How to treat plantar fasciitis
Discomfort or pain at the base of your heel is often referred to medically as plantar fasciitis or heel spur syndrome. The most common symptom is heel pain after rest located at the bottom of the heel, which can worsen first thing in the morning. The pain will often subside partially throughout the day and return after rest.
My Sports Podiatrist has clinics conveniently located in Docklands and Ascot Vale. We offer a premium service to get you back on your feet if you suffer from plantar fasciitis. Plantar fasciitis is common in football, soccer, netball, golf, and hiking.
What is plantar fasciitis?
Plantar fasciitis is an overuse condition caused by repetitive straining of the plantar fascia ligament that runs from your heel to your toes and stabilises the arch of your foot. The most common location for the pain to develop is where the ligament attaches at the base of the heel. Repetitive overuse results in ligament degeneration, which makes it susceptible to micro-tears or partial tears if left untreated. It is crucial to assess all the causative factors at the first sign of heel pain to determine what could contribute to this condition's development. Acting fast will reduce the severity and the time it takes to heal.
In some cases, plantar fasciitis may not be the cause of your heel pain. You should seek further evaluation ASAP if your symptoms include:
- Pain during the night
- Swelling or redness around the heel or leg
- An inability to support weight on your foot
- Morning pain that does not decrease during the day
How is plantar fasciitis diagnosed?
Plantar fasciitis is diagnosed following a thorough history and clinical examination. Often an ultrasound scan is performed to confirm.
An x-ray may reveal a heel spur, which is often present in cases of chronic heel pain. Heel spurs develop as a response to excessive stress on the bone of the heel. While not all people with heel spurs develop heel pain, these spurs can indicate elevated pressure and strain on the plantar fascia ligament, predisposing people to develop heel pain.
Ultrasound is a non-invasive scan to assess the anatomy of the heel and ankle. Thickening of the plantar fascia connection point and micro-tearing or inflammation are typical signs seen on ultrasound that can confirm the diagnosis of plantar fasciitis or a torn plantar fascia.
Following diagnosis of plantar fasciitis, your podiatrist may recommend several measures aimed at improving the condition.
These may include:
- Changes in footwear
- Stretching and certain exercises
- Icing or heat
- Massaging the arch and heel with a golf ball or spiky ball
If your heel pain has been present for an extended period or it is not responding to the measures listed above, it is essential that your podiatrist or doctor refer you for an x-ray and ultrasound. An MRI is not typically required to diagnose plantar fasciitis but can be useful should a nerve entrapment or stress fracture be suspected. An x-ray may reveal a heel spur, which is often present in cases of chronic heel pain. Heel spurs develop as a response to excessive stress on the bone of the heel. While not all people with heel spurs develop heel pain, these spurs can indicate elevated pressure and strain on the plantar fascia ligament which can predispose people to developing heel pain.
Ultrasound is a non-invasive scan which is performed by a sonographer and some podiatrists, if they are trained in diagnostic ultrasound. An ultrasound scan allows the doctor to see the plantar fascia, heel bone, and fatty padding. Thickening of the plantar fascia connection point, along with micro-tearing or inflammation, is a typical sign seen on ultrasound which can confirm the diagnosis of plantar fasciitis.
Steps you can take to control your heel pain
Wear appropriate footwear
Over years of treating patients as a podiatrist, I have often found that the patient's footwear is inappropriate and contributes to the development of their heel pain. Addressing your footwear is essential if you tend to walk around in flat, loose, unsupportive shoes. Wearing a lace-up shoe with good arch support is often the first step I recommend for my patients. Wearing supportive footwear is essential to reduce unnecessary strain on the foot's arch. It is necessary to find a shoe with a firm heel counter that provides ankle support. Stiffness through the shoe's midsole is essential to reduce pressure on the arch, but it is also vital to bend the big toe joint during walking and running adequately. It is also necessary to make sure the shoes have good cushioning and aren't too heavy.
