PLANTAR FASCIITIS AND HEEL PAIN: Current Evidence and Best Practice For Exercise Programming.

COGENT EVIDENCE

Folarin Babatunde PT PhD MScSEM MScPT BScPT

Plantar fasciitis (fashee-EYE-tiss) or plantar heel pain is the most common cause of pain at the bottom of the heel in adults and affects 4%–70% of the community. Plantar fasciitis accounts for 15% of all adult foot complaints requiring professional care and is prevalent in both nonathletic and athletic populations. It mostly affects sedentary middle-aged ,and older adults, and is estimated to account for 8% of all injuries related to running. In the athletic population, plantar fasciitis is a common injury reported by high school, competitive, and recreational distance runners. Current evidence supports the inclusion of exercises as part of the best practice guideline for managing plantar fasciitis.

Anatomy

The plantar fascia is a long, thin ligament that lies directly beneath the skin on the bottom of your foot. It connects the heel to the front of your foot and supports the arch of your foot. The plantar fascia is an aponeurosis that originates from the medial side of the calcaneus (heel bone) and goes all the way down to attach to the bones in the toes. The Windlass Mechanism is a term used to describe how the plantar fascia acts like a pulley, developing tension during dorsiflexion (lifting) of the big toe. This shortens the distance between the calcaneus and the metatarsals, as the plantar fascia winds around the metatarsal head causing a rise in the medial longitudinal arch. Together with the intrinsic foot muscles the plantar fascia stabilizes the arch and provides dynamic sensory and motor control to the foot.

What Causes Plantar Fasciitis?

The plantar fascia is designed to absorb the high stresses and strains placed on our feet during walking, running, and doing other activities like playing sports. However, too much pressure damages or tears the tissues in the plantar fascia and the body's natural response to injury is inflammation, which results in the heel pain and stiffness.  Plantar fasciitis occurs when the plantar fascia, a strong band of tissue that supports the arch of your foot, becomes irritated and inflamed.

Other common conditions such as fat pad contusion, and less common conditions such as calcaneal stress and traumatic fractures, medial calcaneal nerve entrapment, lateral plantar nerve entrapment, tarsal tunnel syndrome, talar stress fracture, retrocalcaneal bursitis, spondyloarthropathies, osteoid osteoma and post knee or ankle injury complex pain syndrome (CRPS Type 1) can also cause heel pain which mimics plantar fasciitis.

Figure 1: Anatomy of the foot muscles and plantar aponeurosis called plantar fasciitis

What Are The Risk Factors For Plantar Fasciitis?

There are several factors involving the development of PF. Reduction of the ankle dorsiflexion angle accompanying with calf muscle tightness was suggested to be one of the implicating factors of PF development of PF. In most cases, plantar fasciitis develops without a specific, identifiable reason. There are, however, many factors that can make you more prone to the condition:

• New or increased activity

• Runners (street running, spiked shoes, cavus foot, hind-foot varus)

• Prolonged standing on hard surfaces, time spent walking, repeated getting in and out of vehicles, 4 to 7 years employment in factory workers, nurses and teachers

• Anatomy (flat feet or a high arch foot type, decreased ankle dorsiflexion range-of-motion)

• Tight calf and hamstring muscles

• Greater Body Mass Index (BMI)

• Age (most common among adults aged 40 to 60 years)

What are The Symptoms of Plantar Fasciitis?

Plantar fasciitis is associated with impaired health-related quality of life including social isolation, a poor perception of health status and reduced functional capabilities. The most common symptoms is pain at the inferior heel region and difficulty in walking. Patients often have particular severe pain at the first few steps in the morning or after a long period of non-weight bearing activities such as sitting or lying. And this pain will appear again after having a period of weight-bearing

Self-Management Exercises for Plantar Fasciitis

Stretching of the calf muscles is regarded as a 'DO' that must be universally applied for plantar fasciitis according to current Clinical Guidelines for plantar fasciitis. Evidence suggests stretching of the ankle and foot provides short-term (2 weeks to 4 months) clinical benefit for individuals with heel pain/plantar fasciitis. The dosage for calf stretching can be either 3 times a day or 2 times a day, utilizing either a sustained (3 minutes) or intermittent (20 to 30 seconds) stretching time resting between exercises for 10 s for 10 sets. Neither dosage produced a better effect. Potential adverse effects include increased pain in the heel, calf, and other areas of the leg.

Recommendation: Clinicians should use plantar fascia–specific and gastrocnemius/soleus stretching to provide short-term (1 week to 4 months) pain relief for individuals with heel pain/plantar fasciitis

EXERCISE 1: Cross Friction Massage

Why it works: Cross friction massage is a technique applied over an area of trauma or inflammation to reduce adhesions and prevent excessive scar tissue formation. It is believed that this technique induces a traumatic increase in blood flow, facilitating the removal of substance P, through the release of histamine. Progressive cross friction massage at the origin of the plantar fascia to break down the scar tissue, may improve plantar fascia flexibility.

