Plantar Fasciosis- Why is it happening to me, and why isn't it easier to get rid of?

By Anya Gue, DPT

Plantar heel pain, most often diagnosed as plantar fasciitis or plantar fasciosis, affects approximately 10% of the population. So if you happen to develop this issue, what should you do? Stretch your calves? Buy some supportive orthotics? Strengthen your feet? Unfortunately, there is no one magic treatment that works for all individuals, but I am hopeful that this article will provide a little guidance to help you better understand the next step you need to take in order to get on the right track to rehabilitation.

Most often, the development of plantar fasciopathy can be attributed to one or more of the following musculoskeletal impairments:

  • Stiff calf musculature or ankle joint restriction leading to limited ankle dorsiflexion mobility
  • Excessively low and overly compliant medial longitudinal arch (pes planus) 
  • Excessively high and ridged medial longitudinal arch (pes cavus)
  • General foot and ankle muscle weakness
  • Poor motor control and proprioception of the foot ankle
  • Poor proximal strength of the hip and core leading to impaired mechanics at the foot 
  • Significant increase in load to the foot muscles and ligaments over a short period of time. For example: increase in running mileage or intensity; increase in time on feet during the day in general; abrupt change in footwear from supportive shoe to less supportive shoe

Once the overload and acute damage to the plantar fascia tissue has occurred, the best action for treatment should include several different steps:

1. Protect the overloaded tissue to allow for healing and pain reduction to occur (reduce stress to the plantar fascia by reducing time on feet, use of a heel lift and/or orthotic (more on this in the discussion below), and activity modification

2. Address any underlying impairments- this may mean aggressive calf stretching, use of night splint, foot strengthening, and/or movement retraining. You may want to consult with a physical therapist to determine what these are for you as an individual.

3. Address any extrinsic loading issues such as managing training volume, poor footwear, or excess time on feet

4. Progressively re-load the tissue without overloading and causing more damage. This part can be tricky and must be very patient specific. Often the pain that results from plantar fascia injuries is correlated with microtearing and change in composition of the structural collagen fibers. If the tissue is completely unloaded and allowed to "rest," it will likely continue to remain in this state. It must be stimulated to remodel back to its functional form. Most recent research has revealed that this can best be achieved through a loading program that is progressed based on symptom presentation and pain provocation.

Is it worth buying orthotics?

Collapse of the medial longitudinal arch places excess stress on the plantar fascia

Collapse of the medial longitudinal arch places excess stress on the plantar fascia

It would be nice if treatment was as simple as buying the right orthotic, putting it in your shoe, and BAM...pain is gone. Shoe inserts, or foot orthoses are one of the most commonly prescribed treatments for plantar heel pain, but the evidence to support this as an effective treatment is outdated and conflicting. However, in September 2017  a systematic review and meta-analysis was published in the British Journal of Sports Medicine with some useful results:

A foot orthosis is meant to provide support for the medial longitudinal arch and decrease the stress on the plantar fascia

A foot orthosis is meant to provide support for the medial longitudinal arch and decrease the stress on the plantar fascia

Do foot orthoses reduce pain? In the short term of 0-6 weeks, there was no significant reduction in pain. There was a moderate reduction on pain in the medium term of 7-12 weeks, and there was no conclusive reduction in pain in the long term of 13 to 52 weeks. 

Are custom orthotics any better at reducing pain than prefabricated? Not necessarily! The results of this study indicated no difference in pain reduction between the custom orthotics (often very expensive) than the prefabricated orthotics.

In conclusion, treatment of plantar fascia pain needs to be individualized depending on the causative factors. Shoe inserts may be an effective way to reduce symptoms, but custom orthotics are generally not necessary. 

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Whittaker GA, Munteanu SE, Menz HB, et al. Foot orthoses for plantar heel pain: a systematic review and meta-analysis. Br J Sports Med Published Online First: 21 September 2017. doi: 10.1136/bjsports-2016-097355