I have had a recent influx of people presenting to Bend + Mend Darling Park this month with heel pain or Plantar Fasciopathy (previously called plantar fasciitis). Plantar fasciopathy is a generalised term for pain around the plantar fascia in the foot. The plantar fascia is the tissue that runs from your heel bone towards your toes and helps to support your foot when walking.
In plantar fasciopathy the plantar fascia has been found to be degenerative. This degenerative process is not dissimilar to what occurs in a tendinopathy. The plantar fascia becomes swollen and sensitive. This affects the area where it joins to the heel bone and therefore the inside of the heel is the most common place to feel symptoms. Pain tends to be worse on the first steps in the morning, after staying still for a long period of time or after walking for a while.
Generally plantar fasciopathy is a self-limiting condition and presents for around 3-9 months. This duration may differ if the aggravating factors are unable to be altered, for example if your job requires you to spend a lot of time on your feet.
It is important to remember that the plantar fascia has just been overworked and overloaded but not damaged. The first step to improve symptoms is to calm down the pain and then slowly increase the load through the tissue.
Plantar fasciopathy is common in both active and sedentary populations. The possible risk factors for these two groups differ. Many of these are observed risk factors and require further research.
- High body mass index (BMI)
- Decreased ankle range of motion (dorsiflexion)
- Decreased big toe range of motion (extension)
- Calf strength changes
Possible risk factors in an athletic population
- Increased training volume (increased mileage)
- Increased running or training pace
- Change in running style
- Change in footwear
Prognosis and Treatment
Like a tendinopathy, plantar fasciopathy symptoms appear to progress through different stages.
Stage one (pain dominant): During this stage the plantar fascia is swollen and very sensitive causing morning pain and limiting the ability to do everyday activities that require time on your feet. This can last anywhere between one to eight weeks in duration.
Stage two (load dominant): During this stage the symptoms are more stable, pain decreases, and the plantar fascia can tolerate more load.
There is normally a gradual transition between these stages. Slowly your heel will feel less irritable and able to tolerate more walking. The first steps in the morning or on standing will become more comfortable. Overall symptoms will have decreased unless the plantar fascia is overloaded.
Treatment for plantar fasciopathy depends on what stage and how much pain you are experiencing. It is important first to modify aggravating activities to settle the pain down during the pain dominant stage. Once symptoms settle treatment focuses on slowly load the fascia to encourage healing and strengthening the surrounding muscles. Manual therapy can be used address other contributing factors such as decreased ankle and big toe range of motion.
Generally conservative treatment is the first port of call and in most cases, imaging will not change the management. Imaging is only really needed if you are not responding to treatment or if other causes need to be ruled out.
An ultrasound scan is thought to be a good first choice for imaging and sensitive for plantar fasciopathy. This allows a view of the plantar fascia at the insertion point into the calcaneus where it can show thickening of the tissue. Significant thickening at insertion point is a common finding.
Magnetic resonance imaging (MRI) can also be used but is of more assistance in ruling out other causes of symptoms.
Calcaneal heel spurs are very common on imaging for plantar fasciopathy, but this could be an incidental finding. It may not be related to plantar fasciopathy as heel spurs are also found in asymptomatic patients.
If you have foot or heel pain book in to see one of Sports Physio’s at Bend + Mend in Sydney’s CBD for a thorough assessment and treatment of your condition.