07 Feb How To fix Plantar Fasciitis: Get Rid of Your Heel Pain
Plantar fasciitis is one of the most nagging and limiting orthopedic pathologies in the foot. It’s estimated that nearly 2 million Americans experience plantar fasciitis each year and it is the most common condition of the foot in runners. Plantar fasciitis can be defined as inflammation of the plantar fascia and surrounding fascial tissues due to repetitive microtrauma from excessive traction and/or loading forces. However, that nagging heel pain that drives people to want to fix plantar fasciitis is typically not just an acute inflammatory condition but rather a chronic issue that is now revealing itself. In this article, we are going to discuss the common causes and risk factors for this heel pain, as well as how to fix plantar fasciitis!
What Is Plantar Fasciitis?
The plantar aponeurosis, or better known as the plantar fascia, is one of the many passive structures within the foot that provides support to the medial longitudinal arch. It is comprised of three separate bands, a medial, central, and lateral band. The most common site of patient-reported pain is usually at the medial tubercle on the plantar aspect of the heel, or calcaneus, which is the origin of the central band of the plantar fascia.
The specific cause of plantar fasciitis is poorly understood; however, there are many risk factors and impairments that have been strongly associated with plantar fasciitis. Most commonly, individuals report plantar fasciitis pain after a period of increased or unaccustomed activity, especially after a period of inactivity. This could be after partaking in more vigorous activity, increasing your running/walking mileage, or simply increasing the time spent on your feet every day at work. Additional risk factors include a body mass index between 25-30kg/m2, limited dorsiflexion range of motion, and running. A term the medical world is turning to is plantar fasciopathy because chronic plantar fasciitis can be looked at as being parallel to conditions like chronic tennis elbow or any chronic tendinitis issue, where it is more a chronic degenerative issue versus an acute inflammatory issue.
Dealing With Nagging Plantar Fascia Pain? Fix It Now!
The Foot & Ankle [P]Rehab Program is a physical therapist developed, step-by-step program that teaches you how to optimize your foot & ankle health. This 3-phase program will expose you to various foot & ankle strengthening and stabilization exercises supported by science. This program will bulletproof this region, and help combat movement impairments that often times can be contributing to your plantar fasciitis. Learn more HERE!
Fix Your Plantar Fasciitis!
Common Plantar Fasciitis Findings
- Plantar medial heel pain: most noted with initial steps in the morning or after a period of inactivity as well as prolonged weight-bearing.
- Symptoms may appear after an increase in weight-bearing activity (running, walking).
- Bone spur on the heel (due to excessive tension from the plantar fascia causing periosteal lifting of the bone).
- An antalgic (painful) gait pattern due to pain originating from the plantar fascia
There are many risk factors that are attributed to developing plantar fasciitis including stiffness in the gastroc-soleus complex, high BMI, poor ankle joint dorsiflexion, running, and an inefficient windlass mechanism, which will be defined later in this article.
Overpronation Versus Underpronation
Pronation is a normal movement that occurs at the foot whenever walking or running. As you take a step, your heel strikes the ground first. From that position, your foot will naturally ‘rollover’ from the outside portion of your foot to the inside portion of your foot.
In regards to foot pronation, there may be instances where someone will either overpronate or underpronate, which can be due to a lack of control at the foot and ankle complex, pain, or a combination of these factors. There is a misconception that only people who overpronate are at risk for plantar fasciitis, however people who underpronate can also develop fasciitis. It is the duration of how long you remain in pronation, rather than pronation itself, that is problematic.
- Overpronation: This leads to a flattening of the medial longitudinal arch (MLA) causing the plantar fascia to elongate and have increased tensile forces causing microtears. This type of foot has too much mobility.
- Underpronation: Limits shock absorption and unable to dissipate forces so the fascia takes the brunt of the load. This type of foot has too much rigidity. A stiff GSC will encourage a person with a very mobile (planus) foot to unlock the midfoot and pronate excessively as a compensation, placing stress on the fascia. A stiff GSC in a person with a stiff (cavus) foot will also apply more tension to the fascia due to the inability to absorb shock and dissipate forces.
