Plantar Fasciitis Heel Pain Treatment

Research has demonstrated a considerable association between limited ankle joint range of motion and plantar fasciitis. 211 of 254 (83%) patients had limited ankle dorsiflexion (Patel & DiGiovanni 2011). Dorsiflexion is the movement which points the foot towards shin bone.

DiGiovanni and colleagues (2003) compared protocols of Achilles tendon stretching versus specific stretching of the plantar fascia. An Improvement was found in the plantar fascia stretch specific group at 8 weeks in 52% of patients, compared with 22% in the Achilles tendon only stretching group.

It is has recently been found that patients are 8 times more likely to develop plantar fasciitis with tight hamstrings. The Labovitz et al (2011) study results indicate that an increase in hamstring tightness may induce prolonged forefoot loading and through the windlass mechanism be a factor that increases repetitive injury to the plantar fascia.

Soft tissue stretching exercises are generally very safe, low risk treatment with no common associated risks providing they are done with the correct technique. If you experience any pain whilst performing any of these exercises you discontinue them immediately and consult your medical doctor.

Poor flexibility of the posterior leg muscles (muscles at the back of the leg) is one of the main contributing factors to the development of plantar fasciitis due to the excess mechanical overloading that occurs on the plantar fascia.

There is also a good body of evidence to prove this association. Addressing posterior leg tightness is the most important factor that must be addressed in the treatment of plantar fasciitis.

Plantar Fasciitis Stretching Exercises

There is evidence to demonstrate an association of weak plantarflexor muscles with plantar fasciitis and other foot disorders (Kibler et al 1991; ). Although it is not known if the strength deficits are present before injury or whether they are caused secondary to the condition.

The authors from this study (Kibler et al 1991) concluded that a strength deficit of the posterior calf is present in the foot suffering with plantar fasciitis, which creates a functional deficit in the normal foot biomechanics. This deficit either contributes or causes to overt clinical symptoms and should be addressed in the evaluation and treatment of plantar fasciitis.

Soft tissue strengthening exercises are generally very safe, low risk treatment with no common associated risks providing they are done with the correct technique.

It is possible one may over work a muscle by doing too much of their stretching exercises and over exert themselves. It is therefore advised that you introduce the exercises regime with a modest start with very gradual progression.

If you experience any pain whilst performing the strengthening exercises you discontinue them immediately and consult your medical doctor.

Strengthening exercises play a very important role in preventing recurrence of plantar fasciitis as strengthening exercises will improve posterior calf muscle strength and help optimise gait (walking).

Plantar Fasciitis Stretching Exercises

Campbell and Inman in 1974, were the first authors to describe success with mechanical therapy using arch supports. They treated 33 patients and retrospectively reported a 94% success rate.

Another study by O’Brien and Martin, in 1985, performed a retrospective telephone survey of 41 patients with 58 painful heels.

Excellent and good results were recorded for 96.7% of the patients, most of whom received multiple therapies. Subjectively, the patients stated that insoles were the most successful treatment modality.

A recently published study by Lynch et al (1998) concluded that mechanical control of the foot via insoles was more effective than anti-inflammatory therapy or accommodative therapy in the conservative treatment of plantar fasciitis.

The use of Insoles is generally a very safe treatment option and is commonly prescribed to help with a large array of musculoskeletal conditions including plantar fasciitis.

A small percentage of people experience adverse effects from wearing insoles which may include blistering of the skin on the sole of the foot, aches and pains in other joints such as knee, hips and lower back. Wearing insoles should not cause pain.

If you experience pain as a result of wearing insoles you should stop wearing them immediately and seek advice your local podiatrist or medical doctor.

Insoles play an important role in the multi-faceted approach to treating plantar fasciitis. Like stretching exercises, insoles help address and reduce mechanical stress that leads to injury of the plantar fascia.

There is a decent amount of evidence to prove their efficacy in the treatment of plantar fasciitis and are therefore considered an evidence based treatment option which is inexpensive and safe.

