Treating Plantar Fasciitis

Patients often ask me what some of the most common injuries I treat are, and being a PT in a predominantly walking city, it’s no surprise that foot/heel pain is among the most prevalent. Although foot and heel pain arecommon, it is often mis-diagnosed, and treatment is poorly understood. Far too often, by the time the patient makes it to my office, they are in significant pain and running out of hope. Among the most common causes of foot and heel pain is plantar fasciitis. So what exactly is it?

Plantar fasciitis is a common and often persistent kind of repetitive strain injury afflicting runners, walkers and hikers, and nearly anyone who stands for a living (cashiers, for instance), especially on hard surfaces. Working on concrete and running on pavement are probable risk factors.

Most people recover from plantar fasciitis with a little rest, arch support (regular shoe inserts or just comfy shoes), and stretching, but not everyone. Plantar fasciitis can be stubborn, and severe chronic cases can stop you in your tracks, undermine your fitness and general health, and drag on for years if left untreated. Don’t lose hope though, because with the right physical therapist and course of treatment, studies have shown conservative treatment to be effective in 90% of patients.

Let’s first start by discussing the common symptoms of plantar fasciitis:

  • It causes mainly foot arch pain and/or heel pain which is worsened upon weight bearing
  • Stopping suddenly
  • Morning foot pain is a signature symptom
  • Plantar fasciitis is not the same thing as heel spurs and flat feet, but they are related and often confused

What is Plantar Fasciitis?

Plantar fasciitis is a foot injury caused by an overuse, stretch or a rupture of the plantar fascia, a fibrous membrane that goes from the bone of the heel to the base of the toes. This membrane is the “floor” of the foot. About 1% of the population is affected.From the physiological point of view, plantar fasciitis is the reflection of an inflammation of the plantar fascia. This fascia covers and protects tendons and other deep structures of the foot. It helps maintain the arch of the foot. Inflammation appears as a result of abrasion of the fascia.

The arch of the foot functions like a bow (as in a bow & arrow) and the plantar fascia is like the string of the bow. The tension in the “bow string” holds the shape of the arch. But every time you step, the “bow string” stretches, and when stretched too hard & too often, it gets irritated. These irritations lead to inflammation and pain, and occasionally tears.

What are risk factors?

  • Increased mechanical stress and biomechanical imbalance
    • Foot overpronation, discrepancy in leg length, excessive lateral tibial torsion and excessive femoral anteversion
  • Functional risk factors include tightness and weakness in the gastrocnemius, soleus, Achilles tendon and intrinsic foot muscles
  • Poor footwear
    • Flats or shoes that do not support the arch of the foot or heel, resulting in a biomechanical imbalance
    • Shoes whose soles or heels are too hard
    • High heels
  • Inadequate warm up before sports or physical activity
  • High arches (hollow feet) or flat feet
  • Walking or standing on hard surfaces
  • A history of an increase in weight-bearing activities is common, especially those involving running, which causes microtrauma to the plantar fascia and exceeds the body’s capacity to recover
  • The normal aging of the plantar fascia makes it more susceptible to tears as the fascia lose their flexibility with age

What to do at the first sign of foot or heel pain:

When such a problem is diagnosed, it is important to reduce physical activity and to have adequate care not to inflame the plantar fascia even more. Otherwise, fasciitis is likely to worsen. People who suffered once retain a fragility and increased risk of getting it again.

  • Possible consequences if left untreated:
    • Since the foot is constantly under pressure from standing and walking, the pain may persist if nothing is done to correct the situation.
    • Over time, a heel spur may appear(it is a small bone spur that forms where the plantar fascia joins the bone of the heel).
    • In very rare cases, the calcium heel spur forms a bony outgrowth big enough to be felt under the skin. The heel spur itself causes no pain but the inflammation caused by plantar fasciitis to the plantar fascia.