Figure 2: Cross-friction massage for plantar fascia.

How to do it:

1. Seated, cross right foot over left knee.

2. Grasp toes with right hand and pull back, focusing the most on big toe, until you feel a stretch along the arch of your foot.

3. Hold for 30 seconds. Then repeat on the the foot.

Research Evidence: Yelverton et al (2019) - Cross friction massage of the plantar fascia and stretching of the calf (gastrocnemius-soleus complex) showed the greatest overall improvement in terms of reducing the pain and disability and ankle dorsiflexion ROM

EXERCISE 2: Toe Stretch

Why it works: Stretching the plantar fascia helps to improve mobility in the big toe and demonstrated to be a successful technique in the management of plantar fasciitis.

Figure 3: Passive stretching of the big toe.

How to do it:

1. Perform this exercise while sitting by first

   crossing the affected leg over the opposite leg.

2. While using the hand of the affected side, place the fingers across the base of the toes on the sole of the foot and pull the toes back toward

   the shin until you feel a stretch in the arch of the foot.

3. Confirm that the stretching is correct by checking the tension in the plantar fascia with the opposite hand while performing the stretching.

   
   
   
   
   
   

Figure 4: Active stretching of the plantar fascia in standing.

A modification (shown in Figure 4) is to take the heel with the opposite hand and impose an additional longitudinal stretch on the plantar fascia.

1. Hold each stretch for a count of 10sec and repeat ten times.

2. Perform the stretching program three times per day.

3. The first stretch is to be done before taking the first step in the morning.

   
   

Research Evidence: Rompe et al (2010) - A program of manual stretching exercises specific to the plantar fascia is superior to repetitive low-energy radial shock-wave therapy for the treatment of acute symptoms of proximal plantar fascia.

EXERCISE 3: Calf (Gastrocnemius and Soleus) Stretch

Why it works: Stretching the your calf muscles helps to ease the stress on your plantar fascia due to tightness in the gastrocnemius or soleus muscles. It is essential to target both the upper gastrocnemius and the lower soleus to achieve a full stretch of the posterior leg muscles.

Figure 5: Active gastrocnemius muscle stretch in standing with the knee straight.

How to do them:

1. Stand about arm’s length from a wall or chair with both palms flat against it.

2. Step right foot back.

3. Lean into wall to feel a deep stretch in calf. Hold for 30 seconds.

4. Then bend right leg until you feel the stretch lower down calf. Hold for 30 seconds.

5. Repeat both stretches on opposite side.

Figure 6: Active soleus muscle stretch in standing with the knee bent.

Research Evidence: Boonchum et al (2020) - A home-based stretching exercise was an effective program for reducing pain, enhancing muscle strength for both extrinsic and intrinsic foot muscles in patients with PF.

EXERCISE 4: Toe Lift

Why it works: Working on the muscles that help lift your toes strengthens the muscles that run along the arch of the foot and support the plantar fascia region. This stretch has been shown to provide instant relief for most people with heel pain.

Figure 7: Toe lift exercises

How to do it:

1. Stand or sit with bare feet flat on floor.

2. Keep the four smaller toes pressed into floor, lift big toe.

3. Pause, then lower slowly.

4. Repeat. Do 10 reps.

5. Then, keeping big toe pressed into floor, lift four smaller toes.

6. Pause, then lower slowly.

7. Repeat. Do 10 reps.

EXERCISE 5: Ice Massage

Why it works: This activity works to reduce the inflammation in the foot causing heel and foot pain.

Figure 8: Ice bottle massage for plantar fasciitis

How to do it:

1. Place a towel flat on the floor and put right foot flat on a frozen plastic bottle of water or soda pop can.

2. Roll the frozen bottle/can under the foot with moderate pressure.

3. Repeat for five to ten minutes at the end of each day.

   
   
   
   
   
   

Research Evidence: (Laymon et al, 2013) - Cold applied for 20 minutes prior bedtime is effective for reduced symptomology caused by plantar fascia inflammation.

EXERCISE 6: Heel Raise

Why it works: The foot-strengthening power of this move is greatly increased when you do it on a step, with the plantar fascia taut at the start of the exercise. Begin the exercise with both feet and gently progress to doing it one leg at a time.

Figure 9: Heel Raise from the edge of a step

How to do it:

1. Stand with the ball of each foot on the edge of a step, with heels hanging off it so foot is flexed.

2. Engage your calves as you gently lift your heels.

3. Pause, then slowly lower your heel back down.

4. Repeat. Do 10 reps.

5. Modifications to this exercise includes doing the heel lift with the feet on a floor to make it easier or doing heel lift at the step with only one foot to make it harder.

