Overview

Effective pain management is a crucial aspect of modern healthcare aimed at reducing risks and improving quality of life. One condition that can significantly impact daily activities is plantar fasciitis, a common source of heel pain. This condition is often treated by using conservative treatment approaches like physical therapy. Physical therapy involves exercises, stretching and lifestyle adjustments to reduce pain,  improve function and avoid future episodes. Let's understand how plantar fasciitis can be effectively managed using physical therapy.

What is plantar fasciitis?

Plantar fasciitis is a condition resulting from inflammation and pain in the plantar fascia. The plantar fascia is a dense fibrous tissue located at the bottom of the foot that links the heel to the toes.¹ It functions as a stabiliser for the foot’s arch while also acting as a cushion for shock absorption² during standing and walking. This condition mostly develops gradually over time and can last for a while if not managed correctly.

Possible causes of plantar fasciitis

Plantar fasciitis is an overuse injury often caused by: 

• Prolonged weight bearing¹
• Workout errors 
• Improper footwear¹
• Obesity 
• Weakness or stiffness in plantar flexor muscles.

What are the common symptoms of plantar fasciitis?

People with plantar fasciitis frequently experience intense, stabbing pain in their heels, particularly when they first get out of bed in the morning. The most common symptom is discomfort in the lower part of the heel, which tends to worsen with activities that put pressure on the feet, such as prolonged walking or standing.¹

The location and severity of the pain can vary among individuals. Some may primarily feel it in the heel’s inner, outer, or lower regions, while others may experience it at the sole of the foot. The severity of this pain can range from mild and short-lived (subacute) to more persistent and chronic.³

Role of physical therapy in treating plantar fasciitis

Physical therapy plays an important role in the treatment of plantar fasciitis. A comprehensive approach is used to:   

• Reduce pain, inflammation and tissue stress
• Improve foot and ankle movements
• Restore strength and provide stability
• Prevent recurrence through long-term management

Assessment by a physical therapist

A thorough evaluation is usually carried out to diagnose plantar fasciitis. The therapist begins the assessment by asking about the individual's medical history which includes symptoms, onset, and any activities that may worsen the pain. Subsequently, a foot examination is conducted where the therapist carefully palpates (presses on various areas of the foot) to pinpoint the pain and tenderness along the plantar fascia.

The assessment is followed by testing the range of motion that evaluates the knee, ankle, and foot movements for any stiffness. The therapist also evaluates the strength of the calf and foot muscles by incorporating manual muscle testing.⁴ The therapist observes the patient’s walking pattern and body alignment to identify imbalances or poor posture. Lastly, special tests are performed by the therapist to confirm plantar fasciitis and rule out other potential conditions that may be causing foot pain. This holistic approach enables the development of a tailored treatment plan for effective recovery.

Common physical therapy techniques for plantar fasciitis 

Stretching exercises

• Regular stretching of the plantar fascia which is the thick fibrous tissue that runs along the length of the foot can significantly reduce pain and enhance both foot and ankle mobility⁵
• Stretching the calf muscle and Achilles tendon helps relieve tension caused in the plantar fascia. This stretch also enhances ankle movement which leads to increased flexibility in the calf muscles

Strengthening exercises

Physical therapists frequently suggest exercises to strengthen the muscles of the foot and ankle joint which can aid in restoring stability and providing better support.

• Toe curls: One useful exercise is toe curls⁷ which strengthens the long arch of the foot
• Ankle eversion and inversion: Range of motion can be assisted with resistance bands to strengthen the movement of ankle eversion (turning the foot outward) and inversion⁷ (turning the foot inward) for improved stability and strength of the foot and ankle joint
• Heel raises Another great exercise targeting the calf muscles and Achilles tendon to make them stronger

Manual therapy

Manual therapy techniques are commonly used for individuals with plantar fasciitis condition which involves interventions like joint and soft tissue mobilisation, trigger point therapy, deep massage, and myofascial release. Such techniques aid in improving the general range of motion in terms of foot movement and flexibility, thus allowing the plantar fascia to function more effectively⁸

