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Plantar Fasciitis: Heel pain that’s difficult to heal

What is Plantar Fasciitis?

Plantar Fasciitis, also referred to as plantar fasciopathy or plantar heel pain, is an overuse injury of the plantar fascia at its insertion point on the heel. The injury is one of the most common running injuries affecting up to 31% of runners (1) and up to 8% of the general population.(2) Plantar Fasciitis often presents as pain in the heel during weight bearing and can typically be worse first thing in the morning or following periods of rest. Symptoms may ease into activity and “warm up” but can worsen with repeated activity such as prolonged standing, walking or running. The injury can often be challenging to manage with symptoms persisting for 12 months or longer.(3,4)

Originally Plantar Fasciitis was proposed to be an inflammatory condition; however, studies have suggested that the injury lacks a true inflammatory process, instead being associated with degenerative changes to the plantar fascia insertion.(5,6) Changes include thickening of the plantar insertion, deterioration of collagen fibres, increased fluid accumulation, increased secretion of ground substance proteins, increased fibroblast proliferation and increased vascularity,(5,6) similar to features observed in tendinopathies (such as Achilles Tendinopathy). The lack of a true inflammatory process is why this condition is more frequently being referred to as plantar fasciopathy or plantar heel pain rather than an “itis”.

What is the Plantar Fascia?

The plantar fascia is a thickened sheet of connective tissue, arising from the calcaneus (heel bone) and connecting into the base of the toes.(7) The plantar fascia provides support for the medial longitudinal arch of the foot and acts as dynamic shock absorber during activities of walking, running and jumping. Biomechanical studies have reported that the plantar fascia may play a role in storage and release of energy for propulsion during walking and running (8) (see our video below).

What causes Plantar Fasciitis?

Currently the exact cause of Plantar Fasciitis is largely unknown, although it is thought to be due to repeated mechanical overload of the plantar fascia with insufficient time for recovery.(9) Several factors appear to be associated with this injury, including increased body mass index, reduced calf muscle and toe flexor strength, increased dynamic foot pronation, reduced ankle dorsiflexion range of movement as well as both a more pronated foot posture and a high arched foot posture.(10) Additionally, high weekly running mileage and sudden increases to training volume, intensity or duration may also result in overload and injury to the plantar fascia.(11) Collectively, these factors may contribute to both a reduction in the ability of the plantar fascia to tolerate mechanical loading and expose the plantar fascia to elevated mechanical loading.

What are the treatments for Plantar Fasciitis?

Several treatments are often advocated for the management of plantar heel pain. These include plantar fascia stretching,(12) strengthening exercises,(13) orthotics,(14) shockwave therapy (15) and corticosteroid injections.(16) Interestingly, current scientific evidence remains inconclusive regarding the most effective treatment for Plantar Fasciitis, with varied effects observed amongst patients.(14,17)

How can I recover from Plantar Fasciitis?

Successful recovery from Plantar Fasciitis is likely to require a combination of management approaches. We would suggest that management of Plantar Fasciitis should began with the aim of reducing pain symptoms to that of a manageable level, improving the ability of the foot and Plantar Fascia to tolerate mechanical load through strengthening exercises and the gradual progression back to loading activities. This injury can often take considerable time for recovery and may result in significant psychological distress to patients.(18) Therefore, it is important that a progressive treatment plan is in place with adequate monitoring of progression of symptoms and function.

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1. Di Caprio F, Buda R, Mosca M, Calabro A, Giannini S. Foot and lower limb diseases in runners: assessment of risk factors. Journal of sports science & medicine. 2010; 9(4):587-596.

2. Landorf KB. Plantar heel pain and plantar fasciitis. BMJ Clin Evid. 2015; 2015.

3. Nielsen RO, Rønnow L, Rasmussen S, Lind M. A prospective study on time to recovery in 254 injured novice runners. PloS one. 2014; 9(6):e99877.

4. Hansen L, Krogh TP, Ellingsen T, Bolvig L, Fredberg U. Long-Term Prognosis of Plantar Fasciitis: A 5- to 15-Year Follow-up Study of 174 Patients With Ultrasound Examination. Orthop J Sports Med. 2018; 6(3):2325967118757983.

5. Lemont H, Ammirati KM, Usen N. Plantar fasciitis: a degenerative process (fasciosis) without inflammation. J Am Podiatr Med Assoc. 2003; 93(3):234-237.

6. McMillan AM, Landorf KB, Barrett JT, Menz HB, Bird AR. Diagnostic imaging for chronic plantar heel pain: a systematic review and meta-analysis. J Foot Ankle Res. 2009; 2:32.

7. Stecco C, Corradin M, Macchi V, et al. Plantar fascia anatomy and its relationship with Achilles tendon and paratenon. J Anat. 2013; 223(6):665-676.

8. McDonald KA, Stearne SM, Alderson JA, North I, Pires NJ, Rubenson J. The Role of Arch Compression and Metatarsophalangeal Joint Dynamics in Modulating Plantar Fascia Strain in Running. PloS one. 2016; 11(4):e0152602.

9. Wearing SC, Smeathers JE, Urry SR, Hennig EM, Hills AP. The pathomechanics of plantar fasciitis. Sports medicine. 2006; 36(7):585-611.

10. van Leeuwen KD, Rogers J, Winzenberg T, van Middelkoop M. Higher body mass index is associated with plantar fasciopathy/'plantar fasciitis': systematic review and meta-analysis of various clinical and imaging risk factors. Br J Sports Med. 2016; 50(16):972-981.

11. Sullivan J, Pappas E, Burns J. Role of mechanical factors in the clinical presentation of plantar heel pain: Implications for management. Foot (Edinb). 2020; 42:101636.

12. Digiovanni BF, Nawoczenski DA, Malay DP, et al. Plantar fascia-specific stretching exercise improves outcomes in patients with chronic plantar fasciitis. A prospective clinical trial with two-year follow-up. J Bone Joint Surg Am. 2006; 88(8):1775-1781.

13. Rathleff MS, Mølgaard CM, Fredberg U, et al. High-load strength training improves outcome in patients with plantar fasciitis: A randomized controlled trial with 12-month follow-up. Scand J Med Sci Sports. 2015; 25(3):e292-300.

14. Babatunde OO, Legha A, Littlewood C, et al. Comparative effectiveness of treatment options for plantar heel pain: a systematic review with network meta-analysis. Br J Sports Med. 2019; 53(3):182-194.

15. Sun J, Gao F, Wang Y, Sun W, Jiang B, Li Z. Extracorporeal shock wave therapy is effective in treating chronic plantar fasciitis: A meta-analysis of RCTs. Medicine (Baltimore). 2017; 96(15):e6621.

16. Whittaker GA, Munteanu SE, Menz HB, Bonanno DR, Gerrard JM, Landorf KB. Corticosteroid injection for plantar heel pain: a systematic review and meta-analysis. BMC Musculoskelet Disord. 2019; 20(1):378.

17. Riel H, Olesen JL, Jensen MB, Vicenzino B, Rathleff MS. Heavy-slow resistance training in addition to an ultrasound-guided corticosteroid injection for individuals with plantar fasciopathy: a feasibility study. Pilot Feasibility Stud. 2019; 5:105.

18. Cotchett M, Munteanu SE, Landorf KB. Depression, Anxiety, and Stress in People With and Without Plantar Heel Pain. Foot Ankle Int. 2016; 37(8):816-821.


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