Plantar Fasciitis Insoles

There has been a number of studies published looking at the effectiveness of night splints for plantar fasciitis which are detailed below:
The Journal of Foot and Ankle Surgery published a study in 2002 which compared 2 groups of patients with plantar fasciitis; group 1 wore a night splint and completed a stretching programme and group 2 only completed a stretching programme.

Group 1 results – All but two of the patients treated with night splints recovered within 8 weeks (97.8%),
Group 2 results – only 57.7% of these patients that utilized the stretching protocol recovered within 8 weeks.
Conclusion – “The night splint treatment group had a significantly shorter recovery time compared to the stretching group” (Barry et al 2002).

Another and very recent study compared two different night splint designs
An anterior night splint – this means the material of the splint covers the front of the shin bone
A posterior night splint – this means the material of the splint covers the calf muscle on the back of the leg.

The results indicate that the anterior night splint is more effective in the treatment of plantar fasciitis. It was also proven to be better tolerated and more comfortable than the posterior night splint (Attard & Singh 2012).

The night splint is a safe treatment option for plantar fasciitis with no common associated risk.

Ensure the night splint is fitted correctly and not fitted too tight to prevent.

The night splint is an incredibly effective device at eliminating heel pain first thing in the morning which is what almost every patient with plantar fasciitis suffers with.

The reasons for this are explained under the rationale section. The night splint of one of the most important treatment components for plantar fasciitis as it reduces damage to the plantar fascia when the patient gets out of bed in the morning.

This breaks the pain cycle and promotes faster recovery time from plantar fasciitis.

Plantar Fasciitis Night Splint

Despite its popularity there is a lack of evidence to support massage therapy as a treatment option for musculoskeletal injuries in isolation.

On the other hand there is recent evidence to suggest that massage can play an anti-inflammotory role and aid healing in soft tissue injuries in a similar way to that of non steroidal anti-inflammotory drugs such as ibuprofen (Crane et al 2012).

The massage roller is a safe therapeutic treatment option to aid healing of plantar fasciitis.

Massage therapy in isolation is unlikely to heal plantar fasciitis as this treatment does not address the underlying mechanical cause of the condition.

It does, however, provide a therapeutic benefit to the patient and complements other mechanical treatment modalities to aid the healing the process.

Plantar Fasciitis Massage Roller

As far as we are aware currently there have been no studies to investigate the effectiveness of footwear change in the treatment of plantar fasciitis, however an interesting case report published in a medical journal The Foot highlighted the importance of suitable footwear.

A patient presented with bilateral plantar fasciitis with a 1 month onset. Following a footwear assessment it was noted that the inner material in the heel of the shoes were excessively worn.

A simple footwear change to new shoes with no other treatment method applied, fully resolved the pain after 4 weeks (Rajput & Abboud 2004).
This study suggests that footwear is often over-looked as a causative factor in the development of plantar fasciitis and is an independent causative factor of plantar fasciitis

The importance of suitable footwear is paramount in the success of treating plantar fasciitis. Unsuitable footwear can affect the effectiveness of treatment or prolong the condition, which might be alleviated otherwise. See our available video on basic footwear advice and recommendations.

Shoes and Footwear For Plantar Fasciitis Treatment

Research supports the logical assumption above by demonstrating that obese adults experience higher plantar pressures in comparison to non-obese adults (Hills et al 2001).

One study observed that individuals with a body mass index (BMl) > 30 kg/m had an odds ratio of 5.6 for PF compared to those with a BMI < 25 kg/m2 (Riddle et al 2005).

Another study consisting of 1411 patients found that being overweight or obese significantly increased the chances of having tendinitis in general. If the person were overweight or obese, there was an increased likelihood of plantar fasciitis (Frey C & Zamora 2007).

There is an additional explanation for the link between high BMI and plantar fasciitis, Faria et al (2009) found that as body mass index increases, muscle-tendon unit stiffness also increases. This suggests that people with a higher BMI will have an increases risk of a tight Achilles tendon which as we know, increases the risk of developing plantar fasciitis.