Research Evidence: Boonchum et al (2020) - A home-based stretching exercise was an effective program for reducing pain, enhancing muscle strength for both extrinsic and intrinsic foot muscles in patients with PF.

EXERCISE 7: Clamshell

Why it works: Weakness in the hips contributes significantly to plantar fasciitis. This move is very effective for strengthening the hips.

Figure 10: Clamshell exercises for strengthening the hip muscles.

How to do it:

1. Lie on right side, resistance band around thighs, just above knees. Rest head on right arm. Stack shoulders, hips, and knees, with hips and knees bent about 45 degrees.

2. Engage glutes and externally rotate left hip, lifting left knee. Keep feet together.

3. Pause. Then lower back down.

4. A modification to this exercise is to do the hip movements without a band or use a band with more resistance.

5. Repeat on the other side.

6. Aim for 12 times and do 3 sets.

Research Evidence: Martin et al (2014) - A 6-week training program to strengthen the hip abductors and external rotators resulted in improved lower extremity joint load response during running.

EXERCISE 8: 4-Way Foot Flex

Why it works: This exercise strengthens the muscles of the foot, but also those of the lower leg that attach to the ankle and help support your feet as you run.

Figure 11: Ankle and foot resistance exercises using a Theraband.

How to do it:

1. Start seated with the affected knee straight.

2. Loop a long resistance band around your foot and hold it with both hands.

3. Pull toes toward you (shown in DF). Pause. Then return to neutral, toes over ankle.

4. Next, point toes against resistance band (shown in PF).

5. Pause. Then return to neutral.

6. Drive foot to the left (shown in IV).

7. Pause. Then return to center.

8. Drive foot to the right (shown in EV).

Pause. Then return to center.

9. A modification to this exercise is to use a stronger band for resistance.

Research Evidence: Huffer D et al (2017) - There are indications that high load resistance training for the plantar fascia can aid in a quicker reduction of pain and improvements in function based on the significant association between intrinsic foot muscle weakness and painful foot pathologies such as plantar fasciitis.

FOR MORE INFORMATION

Book an appointment with one of our physiotherapists at Cogent Physical Rehabilitation Center for an assessment and discussion on how physiotherapy can help you find relief from plantar fasciitis.

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Sources

1. Boonchum H. et al. Effect of a home-based stretching exercise on multisegmental foot motion and clinical outcomes in patients with plantar fasciitis. J Musculoskelet Neuronal Interact 2020;20:411-420.

2. Huffer D et al. Strength training for plantar fasciitis and the intrinsic foot musculature: A systematic review. Physical Therapy in Sport. 2017;24:44e52

3. Kamonseki et al. Effect of stretching with and without muscle strengthening exercises for the foot and hip in patients with plantar fasciitis: A randomized controlled single-blind clinical trial. Man Ther. 2016;23:76-82.

4. Laymon MS et al. Evidence-based use of cold for plantar fasciitis. Phys The and Rehab Sci. 2013;2:75-80

5. Martin RL et al. Heel Pain—Plantar Fasciitis: Revision 2014 Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability and Health From the Orthopaedic Section of the American Physical Therapy Association J Orthop Sports Phys Ther. 2014;44:A1-A23.

6. Morrissey D. et al. Management of plantar heel pain: a best practice guide informed by a systematic review, expert clinical reasoning and patient values. Br J Sports Med 2021;55:1106–1118

7. Rompe JD et al. Plantar fascia-specific stretching versus radial shock-wave therapy as initial treatment of plantar fasciopathy. J Bone Joint Surg Am. 2010;92:2514-22.

8. Yelverton et al. Manual therapy interventions in the treatment of plantar fasciitis: A comparison of three approaches. Health SA. 2019;24:1244.

   
   

Exercise Disclaimer

Before participating in any exercise program or completing any exercise please ensure you have read and understood the following:

• You should always consult with a medical professional before commencing any new exercise program or activity.

• If you have any underlying medical conditions you should consult with your Family Doctor or healthcare professional to confirm that the exercises/exercise program you are looking to follow is appropriate for you and your needs.

• If you are fit and well, or been given approval to take part in exercise by your Family Doctor or healthcare provider, please ensure that you take responsibility with regard to your health and always stop activity if a new health issue occurs or an existing condition worsens.

• Be aware that taking part in exercise does have an element of risk of injury. Therefore please take appropriate steps to ensure you are working in a safe environment, wearing appropriate attire, following instructions correctly, and have medical clearance to take part.

• If you are not feeling well before you start exercise do not continue and seek advice from a professional.

Cogent Physical Rehabilitation Center will not be held liable for any injuries caused, and will be released from any claims of negligence. Ensure your exercise/activity program is safe and effective at all times!