Plantar fasciitis can be a downright incapacitating condition. The internet is plagued with quick-fixes which offer short term symptomatic treatment but beware - they won't work if you actually have plantar fasciitis (this will make sense in a second). To properly treat your plantar facia, you need to understand a bit about it and then I'll run you through some things you can do to treat it for good.
What essentially happens to the foot is the common tendon of a lot of the little foot muscles gets overloaded - normally from injury or overuse. Tendons tend to be tricky though - they don't just heal up like muscles or bones but they go through a nasty process where these little proteins called proteoglycans swell the tendon and this is what often causes most of the pain. The downside to this is that the swollen tendon can't take as much load which leads to a chronic condition. Depending on how long you've had your plantar fasciitis for can somewhat predict your recovery. If it's relatively recent, then chances are good that you can bounce back relatively quickly. If, however it's been going on for a while then you will need a good plan of action.
Tendon problems tend to be classed into different stages. There's the reactive stage (very painful) which lasts for the first 2-3 weeks. Best thing to to is take it easy and rest the tendon if you're still at this stage (check out how below). Then comes the disrepair stage which is where the swelling of the tendon weakens it so much that the load you place through it weakens it more and it creates a negative feedback loop. This normally goes for 1-6 months. The good news if you're at this stage is that there tends to be good potential for reversibility, the bad news is it tends to take a while to recover. The tendon his not healing itself and needs a controlled load program (see below) to recover its loading capacity. The third and final stage sounds worse than it is but is called the degenerative stage. This is when the problem has gone on for over 6 months and the pockets of protein swelling have weakened the tendon. If this is where you're at it can actually be quite useful to image the tendon with ultrasound to confirm it. It can take quite a bit of time to come back from this (you definitely can) but you'll likely want to get a heath care team involved to help with your recovery.
Image from Cook and Purdam (2008) see reference at bottom of page.
At this point, if you're confused - fair enough! The rest will be easy, I'll guide you through what to do. There's three main things you need to keep in mind.
MANAGE YOUR LOAD
This is your best chance of success with management. If whoever you're currently seeing hasn't mentioned load management and has been trying to treat your tendon with passive modalities like ice, ultrasound or massage - run for the hills!
There's a few pretty simple tricks you can do to manage load on your tendon. The first thing to do is to get a step counter. You will likely have one in the health app on your phone. What you need to do is work out the current step tolerance of your tendon. This is the amount of steps you can do in the day without morning pain the next day. I can't stress this enough - gauge your load not by how much you have when you're using it but rather gauge it on the following morning. Find the 'goldilocks' amount of steps - not too little and not too much. If the tendon feels stiff the next morning - that's fine. Once you've found the sweet spot, increase your step count by 10% a week (no more). It's a good idea to do this under the direction of a good physiotherapist.
The second thing I would highly recommend is to strap your plantar fascia. It's not as hard as you think just check this video:
2. WARM THE TENDON UP IN THE MORNING
Often the morning is the worst part of the day. I sometimes think of tendons a bit like a squash ball. They're hard have no bounce when cold but warm them up and they can bounce all over the court. In the morning, the tendon is less flexible and adaptable to any load, so when you go to put all of your weight through . There's a couple of pretty easy things you can do to help this. First of all, wear warm socks - I know it sounds silly but it can help a lot. Secondly, do a couple of exercises to warm it up before putting your weight through it. This will actually help a lot with the step tolerance throughout the day (point 1). Also, don't use ice. This is an inflammatory condition like a muscle strain. As discussed above, the swelling of the tendon is from the proteins, not inflammation.
3. TRAIN YOUR FEET
The foot is quite a complicated part of the body - as complex as your hands. The foot has 26 bones and 33 articulations. There's a lot of capacity for good movement and biomechanics but unfortunately we rarely use our feet as they're supposed to be used. There's a few things you can start to do to help with better biomechanics. When the load gets distributed evenly through them, The foot works a bit like a spring when you walk. It's really quite a fascinating concept but not the centre point of this blog. But it's definitely a good idea to work on a bit of release and train better loading through the foot and toes. The plantar facia also blends with the toe muscles so the stronger you can get your toes, the less load will go through the plantar facia and the faster your recovery will be.
4. ITS PROBABLY NOT JUST YOUR FEET
Last but definitely not least is the plantar facia are most commonly overloaded by problems coming from the axial skeleton (everything higher up). More often than not things like old injuries and repeated movement patterns can change how you load on your feet. Feel free to check the bottom of some old shoes - is the wear pattern on your shoes perfectly even left to right? I highly doubt it. Is your condition worse on one foot? More than likely. Often what happens in your hips and torso will change how you load your feet by changing your centre of mass. This affects how the feet will load when you're walking/going about your day and contribute to an overload injury. I can't stress this enough. So I hate to say it but if you're only managing your condition from your feet up, your chance of success is going to be quite low.
WHERE TO NOW?
In my 10 years of practice I've tried all sorts of things to manage this tricky condition but there's a few key takeaways:
- Focus on active management that you can do at home (not passive treatment)
- Keep the tendon warm (don't use ice)
- Tape your feet every day and keep an eye on your daily steps and then increase slowly.
- If there's uneven wear on your shoes, you'll probably want to chat with a physio.
- If your condition has gone for >6 months, get some imaging done and a healthcare team involved. You may need light duties at work and lifestyle modification as well as a good treatment plan.
- You might need the help of a physiotherapist to plan your recovery.
Please note: the correct term for this condition is plantar fasciopathy or plantar fasciosis. In medical terminology -itis means inflammation which can actually lead to mismanagement (ice, NSAIDS) which can worsen or delay recovery of the condition.
Cook, J., Purdam, C. (2008) Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. BJSM
McCreesh, K., Lewis, J (2013) Continuum model of tendon pathology – where are we now? Int J Exp Pathol. 2013 Aug; 94(4): 242–247.