Taping techniques

• Kinesiotape applied to the plantar fascia (bottom of the foot) and the calf muscles can help offload the pressure on these areas. This can help encourage further recovery and avoid re-injury to the plantar fascia. The tape may also improve blood flow in the affected area which could help reduce inflammation and support the healing process⁹
• Low-dye taping is typically applied to manage plantar fasciitis¹⁰ This type of taping may be highly effective in reducing the level of pain in people associated with this condition

Modalities

Phonophoresis combined with ketoprofen gel⁴ is a treatment method that effectively reduces pain. This technique involves using ultrasound to enhance the absorption of the anti-inflammatory gel through the skin, providing targeted relief to affected areas.

Shockwave therapy is a safe and effective treatment for people with plantar fasciitis. It also provides long-term relief with minimal chances of recurrence.¹¹ This therapy works by increasing blood circulation and decreasing the inflammatory response in the affected area. As a result, it stimulates the repair processes and gives long-term relief from the discomfort.

Foot orthoses 

Foot orthoses also known as shoe inserts, are most effective since they are usually recommended to be used in conjunction with other treatments⁴ and are prescribed by the therapist. Whether bought off the shelf from the pharmacist or ordered according to a specific prescription, these aids are of tremendous value providing support to the medial arch of the foot and cushioning to the heel. They are most helpful for people who exhibit symptoms of excessive pronation (inward rolling of the foot) or for those people who benefit from the use of anti-pronation taping.⁴ For people with excessive supination (foot rolling outward) that reduces the foot's ability to absorb shock, using over-the-counter heel cushions or footwear with added heel cushioning can be especially helpful. This modification is crucial for enhancing shock absorption and relieving individuals with this condition.

Night splint

A night splint is another orthotic device that is part of the treatment for certain foot and ankle problems. Night splinting for 1 to 3 months is advised to prevent pain during the first step in the morning for people with plantar fasciitis.⁴ The splints help keep the foot stretched during night time which minimises morning stiffness and pain.

Home exercises and self-care

Home-based exercises are beneficial in managing plantar fasciitis and can help prevent symptoms from recurring. Incorporating a few simple strategies into your routine may lead to noticeable improvement. You may consider:

• Daily stretching routine of plantar fascia
• Incorporate a self-massage by rolling a golf ball or frozen bottle below the painful arch of the foot, which can help relieve discomfort¹²

Lifestyle modifications

• Weight management: For overweight individuals, losing weight can lower the impact on the heels while walking or running which can improve symptoms
• Activity modification: Incorporating cross-training and low-impact exercises like swimming or cycling into their routine may benefit the runners by reducing the pressure on their feet
• Footwear recommendations: Wearing shoes with good arch support can help correct biomechanical abnormalities that may contribute to the pain

Adhering to these lifestyle changes would help in the recovery process and lower the risk of worsening the condition.

When to seek further medical treatment

It is considered that further medical treatment is required if other conservative measures do not provide relief for the symptom in a few months, a sign that may require advanced treatments like injections or surgical procedures.

Summary

Plantar fasciitis is a condition that is associated with swelling of the plantar fascia, a thick tissue structure which runs along the floor of your foot and serves the purpose of providing support to the arches of the foot. Many individuals experience sharp heel pain, especially in the morning or after sitting or standing for a prolonged duration of time. Different reasons can contribute to the development of this condition, such as overuse, wearing improper shoes, being overweight, or having tight muscles. Treatment usually involves physical therapy that focuses on stretching and strengthening exercises, along with other techniques like joint and soft tissue mobilisation and taping. Additionally, it is advised to incorporate home exercises like stretching and massage into your daily routine for the affected area. Adopting lifestyle changes like managing weight and opting for supportive footwear can greatly improve overall foot health. If symptoms continue for six to twelve months despite these efforts, seeking guidance from a specialist is advisable, as they can recommend more advanced treatment options for effective relief.