How To Fix Plantar Fasciitis? Exercise!
The good news is that over 90% of those diagnosed with plantar fasciitis will recover in 6-12 months with conservative treatment. There are a host of conservative treatment options available that are strongly supported in the literature for treating plantar fasciitis including rehab. If you can’t see a local physical therapist, there are still plenty of things you can do at home to treat your plantar fasciitis. The first, and easiest thing to do at home, is to stretch your calf and plantar fascia. Plantar fascia-specific self-stretches and calf stretches are easy to implement and have been shown to provide short-term pain relief. Calf stretching is important because not only do tight calves limit dorsiflexion range of motion (which is a risk factor for the development of plantar fasciitis itself), but there is also a soft tissue connection between the Achilles tendon and the plantar fascia.
Thus, calf and Achilles tendon tightness can translate into plantar fascia tightness as well.
Stretching should be implemented at least two to three times per day. Calf and plantar fascia stretches can either be held for sustained or intermittent stretching times as neither dosage demonstrates a better effect in the literature. Here are some stretches you can work on!
Calf Stretch – Off Step
- HOW: Place an elevated surface next to a wall. Stand on the surface and use the wall for support. Straighten one leg as you keep your toes on the surface and let your heel drop to the ground creating a stretch in that calf. Hold that stretch for as long as prescribed.
- FEEL: You should feel a stretch in your calf.
- COMPENSATION: Keep your knee straight as you stretch. Keep your toes on the surface to create the best stretch.
Wall Calf Stretch – Knee Bent
Having the knee bent will bias your soleus muscle, which is one of your two calf muscles. It is important to stretch both of your calf muscles for optimal mobility!
Foot On Wall Calf Stretch – 3 Way
Wall Calf Stretch – Knee Straight, 3D
Joint Mobilizations For Ankle Dorsiflexion
Physical therapists might perform soft tissue mobilizations to your calf to improve dorsiflexion range of motion, or joint mobilizations to your foot and ankle to ensure that there is adequate joint motion. Inadequate joint motion means that other structures in your foot must compensate for the increased demand, and many times that structure is the plantar fascia. Specifically, limited ankle dorsiflexion has been shown to be a low to moderate risk factor for the development of plantar fasciitis. Here are some ways you can enhance your dorsiflexion mobility!
Ankle Dorsiflexion Mobilization – Static
- HOW: Get your foot set-up and supported on an elevated surface while balancing on the other leg. To perform the mobilization, bring your knee and shin bone forward over your toes while keeping your heel down on the ground. While driving the knee forward, also attempt to drive the knee slightly outward towards you pinky toe.
- FEEL: You should feel a stretch in your calf and your ankle.
- COMPENSATION: Keep your entire heel flat on the ground as best as you can
LISTEN: ANKLE DORSIFLEXION WITH [P]REHAB
Ankle Dorsiflexion Mobilization – Kettlebell
Placing a weight like a kettlebell on top of your leg as you perform this mobilization will help you create more load through the joint as you work through the movement!
Ankle Dorsiflexion Distraction
Utilizing a thick resistance band will help provide distraction of the talocrural joint, which also assists in enhancing joint mobility.
Ankle Dorsiflexion Mobilization
Big Toe Mobility
Limited great toe mobility can also be a risk factor for developing plantar fasciitis. If you do not have big toe extension and plantar fascial mobility, you will not be able to roll through your foot and your toe as you walk!