It is vital to evaluate if any particular activities aggravate your heel pain. Many walking up and down stairs or ladders are also typical factors contributing to heel pain. Plantar fasciitis is common in occupations that involve standing for many hours, particularly on hard surfaces.
Generally never recommend patients stop walking entirely. However, if you're developing heel pain and walking or running contributes to that, it may be necessary to reduce the amount of running and increase the recovery time between exercise sessions. For instance, if you typically go for an hour-long walk each day, you might break it up into two half-hour walks with a rest in between. Modifying your exercise may also include switching to swimming and bike riding, which typically do not aggravate plantar fasciitis.
Plantar fasciitis commonly causes pain towards the end of the day, particularly when you start walking following rest. Icing is a great way to reduce inflammation and pain. I recommend icing the heel for 10–15 minutes every hour. Another great trick is to freeze a plastic bottle of water. By using the frozen bottle to roll under the arch and heel, we address two factors by both massaging and icing the heel and arch.
Stretching and exercises
Restricted movement at the ankle joint or big toe joint is often a contributing factor in the development of heel pain. This is because limited movement at these joints results in overcompensation during walking. If the movement is blocked, the body needs to find an alternative way to move. The problem with these compensations is that repetitive activity such as walking can create additional stress in specific tissues, breaking down and causing pain.
When stretching the ankle or the big toe joint, noticing that the motion hits a hard point and will not go any further suggests a bony block that stops the joint from moving correctly. In this case, stretching will not improve the motion at the joint, and it is essential to have it assessed by a podiatrist or experienced physical therapist. There are specialised techniques that can help improve the movement in these joints.
Unfortunately, many people find that home treatment methods such as stretching, icing, and massage are insufficient to significantly reduce the pain and allow them to enjoy daily activities without pain. If the pain you are experiencing is impacting your everyday life and does not improve with simple measures, an experienced sports podiatrist must assess you. It is vital to understand the specific risk factors involved in your experience of chronic heel pain. Failure to correctly identify and adequately address these factors will delay healing.
Orthotics and shoe inserts change the impact of pressure created during running and walking on the foot's joints, ligaments, and bones. If you are experiencing chronic lower limb injury such as heel pain, it is essential to have your biomechanics assessed to help understand the root cause. Biomechanics is the analysis of how your body is moving and how those movements and stresses affect the body's various tissues. A biomechanical assessment leads to a better understanding of how chronic repetitive stress injuries (such as plantar fasciitis/heel pain) occur and provides indications of how they can be best addressed.
As a podiatrist, I use orthotics when trying to reduce or modify the high pressure, which results in damage to the lower leg, ankle, or foot. Two standard orthotics used to treat heel pain are off-the-shelf and custom orthotics.
Off-the-shelf orthotics typically come in small, medium, and large. They are designed for the average foot and provide mild support. In some cases, if the heel pain is minor or new, an off-the-shelf orthotic can be a good starting po
int and may mildly reduce some of the stress on the heel. The downside with an off-the-shelf orthotic is that greater support and correction may be required, such as when a foot does not fit the "average" category. As a podiatrist, I see feet that fit into this cate
gory, and all feet are individual. An off-the-shelf orthotic is cheaper than a custom orthotic. However, they do not last as long due to their materials. If you require more support or correction, an off-the-shelf orthotic is also tricky to adjust.
A prescription custom orthotic is designed following a comprehensive biomechanical assess
ment and a 3D laser scan or cast of both feet. Custom orthotics allow the podiatrist to create the specific features required to reduce the stress on an injured area. A custom orthotic is manufactured from higher-quality materials, which signi
ficantly increases its longevity. Custom orthotics typically last between 4–10 years, so in reality, they can work out cheaper than continuously replacing an off-the-shelf orthotic that stops providing sufficient support after six months. Custom orthotics also allow fine-tuning and adjustments, thus ensuring optimal comfort and support.