If you are overweight and suffer with plantar fasciitis it is of paramount importance that you include weight loss as part of your treatment plan. Ignoring this simple component may prevent a person from gaining the most out of the treatment package as carrying excess weight is linked to plantar fasciitis.

Weight loss can be achieved in a number of ways. Amongst the most effective are diet and exercise. We realise this is easier said than done however there many weight loss programmes readily available that can help you achieve this.

With regards to exercise as a weight loss method we recommend low impact activities such as cycling, using a cross trainer or rowing machine or swimming as these will not cause impact related pain to the heel. Running, particularly on a hard surface not recommended and may worsen your plantar fasciitis as it is a high impact activity.

There is limited high quality research to support the effectiveness of strapping for plantar fasciitis.

Saxelby and colleagues (1997) found a significant improvement in symptoms with the use of taping, however the study group was very small (9 participants) and was only tested over two days.

A decent study was conducted looking at the biomechanical effect of taping at reducing medial arch collapse. It was demonstrated that there are measurable changes to medial arch height and amount of arch height deformation during gait following low-Dye taping.

Although changes were present immediately after application, results were diminished 48 h after application. The most likely explanation for this is the material fatigue of the tape after 48 hours.

Finally a recent systematic review regarding the efficacy of taping concluded – There is limited evidence that taping can reduce pain in the short term in patients with plantar fasciitis (Van de Water & Speknijder 2010).

Incorrect taping technique can lead to blistering of the skin.

Too much tension applied by the tape could lead constriction of the blood vessels in the foot and ankle leading to ischaemia (reduced blood supply), which can result in tissue death and amputation.

This risk is further increased in diabetic patients who often suffer with reduced blood supply to the feet and neuropathy (lack of protective sensation).

Strapping/tapping, at best, can improve plantar fasciitis symptoms in the short term.

However, mastering a correct strapping technique for self application is not an easy task and is deemed impractical as a self care treatment. There is some evidence to suggest taping is effective at reducing plantar fasciitis symptoms but only as a short term effect.

In order for taping to work in long term it would require the patient to continue to tape their foot over months on a daily basis. More importantly due to the limited existing supportive evidence on strapping as an effective treatment for plantar fasciitis we do not recommend the usage of strapping.

Currently there is no consensus of what strapping technique is the most effective therefore we do not recommend any strapping technique suggestions. On the other hand strapping is a low risk treatment.

There is indeed evidence that reports symptomatic relief following surgery (Barrett et al 1995).

However, insufficient data of high quality research exists to support the various surgical procedures available for use in the surgical treatment of plantar fasciitis.

There is no guarantee that surgery will relieve the pain.

Common reported problems following surgery include; stress fractures, lateral column pain, acquired flat foot, and midfoot arthritis (Huang et al 1993; Robert et al 2000).

A avoid surgery at all costs.

Although there is evidence to suggest that plantar fascia release surgery relieves plantar fasciitis specific pain, this surgery is considered a slippery slope to further problems.

There is an increased risk of going on to develop other foot related pain, as the plantar fascia is crucial to normal foot function and support (Brugh et al 2006).

Relieving the plantar fascia tissue of its duty will result in the remaining soft tissue of the lower limb having to work harder to compensate, predisposing to a new problem which can be more painful than the initial heel symptoms.

Unfortunately steroid injections come with their risks. Firstly, as with most injections, steroid injections are a painful experience.

Corticosteroid infiltration has been found to predispose the plantar fascia to rupture and to encourage the heel fat bad to become thinner, which means you heel has less fat pad available to aid in shock absorption. (Sellman 1994).

Corticosteroid injections provide temporary relief from pain and are recommended only in extreme cases, as they may increase the risk of infection and contribute to further degeneration of the plantar fascia and heel fat pad (Roxas 2005).

Best avoided.

In light of recent evidence that plantar fasciitis is more accurately defined as plantar fasciosis, which is a degenerative condition as opposed to an inflammatory condition there is little justification for injecting a potent anti-inflammatory which is not guaranteed to work and comes with risks.

