Introduction

Have you experienced foot pain that gradually increases particularly after rest or in the morning? Have you been confused about why? There are various causes for foot ache and the most common culprit is plantar fasciitis (PA).¹ About 1 in 10 individuals experience PA during their lifetime and it impacts around 1 million individuals per year.¹ Plantar fasciitis, also known as plantar fasciopathy, develops when the plantar fascia is subjected to repetitive microtears that lead to its degradation.² The plantar fascia is found in the foot; it is a connective tissue band that starts at the heel and is inserted on the tendons of the forefoot.² Once this tissue is damaged, it will lead to inflammation and pain in the foot.²

The most common complaint among patients with plantar fasciitis is post-static dyskinesia; which is heel pain in the morning or onstanding after extended sitting, accompanied with relief upon movement.² PA affects our lives on different levels; for example, it can reduce our mobility, alter our gait, affect our ability to do exercise/run, affect our quality of sleep and cause emotional distress.³ Therefore, it is important to look for the signs of PA and how to go about managing its symptoms, which is what this article is aiming to achieve.  

Anatomy function

In order to understand the progression and development of PA, it is essential for us to understand the anatomy of the foot. The main parts include: hindfoot, midfoot, forefoot, joints along with muscles and tendons.² 

The hindfoot is composed of the calcaneus (heel bone) which is the largest bone in the foot, and talus which forms the ankle joint.² The midfoot is comprised of tarsal bones that form the foot’s arch.² Lastly, the forefoot is made up of the metatarsal and phalanges.² The plantar fascia is a thick fibrous band that connects the calcaneus to the phalanges.^2,4 It plays an important role in shock absorption and support of the foot arch which allows proper movement.⁴ 

Causes

The root cause of PA remains ambiguous, but it is thought to be multifactorial, with atypical biomechanics and delayed regeneration acting as contributors.² However, it is worth noting that PA is not a primary inflammatory reaction as many believe it to be, but a secondary inflammation in response to repetitive microtears of the fascia.^2,5 Some factors that can aggravate and contribute to PA include:

• Overuse/strain: plantar fasciitis is more commonly seen in athletes (around 25%), but it also affects sedentary individuals (10%). It is also the 3rd most common injury in runners⁶
• Age⁷
• Obesity⁷
• Biological factors: such as tight achilles tendon or abnormal foot conditions including flat feet, cavus foot (high arch), or abnormal walking manners/gait.^2,8 All of these can cause strain and tension on the fascia
• Occupational strain¹
• Medical conditions: there have been studies that point to arthritis playing a role in the development of PA⁴ 

Symptoms

There are several symptoms associated with plantar fasciitis:

• Heel pain is one of the most common symptoms of PA and appears as stabbing pain towards the heel bone¹
• Foot pain extending from the heel to the arch⁴
• Arch pain⁴
• Stiffness after inactivity⁴
• Tenderness at the bottom of the foot¹
• Pain during activity¹
• Gradual pain development⁴

Diagnosis

Diagnosis of plantar fasciitis is done via:

• Medical history such as history of symptoms, daily routines, and footwear¹
• Physical inspection which is done via a healthcare specialist; they will look for any tenderness at the bottom of the foot, as well as check the range of motion of the foot and ankle⁴
• Gait analysis. An abnormal walking pattern can contribute to PA⁴
• Imaging can be used to look for PA and this is achieved with Magnetic Resonance Imaging (MRI). In addition, X-rays can be used to eliminate other causes of foot injury to help diagnose PA¹
• Differential diagnosis of heel pain to rule out other causes⁴

Treatment

Multiple treatment options are available for plantar fasciitis:

• Stretching and strengthening: 