Extracorporeal Shockwave Therapy is also known as shock wave therapy. Shockwave therapy is a non-invasive treatment that does not involve medication, anaesthetics, or needles. Extracorporeal means that the procedure is performed from outside the body; in this case, the medical device is applied to the skin overlying the painful heel. A high enery accustic pressure wave is generated, which has many biological effects that are advantageous in chronic conditions such as plantar fasciitis.
It is necessary to address the underlying factors that are contributing to your heel pain. It is also essential to assess the biomechanics and implement interventions to address them if they are a contributing factor. However, when dealing with chronic injuries, we know from the medical evidence that rest is insufficient to allow for healing. Chronic conditions often need specialised treatment to stimulate the biological and cellular response necessary to heal the tissue. Shockwave Therapy is an effective treatment for chronic plantar fasciitis and heel spur syndrome.
Shockwave Therapy has three main effects on injured tissue:
- Decreases nerve inflammation. This decrease in nerve inflammation is often instant and is responsible for the dramatic pain reduction the patient often feels immediately after the treatment has been performed
- An increase in growth factors and blood flow. Shockwaves result in increased growth factors in the area treated. These growth factors switch on local stem cells and the immune system to repair the damage to injured tissue. The full effects of increased growth factors and blood flow are often not entirely noticeable until 6-12 weeks following the course of shockwave therapy
- The breakdown of scar tissue and calcification. The high-powered pressure waves significantly impact decreasing scar tissue, adhesions, and calcifications. This often allows for better movement and function in the treated tendon or ligament.
Does Shockwave Therapy hurt?
Shockwave Therapy does not require any painkillers or anaesthetic. There is some discomfort during the treatment; however, this is only for a short period, and the settings are modified to improve patient comfort. The podiatrist asks frequent questions throughout the treatment so they can make the treatment comfortable.
What is the success rate?
Shockwave Therapy has a success rate of 80%, which has been shown in best-practice medical literature as a standalone treatment. When Shockwave is combined with rehabilitation and strengthening exercises, addressing the contributing factors and biomechanics, the success rate is often better than 80% in significantly reducing pain and improving function. It is also shown to be more effective than cortisone injections and exercise alone.
Tissue Regenerative Therapy
Tissue Regenerative Therapy involves an injection of a solution that stimulates cellular repair (also known as Prolotherapy)
Tissue Regenerative Therapy works by promoting your body's natural repair mechanisms to heal injured or weakened joints, ligaments and tendons. It is a natural, non-surgical method of stimulating repair when ligaments or tendons are damaged or torn.
The injected prolotherapy solution leads to a localised reaction, stimulating the growth of collagen and connective tissue. This process is known to tighten and strengthen the damaged tissue, resulting in a stronger tendon or ligament. Pain is often reduced or eliminated. Tissue Regenerative Therapy is an alternative to cortisone injections, which in some cases are not suitable as they may weaken an already damaged tendon.
Surgical intervention is rarely used to treat plantar fasciitis unless the condition has been present for more than three years and has not responded to conservative measures and injection therapy. Surgery for plantar fasciitis is called a fasciotomy, and it involves making a cut to release the plantar fascia from the bone, essentially creating a complete rupture. Because the ligament is no longer attached to the bone, it is no longer under tension, reducing the pain. In chronic cases, there is often some degree of nerve entrapment around the heel, and a skilled surgeon will take special care to decompress the nerves that supply the heel. Surgery is performed in a hospital setting, often as a day procedure, and it can take months of recovery to get back to exercise and prolonged standing. Following a plantar fasciotomy, it is vital to wear a custom orthotic during the recovery period as the arch has been destabilised.
If you are suffering from heel pain, don’t let it get in the way of your life. There are many treatment options available, depending on the severity and individual causative factors. Book now to see our Musculoskeletal Podiatrist in our Docklands or Ascot Vale clinics and start feeling better today.
Dr James Ferrie
B. Pod. (La Trobe); Mem. A. Pod. A
Principal Practitioner / Founder of My Sports Podiatrist