Plantar fasciitis is one of the most common diagnoses given to those suffering from heel pain, with almost 2 million Americans diagnosed each year. Those with plantar heel pain are usually between 35 and 65. They are often runners or slightly overweight and have occupations that require a lot of standing. But not all heel pain is the result of Plantar fasciitis, and many of today’s popular treatments have no merit. Physical Therapy for Plantar Fasciitis can help by first determining the underlying cause.
Plantar Fasciitis is a diagnosis given to most who have heel pain, yet rarely the cause of pain.
A mechanical assessment is required to properly diagnose the cause of heel pain instead of simply blaming the tissue where the symptoms are located. To determine the best treatment for Plantar Fasciitis, it is critical to first differentiate it from other conditions, so the actual problem can be treated.
Other possible diagnoses:
- Ankle derangement
- Biomechanical strain in the ankle
- *Severe’s in children
- calcaneal stress fracture
- fat pad atrophy in seniors
- Baxter’s nerve entrapment (first branch of the posterior tibial nerve)
- Referred from the low back
Symptoms of Those Diagnosed with ‘Plantar Fasciitis’:
Those diagnosed with Plantar Fasciitis have a consistent pain at the bottom of the heel upon standing or weight-bearing. The morning is always the worst. After a few steps, the heel pain improves and may even go away. But the pain returns when initially getting up after a period of inactivity and is often described as tearing or stepping on broken glass. The pain may also appear more intense on bare feet or in shoes with minimal support. There is tenderness to the touch where the plantar fascia inserts over the bottom of the medial heel. The worst part of plantar fasciitis is that it does not go away quickly, instead lingers for months and even up to a year without proper treatment.
The pain is the worst with the first step in the morning and when resuming activity after rest. It tends to decrease with continued motion. (This indicates that more weight and more use of the plantar fascia reduces the pain. The problem does not appear to stem from stress on the fascia but from the rest period. What happens during rest periods that produces pain with initial weight-bearing but corrects after a few steps?) Answering this question is important in determining the best treatment for Plantar Fasciitis.
Plantar heel pain can develop without an obvious cause, but factors can increase your risk of developing this condition and therapy for plantar fasciitis can help eliminate some of these risk factors:
- Foot mechanics. Excessive pronation, flat feet, a high arch or even an atypical pattern of walking because of the way weight is distributed when you’re standing
- Age. Plantar heel pain is most common in people between 35 and 65.
- Certain types of exercise. Activities that place a lot of stress on your heel and the soleus muscle — such as long-distance running, ballet dancing, and aerobic dance
- Obesity. Excess pounds put extra stress on your ankle joint.
- Occupations that keep you on your feet. Factory workers, teachers, and others who spend most of their work hours walking or standing on hard surfaces can be at increased risk.
Anatomy & Biomechanics:
Understanding what causes Plantar Fasciitis pain is essential to learn how to heel Plantar Fasciitis / heel pain quickly. The plantar facia is a tough, fibrous band of tissue that runs along the bottom of the foot, attaching to the heel bone (calcaneus) and the base of the toes. The plantar fascia helps maintain foot structure by supporting the arch and absorbs shock when walking. Weightbearing or standing increases tension in the plantar fascia. This tension further increases when you push off on the ball of the foot. The role of the fascia is to taunt not flexible.
During standing, 10-15 degrees of dorsiflexion is required as the lower leg glides over the foot. Joint mobility is necessary for proper loading and unloading of impact forces and in transferring the associated potential energy. If you do not have ankle mobility to allow the knee over the toes, the body will compensate by turning your foot out (walking like a duck), lifting your foot up early (bouncy gait), or pronating, making up the required motion by dropping your foot arch. Pronation causes the navicular bone to drop down and in. A slight amount of pronation is normal as pronation helps to absorb the initial shock of weight-bearing. But excessive pronation pulls on the plantar facia, leading to stress and possible micro-tears and progressive abnormalities, including the formation of heel spurs.
Tightness in your calf muscles will cause a loss of dorsiflexion. The calf is made up of two muscles, gastrocnemius and soleus muscles which taper and merge forming the Achilles tendon. The gastrocnemius is the larger with two heads forming the bulge that we normally associate with our calf. It is a powerful muscle enabling heel raises and jumping. The soleus is a smaller, flat muscle that lies underneath the gastroch. The soleus functions in prolonged running and is also a major postural muscle designed to stop the body from falling forwards at the ankle during stance. Risk factors for developing plantar heel pain include long distance running and occupations that require prolonged standing, both of which over use the soleus muscle.
Another cause of loss of dorsiflexion is a bony block due to the talus bone being shifted slightly anterior. The talus is fascinating because it is like a floating bone in that it has no muscle or tendon attachments. Because of this, it is also prone to shifting with trauma and sustained pressure. The talus can shift anteriorly due to its shape. When the talus shifts anteriorly, it blocks dorsiflexion. It feels like a “hard stop” at the end range of motion with tightness and sometimes pain at the anterior ankle. Physical therapy for Plantar Fasciitis will address loss of dorsiflexion.
What causes Plantar Fasciitis / plantar heel pain?
Today’s common perception is that tension and stress on the fascia cause small tears until, eventually, the fascia becomes inflamed, causing heel pain with weight-bearing. But research has found that plantar fascia tears are NOT associated with plantar heel pain. Instead, heel pain was associated with: thickened and abnormal plantar fascia and thickened plantar fat pad when loaded. Continued stress on the plantar fascia as it attaches to the heel may cause a spur to develop.