The Importance of Big Toe Mobility
Quadruped Rock Back – Big Toe Extension Bias
Big Toe Extension – AROM
Split Stance Lunge Big Toe Extension Bias
The Windlass Mechanism
The orientation of the plantar fascia helps maintain the arch of the foot when walking and to maintain the appropriate timing of pronation and supination. Originating from the calcaneus (heel) to the phalanges (toes), the plantar fascia helps to maintain the medial longitudinal arch via the windlass mechanism. The windlass mechanism occurs with dorsiflexion of the big toe (toe pointed upwards) and plantarflexion of the metatarsal, allowing for a rigid foot needed for efficient propulsion and push off during the gait cycle. If this mechanism is altered there may be over flattening of the arch causing excessive tensile stress to the fascia. If you are an overpronator, you will benefit greatly by improving your windlass mechanism, minimizing tissue stress and thus pain.
Windlass Mechanism Exercise
- Step 1: Sit in a chair with both feet placed flat on the floor
- Step 2: Raise the arch of your foot by sliding your big toe toward your heel without curling your toes or lifting your heel.
- Step 3: Hold the position for 2seconds then relax. Once you feel comfortable performing the short foot movement you can gradually progress to performing the exercise while standing and then eventually from a single-leg standing position.
Therapeutic Modalities and Taping Techniques For Plantar Fasciitis
A physical therapist can also deliver medications directly to your area of pain, such as dexamethasone or acetic acid via iontophoresis, to provide short-term pain relief. Additionally, a physical therapist can utilize taping techniques or design custom orthotics to complement their manual interventions to treat your plantar fasciitis. The goal of taping techniques and orthotics is to decrease abnormal foot pronation, which is thought to increase the stress placed on the medial longitudinal arch.
While direct evidence to establish an association between plantar fasciitis and abnormal foot motion is inconclusive, there is strong clinical support for the use of taping and foot orthotics for short-term reduction in pain as well as improvement in function. In addition, there is strong evidence for the use of night splints in the short term to reduce plantar foot pain.
Furthermore, night splints should be considered for those who have had symptoms longer than 6 months. When we sleep, our feet are in a slightly plantar flexed (toes pointed down) position; thus, our calf muscles are in a shortened position. This is counterproductive to the stretching we are doing during the day! Night splints keep the foot in a neutral position, which can limit adaptive shortening of the calf muscles, as well as decrease pain that is common with the first steps in the morning.
What About Cortisone Injections
In regards to plantar foot pain, healthcare practitioners may discuss the option of a cortisone injection to alleviate your symptoms. Research has been conflicting in regards to cortisone injections and plantar fasciitis. In the short term, an injection may help alleviate symptoms related to inflammation and pain; however, repeated injections are generally not recommended within literature to address heel pain. If you want to learn more about the specifics of cortisone injections, listen to our [P]Rehab Audio Experience Podcast that goes into the details of this topic with Dr. Alex Weber!
Foot Intrinsic Strengthening
So, how do we fix plantar fasciitis? In addition to improving your foot and ankle mobility into dorsiflexion, foot intrinsic strengthening is crucial when addressing plantar fasciitis. Studies have supported decreased foot intrinsic strength and motor control in individuals with plantar fasciitis. When first performing these exercises, they will be difficult to master. This is because the muscles in our foot are tiny, and to perform isolated contractions of these muscles, our brains must make the connections to those specific muscles! You may find that you are unable to truly isolate one muscle at a time at first, and that is ok. Do not get discouraged. The more you practice these exercises with multiple repetitions, you will master them!
The Benefits of Barefoot and Arch Lift Exercises
Seated Short Foot (Arch Lift)
The short foot exercise is promoting engagement of the muscles that help stabilize and lift the medial longitudinal arch. These muscles when active will help prevent overpronation as well as increase the rigidity of our foot.
Single Leg Short Foot
Once you are able to master the short foot exercise without compensatory movements, you will want to incorporate it with other movements you perform during exercises, such as the single limb stance shown here! The more you are able to translate that short foot to exercise, the more natural it will become, and it will translate to your functional activities as well.
Single Leg Short Foot Hold – Band
Utilizing a band can help facilitate engagement of the musculature in the foot by providing tactile feedback to your muscles.