Exercise can address functional risk factors such as weak intrinsic foot muscles and tension in the calf muscles, which are significant in the treatment of plantar fasciitis. It is crucial to increase the calf muscles' flexibility. Stretching exercises that are frequently performed include wall, curb, and stair stretches. Other useful methods for stretching the calf include using a slant board or positioning a two-by-four-inch piece of wood in places where the patient stands for extended periods of time (such as offices, kitchens, or stoves). It's also helpful to perform dynamic stretches, such as rolling your foot arch over a tennis ball or a frozen water bottle. To stretch the plantar fascia, use a towel to stretch the calf and cross-friction massage above the plantar fascia before getting out of bed.⁹

According to a study, 83% of patients who participated in stretching programs received successful treatment; additionally, 29% of patients stated that stretching had been the most helpful treatment when compared to the use of orthotics, NSAIDs, ice, heat, heel cups, night splints, walking, plantar strapping, and changing shoes.⁹

In another study, strengthening programs were cited as the most helpful treatment by 34.9% of the subjects when compared with exercise, night splints, orthotics, heel cups, NSAIDs, steroid injection or surgery^.9

• Appropriate footwear: 

For certain patients, switching to appropriately sized shoes could be beneficial. Some people wear shoes that are too small, which can make a variety of foot pain conditions worse. Patients frequently discover that the pain they experience from prolonged walking or standing is reduced when they wear shoes with thicker, well-cushioned midsoles. These midsoles are typically constructed of a substance like high-density ethylene vinyl acetate, which is found in many running shoes.⁹ 

Research has indicated that a considerable amount of the shock absorption capacity of running shoes is lost with aging. So, even something as simple as buying new shoes could help reduce pain^.9 Motion control shoes or shoes with improved longitudinal arch support may help people with flat feet feel less pain when walking or standing for extended periods of time^.9

• Corticosteroid injections and anti-inflammatory medications⁸
• Iontophoresis:

This method relies on electric impulses to help push topical corticosteroids into the soft tissue of the foot.⁹ In one study, there were significant improvements after two weeks of using this technique, however there were no long-term differences after 6 weeks.^9,10 It is important to note that this method is costly, time consuming, and requires a physical therapist capable of administering it 2-3 times a week, so this might be a more efficient option for professional and elite athletes rather than regular patients.⁹ 

• Surgery in severe cases¹

The usual treatment plan starts with correcting training errors; this includes rest, use of ice post exercise, and having the proper footwear. This is followed by stretching/strengthening exercises, however if no improvement is seen, then orthotics and night splints can be taken into consideration. Anti-inflammatory medication is used to regulate the pain caused by PA, but it is important to note that it is not a treatment for the underlying problem.^1,9

Prevention

In addition to treatment, preventive measures can be taken before the onset of PA, and these include^{1, 9}:

• Wearing appropriate footwear
• Regular stretching/strengthening exercises
• Gradual increase in physical activity
• Lifestyle adjustments which include weight management and foot care.

Prognosis and recovery

The prognosis and recovery from plantar fasciitis is overall positive and there are studies that show patients improving significantly with conservative therapies.^9,11 However, the recovery time varies between individuals; this is linked to the severity of the case and adherence of the patient to the treatment plan.^{9, 11} 

FAQs

What not to do with plantar fasciitis?

There are multiple things to avoid when faced with plantar fasciitis and these can be:¹²

1. Being overweight
2. Standing or sitting for extended periods of time
3. Neglecting exercise and proper footwear
4. Bearing with the pain

How long does plantar fasciitis usually last?

It usually takes around 3 to 12 months before improvements take place in plantar fasciitis treatment.¹³

Summary

PA is one of the most common foot conditions in adults and can be quite painful to deal with. As we age and grow older, our health becomes our top priority, and this includes foot health. Hence, it is important to take preventive measures before the onset of PA; this can be achieved through regular exercise and proper shoes. However, when we are faced with PA, it is important to treat it before reaching severe stages that require surgery. There are many therapies available and range from simple strengthening and stretching exercises, orthotics, night splints, all the way to corticosteroid injections and iontophoresis.⁹ Consistency is important to improve and alleviate foot pain, and maintain our overall well being.