It is believed that heel spurs is what causes Plantar Fasciitis pain, but contrary to what you may think – the bigger the bone spur, the less pain! The body responds to stress by laying down calcium, and spurs result from excessive stress on a tissue. But to find the best treatment for Plantar Fasciitis, you need to determine first what is causing the stress on the plantar facia?
Heel pain is a symptom located at the insertion of the plantar facia to the calcaneal bone. Instead of assuming the plantar facia is the cause of pain, we need to uncover and address the actual problem!
Proper treatment requires uncovering the root cause of pain
What Causes plantar fasciitis pain? #1 Risk Factor for developing Plantar Fasciitis is reduced ankle dorsiflexion.
Ten degrees of dorsiflexion* is required to walk and at least fifteen degrees is required to run (5 deg in subtaylor neutral). Without adequate dorsiflexion, the body will compensate so that the knee can translate over the foot from stance to swing. When the calf and ankle lack adequate mobility to allow this translation, the body must make up motion in other ways, leading to pain and overuse injuries. Common compensations include excessive foot pronation and knee valgus (knocked knee). (Limited ankle dorsiflexion is also associated with Achilles and patellar tendinopathy.)
Pronation is the most common compensation for lack of ankle dorsiflexion.
If your foot pronates too much, the ankle rolls too far downward and inward with each step. Over time, compensating with pronation can cause the arch to collapse and muscles and supporting tissues to over‑stretch and lengthen. The thick fibrous band of the plantar fascia is pulled with each compensating step of excessive pronation, causing strain and eventual abnormal changes. In response, the bone may also develop a bony growth (heel spur) right in the center of the heel.
Large heel spurs and plantar fascia tears are not associated with heel pain.
If the plantar fascia and heel spurs are not the cause of heel pain, what is?
Faulty biomechanics appears to be the trigger that causes damage to the plantar fascia. The plantar fascia may cause some pain but is not the primary source. Could faulty biomechanics also cause stress elsewhere, triggering pain? It appears so.
Those with plantar heel pain note that their symptoms are always worse with the first steps in the morning. While sleeping at night, the foot rests downward. This plantarflexed position allows the Achilles tendon to tighten and also opens space for an anterior derangement. (A derangment is a disruption within the joint due to a particle or the talus bone moved anteriorly.) Night splints are one of the best treatments for Plantar Fasciitis because the splint keeps the ankle in a neutral position preventing the Achilles from tightening, and also avoids an anterior joint derangement. Night splints work because they address the Achilles tendon and the talus bone, not the plantar fascia.
A lack of ankle mobility is usually secondary to tight Achilles OR a joint derangement in which there is a bony block to normal joint mobility.
Best TREATMENT for Plantar Fasciitis:
Most common therapy for Plantar Fasciitis include anti-inflammatories and plantar fascia stretching. But do they address the problem of plantar heel pain?
- Anti-inflammatories: Heel pain comes and goes, so it cannot be caused by inflammation because pain from inflammation is constant and short-lived, similar to a toothache. Instead, plantar heel pain is worse with initial steps but relieved with continued walking.
- Plantar fascia stretching: The role of the plantar fascia is to be tight and stable to hold and support the foot arch. Stretching goes against the basic role of this dense tissue. The plantar fascia functions like a ligament; its role is to be taut to maintain the stability of our arch. Massaging the tissue, on the other hand, may help to break up abnormalities found with chronic plantar heel pain.
The most common therapy for plantar fasciitis are not the most beneficial because they do not address the root cause of symptoms. Plantar heel pain is usually diagnosed based simply on the location of pain rather than performing an in-depth assessment to determine the true problem. Treating the area where the symptoms are located, rather than the true culprit increases the risk of chronic symptoms.
Reduced ankle dorsiflexion is the #1 risk factor for developing plantar heel pain or what causes plantar fasciitis pain. This is then a key focus. When there is a loss of dorsiflexion, the required motion must be made up by altering mechanics and the most common is excessive pronation. The plantar fascia will then be stretched too much due to excessive pronation pulling on it to compensate for the loss of motion in the ankle.
A mechanical assessment investigates any loss of motion and altered biomechanics and determines why.
Varying research has demonstrated improved plantar heel pain to static Achilles stretching for the best treatment for Plantar Fasciitis. In contrast, another has shown more benefit to quick high load Achilles strengthening, but recent research has suggested slightly better outcomes with progressive loading. These variations on which is best treatment for Plantar Fasciitis boils down to the specific cause of pain. Is the heel pain secondary to a tight Achilles tendon or a stiff ankle joint secondary to the talus bone shifted anteriorly? Static Achilles stretching would aid Achilles flexibility, while dynamic strengthening and progressive loading would be more effective in reducing an anterior derangment.
Achilles stretching with the knee bent is much more effective therapy for Plantar Fasciitis than plantar fascia stretching.
This indicates that the soleus muscle is more involved than the gastrocnemius or an anterior talus benefits from more pressure over the midfoot. The soleus muscle plays a major role in distance running, as well as, the major postural muscle designed to stop the body from falling forwards at the ankle during stance.
What Causes Plantar Fasciitis pain is closely linked to abnormal tightness in the soleus muscle.
- Depending on the patient’s specific limitation, dorsiflexion stretching targeted at either the soleus muscle or the ankle joint.
- Posterior shift mobilization of talus with a band (*if talus anterior – needs to be screened by PT)
- Night splint
- Proper shoewear with arch support
- Biomechanical assessment of running to assure proper form – supination and heel out during swing.
- Modification of activity and progressive plan to return to sports/ function.
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