My approach to treatment and why. Exercise, pain relief and shockwave therapy.
The first thing that I must point out before you read this blog is that it is intended as an informative blog to help with your understanding of plantar fasciitis. It is not intended to replace medical expertise. If you are unsure about anything then consult a suitably qualified medical professional as there are other things that mimic plantar fasciitis.
As with many things in the sports injury world, there does not appear to be a single treatment that has been demonstrated to consistently give the best effect (Badatunde et. Al. 2018), so there is not a one size fits all or set menu approach for plantar fasciitis. This is probably because people are individuals and may respond in different ways to different treatments and have slightly different presentations, with different needs. However, they did find that over the counter anti-inflammatory medication and a ‘wait and see’ approach were the least successful interventions. In fact……… there is some evidence to suggest that delaying treatment could lead to the pain hanging around for longer (Wolgin et. Al. 1994). This makes it a little difficult to give general advice as treatment is specific to the individual, other than – don’t leave it and hope it gets better, this will often make it last longer than necessary.
- Settle the area down by offloading the fascia.
- Identify any causes and predisposing factors.
- Treat the causes and predisposing factors.
- Gradually expose the fascia to load.
- Sports that involve running
- Increased arch height
- Increased ground reaction forces with lower medial arch
- Running in spikes and street running
- Running more Km a week
- High BMI
- Prolonged standing in the day
- Forefoot pronation
- Excessive or limited dorsiflexion
- Varus knee alignment
- Tight hamstrings
Loading the fascia
It then seems to be important that you gradually improve the tolerance of the tissue in the same way that we do with tendon problems. Our bodies are incredible things and when we give it a stimulus it responds to it. For example, if we lift weights that are very heavy, our body responds and gradually builds bigger muscles so that it can lift the weight easier. If we stop however, the body does not waste its time and energy maintaining that muscle and so we lose it. This is the same for tendon, bone and fascia too – it all adapts to the load placed on it and we call the process by which the body does this ‘mechanotransduction’. So, with a degenerative problem, we need to apply a progressive, slow load to the structure in order to gain changes in said structure.
I use the stretch on the left as it tends to be a comfortable stretch to do and was shown to be more effective than a general ‘achilles stretching’ routine (DiGiovanni et. Al. 2003). I usually recommend holding this for approximately 30-40s, repeating 4-5 times a day and every time before you stand from sitting.
What if exercises don’t/haven’t worked?
Thankfully, the emergence of a number of well-conducted studies has found shockwave therapy can be helpful in a good number of people who have plantar fasciitis where exercises have not helped over at 3 month period. It is, however, important that shockwave is not used as a stand-alone treatment but in conjunction with rehabilitation exercises. It has low risk associated with it and generally takes about 12 weeks to see the full effects of treatment, although many people see improvements after their first session.
Thanks for reading
Badatunde OO, Legha A, Littlewood C, Chesterton LS, Thomas MJ, Menz HB, van der Windt D and Roddy E (2018) Comparative effectiveness of treatment options for plantar heel pain: a systematic review with network meta-analysis. British Journal of Sports Medicine, 0: p1-14Chandler TK and Kibler WB (1993) ‘A biomechanical approach to the prevention, treatment and rehabilitation of plantar fasciitis.’ Sports Medicine, 15(5) p344-352
Crawford F and Snaith M (1996) ‘How effective is therapeutic ultrasound in the treatment of heel pain.’ Annals of the Rheumatic Diseases, 55(4) p265-267.DiGiovanni BF, Nawoczenski DA, Lintal ME, Moore EA, Murray JC, Wilding GE and Baumhauer JF (2003) ‘Tissue-specific plantar fascia-stretching exercises enhances outcomes in patients with chronic heel pain. A prospective, randomized study.’ The Journal of Bone and Joint Surgery, 85(7): p1270-1277.
Lemont H, Ammirati KM and Usen N (2003) ‘Plantar fasciitis: a degenerative process (fasciosis) without inflammation.’ Journal of the American Podiatric Association, 93(3): 234-237Radford JA, Landorf KB, Buchbinder R and Cook C (2006) ‘Effectiveness of low-Dye taping for the short-term treatment of plantar heel pain: a randomised trial.’ BMS Musculoskeletal Disorders, 9(7) p64
Rathleff MS, Molgaard CM, Fredberg U, Kaalund S, Andersen KB, Jensen TT, Aaskov S and Olesen JL (2015) ‘High-load strength training improves outcome in patients with plantar fasciitis: a randomized controlled trial with 12 month follow-up.’ Scandinavian Journal of Medicine and Science in Sport, 25(3) p292-300
Whittaker GA, Munteanu SE, Menz HB, Tan JM, Rabusin CL and Landorf KB (2018) ‘Foot orthoses for plantar heel pain: a systematic review and meta-analysis.’ British Journal of Sports Medicine, 52:p322–328Wolgin M, Cook C, Graham, C and Mauldin D (1994) ‘Conservative treatment of plantar heel pain: long-term follow-up.’ Foot & ankle international, 15(3): p97-102.