Plantar fasciopathy (or fasciitis) is pain under the heel during weight-bearing activities. It is also sometimes called plantar heel pain. The plantar fascia is a strong band of connective tissue that supports the structure of the foot. It connects the heel bone (calcaneum) with the metatarsal bones in the forefoot, which link to the toes. Plantar fasciopathy refers to an irritation and overload of the plantar fascia and is seen in both active people, such as runners, as well as less-active (sedentary) people. It has been shown to be more common in people who are overweight.
What causes plantar fasciopathy?
Previously, this condition was thought to be related to inflammation; however, studies have shown this is not the cause of pathology or pain in this condition. Pain is often worst first thing in the morning when getting out of bed and taking your first few steps, as well as after prolonged rest. The condition is most common in people 40–60 years old and often affects both feet.
Plantar fasciopathy is a complex condition with many associated factors, although many are related to increased force being transmitted by the plantar fascia. Sharp changes in load, such as spikes in training load, or starting new physical activity after being inactive, is associated with development of symptoms. High body mass index (BMI) is also linked with plantar fasciopathy. This may be due to an increased amount of fat cells in the blood and connective tissue, as well as excessive load on the plantar fascia structure itself. Excessive rolling in of the foot during weight-bearing (pronation) may be associated with this condition, but the evidence isn’t clear.
How do I know if I have plantar fasciopathy?
Plantar fasciopathy is characterised by pain under your heel. Your physiotherapist or podiatrist will be able to diagnose the source of your pain. They will perform tests to assess the support structures of your foot, as well as the range of motion at your ankle and toes. A number of other conditions also cause pain in a similar area; however, your practitioner will be able to differentiate these with a combination of questions and tests. Imaging such as ultrasound scans or X-rays is not required, unless cases are not responding as expected to treatment. Importantly, ‘heel spurs’—or bony growths under the heel—are not always associated with pain or plantar fasciopathy.
How can physiotherapy help with plantar fasciopathy?
A wide variety of treatments are suggested for plantar fasciopathy; however, evidence for many is lacking. All treatment should be based on individual assessment. Options include:
It will be important for your physiotherapist to identify the overloading factor and try to modify and temporarily decrease it. This may be running load in athletes or standing time in workers. Importantly, prolonged or complete rest will not lead to resolution of symptoms.
Strengthening exercises for the foot and calf muscles can help improve the load tolerance of your foot complex. For these to be effective, they need to have enough load to challenge the foot structures. Stretching of the plantar fascia is also often used as a treatment; however, strengthening exercises will lead to better outcomes.
Taping of the foot can be an effective way to decrease pain in the early stages of this condition. There are a number of different techniques that can support the foot to relieve symptoms.
Generic orthotic devices can be inserted into your shoe to provide extra support to the structure of your foot. These can decrease pain. Custom-made orthotics have not been found to be superior to generic, off-the-shelf orthotics.
Treatments such as massage, mobilisation and dry needling are not supported by research studies. They may manage your symptoms, but must be used with an exercise program.
Extracorporeal Shockwave Therapy (ESWT)
ESWT delivers high-energy shockwaves to the painful area. Evidence suggests it may be useful in the treatment of plantar fasciopathy; however, it should not be considered a first-line treatment, and if used, should be in conjunction with other treatments mentioned above.
How effective is physiotherapy for plantar fasciopathy?
A recent randomised controlled trial in 2015 supports the use of strengthening exercises over stretching-based ones for patients with plantar fasciopathy. Systematic reviews (analysis of multiple studies) show taping can be effective in decreasing pain in the short-term; however, the evidence is only limited. Systematic reviews also support the use of orthoses for decreasing pain, and improving function. However, custom-made devices may not be superior to generic ones.
What can I do at home?
Your physiotherapist will prescribe you a program of exercises to complete at home. For symptom relief, ice may help over the affected area, as well as use of orthotics or gel heel inserts. Wearing supportive shoes at home may decrease pain when compared with barefoot walking. It may also be helpful to learn to tape your foot yourself (before exercise or sport). Ask your physiotherapist to show you how to do this, if this is part of your treatment plan.
How long until I feel better?
Symptoms can be controlled if the overload is modified early after onset of symptoms; however, it may take up to six months. Without appropriate management, symptoms may persist. It will be important to modify the overloading factors while working on other aspects of your treatment, such as strengthening.