Plantar Heel Pain

Plantar heel pain (previously referred to as plantar fasciitis, now plantar fasciopathy), is pain on the bottom of the heel, or arch of the foot. (Monteagudo et al, 2018).

The plantar fascia is a soft tissue on the bottom of the foot which extends from the heel to the balls of the feet.

Why Does It Happen?

This usually occurs when the capacity of the tissue becomes overloaded. This can be due to a change in activity, such as increased training or repetitive high impact activity. But it can also occur in more sedentary people (Riel, 2019).

It can take time to improve, for some people in a few weeks, however some take months to progress.

What are the Symptoms?

• Pain on the bottom of the heel or arch of the foot
• Pain worse first thing in the morning when putting your foot on the ground
• Pain worse after doing activity

What else could it be?

A Physiotherapist can assess for these other conditions;

• Fat pad atrophy – usually worsening pain the longer you are weight bearing
• Heel spurs (Monteagudo et al, 2018)
• Achilles tendinopathy – pain would be at the back of the heel, or bottom of the calf
• Nerve irritation – usually associated with altered sensation, symptoms not always localised to plantar aspect of the foot (Riel, 2019)
• Calcaneal stress fracture (Physiopedia, 2019)

What can I do?

Find out the time, or distance of what you can do without flaring up (being worse after activity, or the next day). This could be e.g. walking/running for around 10 minutes. It is common for the pain to ease in the first few steps or minutes, but the symptoms can be painful in the evening/morning after the activity.

Use this as a baseline, and gradually increase the distance or time as comfortable. If your symptoms flare up, return back to the last comfortable distance/time you managed, try a few more times here, then gradually increase again (Riel, 2019).

If this does not settle your symptoms, you may need to rest from the aggravating activity for a short time e.g. if running, substitute for cycling or cross trainer to keep up the cardiovascular fitness without the impact.

What can physiotherapy do?

• Assess to confirm diagnosis then plan load management and pacing
• Provide an individualised exercise programme to suit your goals
• Work on ankle mobility if indicated
• Deep tissue massage to tight calf muscles if appropriate
• Provide taping to help reduce pain
• Consider a referral to podiatry to see if an insole may help the symptoms if other measures aren’t improving the pain
• Occasionally consider a referral to an acupuncturist

If you are overweight, weight loss can help the symptoms (Riel, 2019).

If symptoms are not settling with conservative management, occasionally a corticosteroid injection can be considered (Riel, 2019). There is some research in to platelet rich plasma injections also (Monteagudo et al, 2018).

There is some research that shockwave therapy can help symptoms, but the results are variable, and the clinician should discuss this and associated risks before referring (NICE, 2009).

Plantar heel pain usually improves over 12 months, so surgical treatment is rarely considered, and this also depends on the underlying cause of the symptoms (Monteagudo et al, 2018).

Exercises

Ball soft tissue release – using a massage or a tennis ball, or freeze a bottle of water and roll your foot on it for 30 seconds to 2 minutes. Try it morning and evening.

Plantar Fascia Stretch – put the foot to be stretched over the other knee. Pull up the toes, like shown in the picture and feel the stretch along the base of the foot. Hold for 20-30 seconds, repeat 2-3 times.

Calf stretches:

Stand with the foot to be stretched behind you, toes pointing forwards. Bend the front knee, keeping both heels on the ground. You can hold on to something like a wall for support if you need.

The second stretch is a similar position, but the legs might not be so far apart. Bend both knees and keep both heels on the ground. You should feel both these stretches in the calf muscles.

Hold for 30 seconds, repeat twice.

Heel raises:

You can do this with a rolled up towel under the toes, but if it is uncomfortable, remove the towel and just do with the toes on the ground.

Hold on to something for balance e.g. wall or kitchen worktop and rise up on your toes. Repeat until the calf feels tired e.g. 8 repetitions, 3 sets.

References:

Monteagudo, M; Martinez de Albornoz, P; Gutierrez, B; Tabuenca, J; Alvarex, I. 2018. Plantar Fasciopathy: A Current Concepts Review. [online]. [Accessed 3^rd October 2019]. Available from: http://www.ncbi.nlm.nih.gov.uk

National Institute for Health and Clinical Excellence (NICE). 2009. Treating Chronic Plantar Fasciitis using Shockwave therapy. [online]. [Accessed 22^nd October 2019]. Available from: http://www.nice.org.uk

Physiopedia. 2019. Plantar Fasciitis. [online]. [Accessed 3^rd October 2019]. Available from: http://www.physio-pedia.com

Riel, H. 2019. Plantar Heel Pain – the Latest Research and how to Apply it. [online]. [Accessed 3^rd October 2019]. Available from: http://www.clinicaledge.co