Treatment guide for plantar fasciitis:

  • Ice and rest
    • Freeze a water bottle and roll the foot over it for an ice massage for 10 minutes
    • Freeze water in a dixie cup, rip off the top half of the cup and ice the plantar fascia and heel pad
  • Stretching and soft tissue mobilization
    • 1st Toe Stretch-Sit on a yoga mat or a plinth with your affected leg extended out in front of you, unaffected leg bent. Reach forward and grab the tops of your toes. Movement: Gently pull your toes up with your hand, curling them towards you. Make sure that your ankle stays in a resting position and that your ankle does not move in or out. Hold 10 seconds x 10 reps.
    • 2-way calf stretch-
      • Gastroc- Begin by standing with the leg you wish to stretch behind the other.  While holding on to a stable surface gently lean forward, bending your front knee.  Make sure to keep your back knee straight and heel firmly planted on the ground.  Continue until you feel a stretch in your calf. Hold 30 seconds x 3-5 reps
      • Soleus- Repeat stretch as explained above, however bend the back knee this time in order to feel the stretch lower in the calf/Achilles. Hold 30 seconds x 3-5 reps
    • Supine Hamstring Stretch- Lay on your back with a belt around your foot and hold on with both hands.  Begin lifting your leg up, keeping your knee straight.  Use the belt to provide a comfortable stretch behind the back of your leg and knee. Hold 30 sec x 3-5 reps
    • Foam rolling/Lacrosse ball release
      • Arch of foot/plantar fascia-Sit in a chair and begin by placing a tennis ball under your foot, directly in front of your heel. Slowly move your foot back and forth so that the tennis ball massages from your heel to the ball of your foot. This can be done by slowly flexing and extending your knee ~10 degrees
      • Calf-Begin by sitting on the floor and placing a foam roller under your lower calves. Next, put your hands flat on the ground next to your hips. Lift your body off the floor and slowly move your body forwards and backwards so that the foam rolls along your calf muscles. Perform this forward and backwards motion by flexing/extending your shoulders. You may apply pressure down against the foam roller as tolerated
      • Hamstring-Same position as above however the foam roller or lacrosse ball will be placed under the back of your thigh along the hamstring musculature
  • Foot/arch strengthening
    • Arch Doming-Starting Position: Standing barefoot flat on the floor. Movement: Curl your toes downward. Keep the ball of your foot on the ground with your toes curled and actively try to increase the height of your arch. Return to the starting position. Tip: Do not lift any part of your foot off the ground. Hold 10 seconds x 10 repsTo increase the difficulty of this exercise perform in the following positions
        • Half-kneeling
        • Tandem stance
        • Single limb stance
    • Towel Scrunch-Sit near the edge of a chair with your hips/knees at a 90/90 degree angle, your feet flat on the floor. Place a towel under your feet. Engage your lower abdominal muscles to maintain a neutral spine position. Movement: Attempt to curl your toes and grab the towel with them. Make sure that you do not lift your ankle/foot off the floor as you are curling the towel with your toes. Continue to do so until the towel is mostly curled up, and then straighten out the towel and start again. Perform for 3 minutes
  • Hip/glute strengthening
    • Bridge with arch-Begin by lying with knees bent and both feet placed on the floor with arms at your sides.  Raise your hips off the surface by squeezing your gluteal muscles, maintain arch in feet as instructed above.  Attempt to bring the hips up to where they are in line  between the knees and shoulders. Perform 10 reps x 10 seconds each
    • Lateral Band Walks-Begin with an exercise band looped around your ankles. Keeping your knees slightly bent, step your foot out to the side. Slowly follow with the opposite foot. Make sure to keep your feet pointed forward at all times. Perform 3 sets x 10 reps in each direction
  • Balance training
    • Single limb stance-Balance on one leg while maintaining an arch in your foot. Hold for 30 sec x 5 reps
    • Russian Dead Lift-Begin by holding a barbell or weights in your hands and stand on the leg to be exercised.  Slowly lean forward until chest is parallel with the ground while simultaneously extending the opposite leg backwards keeping it in line with the trunk.  Slowly return to the starting position.  Perform 3 sets x 10 reps each

Adjunct treatments:

  • Investing in proper footwear
  • Corticosteroid injections
  • Night splints/stretch splint
  • NSAID’s/Anti-inflammatories
  • Orthotics and Arch supports
  • Surgery

Be sure to come and see us here at Cynergy to get you back to optimal performance!

In Good Health,
Kayla Rutherford, PT, DPT, CSCS

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