The evidence on extracorporeal shockwave therapy (ESWT) for refractory plantar fasciitis raises no major safety concerns; however, current evidence on its efficacy is inconsistent.

In a double blind randomised trial to evaluate the role of ESWT, Speed et al. have found no treatment effect of moderate dose ESWT in subjects with plantar fasciitis.

The results of their study indicate that moderate dose ESWT delivered using an electromagnetic generator has no significant benefit over placebo.

Although considered a non-invasive procedure ESWT can be painful and a local anaesthetic injection is sometimes used to anaesthetise the heel which brings about other health risks, including cardiotoxicity, anaphylactic reaction, localised nerve and vessel damage.

Although the technique is widely reported to be safe, there is a potential for haemorrhage and local soft tissue damage through cavitation (Speed et 2003).

ESWT is a plausible treatment option for plantar fasciitis, however it is very expensive costing as much as up to over $1000.

This is a high price for a treatment with limited supportive evidence. This treatment option should only be considered after failing other conservative treatments and as an alternative last resort to surgery.

Despite the rather attractive claims of therapeautic ultrasound, unfortunately there is very limited evidence that active therapeutic ultrasound is more effective than placebo ultrasound for treating people with pain or a range of musculoskeletal injuries or for promoting soft tissue healing (Robertson & Baker 2001).

Amongst the most come treatment options available for plantar fasciitis, therapeutic ultrasound has perhaps the weakest evidence base for its efficacy.

At best, ultrasound may serve an anti-inflammatory purpose which may aid healing of plantar fasciitis.

However, like other anti-inflammatory treatments, ultrasound does not address the underlying cause of plantar fasciitis which is a mechanical cause and is therefore not considered an essential treatment component.

A randomised control trial on acupuncture for the treatment of plantar fasciitis was conducted by Zhang et al (2011). The study compared two different needling techniques: The treatment group (28 participants) received needling at the acupoint PC 7, which is purported to have a specific effect for heel pain. The control group (25 participants) received needling at the acupoint Hegu (LI 4), which has analgesic properties.

In the treatment they found a 40% reduction of morning pain at 1 month follow up, which would be of significance to the patient. The control group demonstrated no improvement however. A limitation to this study was that the authors were not able to assess the efficacy of the intended acupuncture treatment compared with placebo. Therefore it is uncertain whether the positive effects from acupuncture were a result of the specific needling technique, a placebo effect, or a combination of both.

When conducted by a qualified practitioner, acupuncture is safe.

Mild, short-lasting side effects occur in around 7-11% of patients. These include:

pain where the needles puncture the skin
bleeding or bruising where the needles puncture the skin
drowsiness
worsening of pre-existing symptoms

Serious complications from treatment, such as infections or damage to tissue, are extremely rare. They usually occur only as a result of bad practice, carried out by an acupuncturist who has not been properly trained

The available evidence suggests that acupuncture may have positive anti-inflammatory effects on plantar fasciitis pain in the short term.

However, there is no evidence to suggest it is any more effective than conventional anti-inflammatories including ice therapy and non steroidal anti-inflammotory medication such as ibuprofen.

This treatment method like other reported antiflammatory treatments may compliment healing; however it should not be relied on as a long term resolution to plantar fasciitis as it does not address the underlying cause of plantar fasciitis.

Increased risk of deep vein thrombosis (blood clot) due to prolong immobilisation (Healy et al 2010).

Decreased muscle tone and shrinkage of the lower limb muscles (atrophy).

There is the possibility of decreased circulation if the cast, splint, or brace fits too tightly.

Excessive pressure over a nerve can cause irritation or possible damage if not corrected.

Immobilisation can play a very important role in the treatment of plantar fasciitis in chronic cases that have failed conservative treatment and should most definitely be applied before considering surgical intervention.

Once a patient has immobilised the foot for 4-6 weeks to allow healing this should be followed up with rehabilitation programme to prevent recurrence of the condition. Our treatment package is designed to do exactly that.