitis
Plantar Fasciitis can present as symptoms at the base of the heel as well as throughout the tissue itself. Commonly Plantar Fasciitis will follow an inflammatory type symptom pattern, this includes:
- Pain at the base of the heel first thing after getting out of bed;
- Pain will usually settle but not completely resolve once you have ‘warmed up’ and been moving around;
- Pain will usually return when you get up following extended periods of rest during the day;
- Return of pain at the end of a long day on your feet.
How is Plantar Fasciitis diagnosed?
As I mentioned earlier, there may be a number of causes of plantar heel pain, so often self-diagnosis can be difficult. Quite often the diagnosis is made through obtaining a thorough patient history and conducting a clinical assessment, both hands on and functional assessment. Often questions involving when you first noticed your symptoms and the type of pain you are experiencing will give the podiatrist a good idea of how and why your plantar heel pain may have started. If your podiatrist is unable to diagnose the cause of your heel pain from their initial assessment he or she may refer you to have imaging. If at any time your condition is worsening or not responding to treatment they may also refer you for imaging. This may include ultrasound, x-ray or MRI.
The good news is that there are a plethora of treatment options available to try and settle your Plantar Fasciitis. There’s no one-size-fits-all treatment plan that can be followed. What may work for one patient, may be ineffective for someone else so finding the one that works best for your particular circumstances is important. Often a combination of treatment options is used in order to result in more efficient management.
Conservative treatment options:
The main focus of our conservative treatment options is to improve heel symptoms by on reducing the load of the plantar fascia itself, and then putting in place a rehab program which improves your tissues ability to tolerate load in the future.
1) Avoid aggravating activity:
Avoiding aggravating activity or activity modification is one of the most important facets of treatment for patients with plantar heel pain. This doesn’t mean resting completely, in fact, complete rest in majority cases should be avoided. If you have a job where you are standing on your feet or walking most of the day, try to take regular breaks to sit down and give your feet a rest.
Runners, if you’ve noticed that running on hard surfaces irritates your heel, try mixing up your running surfaces to something softer such as a track or grassy field. As part of your load management, cross-training may be advised. You may be required to reduce running frequency/intensity and substitute your cardio for less foot loading activities such as bike sessions or using a cross trainer again until their symptoms settle.
2) Finding the Right Shoes
We often find that patients who present with Plantar Fasciitis will often wear flat style shoes such as ballet flats. It is really important especially in the early stages of management that you avoid flat pitched shoes or bare feet.
Depending on the patient and their foot type, we may give specific shoe options for exercise.
Your podiatrist will need to put in place a plan for appropriate footwear for both day to day life and exercise. Fortunately, there are more and more excellent retailers out there that cater to different needs of our patients.
3) Taping /Orthotics
Taping has been shown to help reduce symptoms of Plantar Fasciitis. There is a number of ways people can tape, and an example is shown below in the video.
Similar to taping, the purpose of using an orthotic in patients with plantar fasciitis is to again reduce the load of the plantar fascia. There is a huge variety of orthotic options both custom and non-custom / prefabricated devices, and what you will require will depend on your foot type, activity load, time spent on feet etc.
4) Strengthening / Rehabilitation
Most of the high-quality evidence that has come out in recent years indicate that high load strengthening exercises targeting the calf and little muscles of your feet is essential in the management of patients with Plantar Fasciitis. As with most injuries, plantar fasciitis should be managed holistically and as a result, we will often refer a patient to a physiotherapist who can assist in putting in place a comprehensive lower limb rehab program. The purpose of rehabilitation will aim at improving the resilience of a patients muscles and to help to reduce the risk of re-occurrence of plantar fasciitis and other lower limb injuries.
5) Stretching / Self Massage
Self-massage or stretching the plantar fascia can be a really beneficial way to reduce your symptoms. Especially in the morning or after rest we often recommend that you spend a few minutes rolling a ball through the arch of your foot.
Often icing can provide relief to patients. If it helps, there is no harm in using it as a symptom reliever at the end of the day. Often a good idea is to use a frozen coke bottle, and while icing gently massages your foot with the bottle at the same time.
Sometimes anti-inflammatories will be used to help break the pain cycle. This shouldn’t be a first treatment option, however, and should never be done without consultation with your doctor first.
8) Night Splints:
Night splints can help reduce tightness of calf and plantar fascia that can occur overnight. In some instances, patients may benefit from a night splint.
9) Weight management:
As mentioned earlier, the key to Plantar Fasciitis management is reducing the load through the plantar fascia. As a result weight management in some cases is extremely important and should be considered in consultation with specialists.
Non-conservative treatment options:
In the case where the above conservative treatment options have been unsuccessful, consideration of other options and referral to specialists may be required. Listed below are treatment options that have been considered in the management of Plantar Fasciitis. There isn’t a lot of high-quality evidence however that supports there use, especially when used in isolation.
- Cortisone injections
- PRP injections
- Local anaesthetic injections
- Extracorporeal shock wave therapy.
- Surgical release
Hopefully, from this blog post you can see that Plantar Fasciitis is a complex pathology, and seeking professional help from a podiatrist is recommended.
Stacey is a motivated and enthusiastic podiatrist who graduated from La Trobe University. She has experience in a wide range of both public and private practices across Adelaide and Melbourne. Stacey has developed a strong interest in the diagnosis and management of injuries related to lower limb biomechanics in all types of patients, from the “weekend warrior” to the elite athlete.
She enjoys all aspects of podiatry including heel pain, sports-related injuries, ingrown toenails, and paediatric care, and prides herself on developing long-term relationships with her patients. Outside of work, Stacey enjoys a wide range of sport, especially AFL and is a big supporter of the Richmond Football Club where her husband has recently retired from playing. She is passionate about all types of dance after spending more than 10 years competing in Dancesport around Australia and performing internationally.