Single Leg Woodpecker
Toes 2-5 Extension AROM
Isolated Toe Extension
Eccentric Posterior Tibialis Control
As stated in previous posts, one cause of plantar fasciitis is prolonged pronation. This is often due to posterior tibialis—known commonly as the post tib—weakness. The post tib is a primary arch stabilizer as it eccentrically controls pronation. Therefore, developing strength of the post tib is critical in helping reduce over-lengthening of the fascia, which can result in microtears and periosteal lifting (bone spurs). A traditional way to strengthen the post tib is with a Theraband around the foot while sitting in a chair or lying down, shown below.
However, a more functional approach is to perform a lateral step down. This will not only train the post tib, but also intrinsic musculature of the foot as well as the glute medius muscle as an added bonus. When you descend into the squat, your foot will naturally pronate. This pronation must be eccentrically controlled by your post tib.
Lateral Step Down
Start with both feet on top of a step. Next, slowly lower the unaffected leg down off the side of the step to lightly touch the heel to the floor. Then return to the original position with both feet on the step. If you do not have a step, a box works just as well for this exercise.
Remember! Maintain proper knee alignment: Knee in line with the 2nd toe and not passing in front of the toes.
Heel Raise – Ball Squeeze
The heel raise with a ball squeeze is a great exercise to activate the posterior tibialis. Calf strengthening is also extremely important when it comes to how to fix plantar fasciitis because if the calves aren’t doing their job, those forces will be transmitted and absorbed through passive structures like the plantar fasica! Thus don’t forget to strengthen your calves and your Achilles!
Eccentric Single Leg Heel Raise – Off Step
Eccentrics off of a step as shown here is another way to promote eccentric control of the post tib. This can easily be replicated by using a set of stairs in your home.
Proximal Stability – Don’t Forget About The Glutes!
Regional Interdependence is defined as a seemingly unrelated impairment in a remote anatomical region contributing to the primary complaints. This concept is especially important when attempting to resolve the poor biomechanics that contributes to plantar fasciitis. Proximal muscle weakness from the gluteus medius, gluteus minimus, and quadriceps may contribute to dysfunction at the foot, causing fascia irritation. How?
These proximal muscles assist with the loading response of gait—when the heel first hits the floor—which is necessary for shock absorption. If these muscles are weak, there may be an excessive transmission of shock to the structures of the feet rather than dissipation throughout the entire limb. Furthermore, weakness of the glutes causes an increase in hip internal rotation, as opposed to external rotation. External rotation is necessary for foot supination as it creates a rigid lever needed for propulsion. Poor supination due to prolonged pronation from glute weakness may cause overstress to the plantar fascia. Let us show you some ways you can strengthen your glute musculature!
Isometric Side Lying Clam – Band
Side Step – band Around Foot
Do Sidesteps The Right Way!!
How To Fix Plantar Fasciitis: Develop High Load Strength
This specific treatment strategy—known as “high-load strength training”—may stimulate an increase in collagen synthesis, encouraging normal tendon structure in addition to the fascia to tolerate load. Additionally, this exercise facilitates an increase in dorsiflexion and intrinsic foot strength. The concept of Davis’s law states that soft tissue heals according to the imposed demands by which it is mechanically stressed.
Loading the gastroc-soleus complex (GSC) is extremely important when it comes to managing plantar fasciopathy. We need to increase the capacity and the tolerance of the plantar fasica, and the best way to do is with strengthening exercises! If you’re looking for more strengthening exercises for this region, definitely check out this program!
There are a host of non-operative treatment options available to decrease pain and improve function related to plantar fasciitis. As mentioned earlier, 90% of patients diagnosed with plantar fasciitis will recover in 6-12 months utilizing many of the non-operative treatment methods outlined in this article. It can be challenging to remain patient when dealing with foot pain for a long period of time, but stay consistent with your exercise and you can overcome it! If your pain or function doesn’t improve, see your local physical therapist (if you haven’t already) and seek a consultation.