<b>What is it?</b>

<b>Describing plantar fasciitis is easy: It's simply an inflammation of the fascia on the bottom of the foot.</b>

<b>Getting rid of plantar fasciitis is hard!</b>

Cases of plantar fasciitis can linger for months at a time, with pain increasing and decreasing in an unpredictable pattern. Often, plantar fasciitis discomfort may nearly disappear for several weeks, only to re-emerge full-blown after a single workout. About 10 per cent of individuals who see a doctor for plantar fasciitis have the problem for more than a year.

The plantar fascia is actually a thick, fibrous band of connective tissue which originates at the heel bone and runs along the bottom of the foot in a fan-like manner, attaching to the base of each of the toes. A rather tough, resilient structure, the plantar fascia takes on a number of critical functions during running and walking. It stabilises the metatarsal joints (the joints associated with the long bones of the foot) during impact with the ground, acts as a shock absorber for the entire leg, and helps to lift the longtitudinal arch of the foot to prepare it for the 'take-off' phase of the gait cycle.

Although the fascia is invested with countless sturdy 'cables' of connective tissue called collagen fibres, it is certainly not immune to injury. In fact, about 5 to 10 per cent of all running injuries are inflammations of the fascia, an incidence rate which in the United States would produce about a million cases of plantar fasciitis per year, just among runners and joggers. Basketball players, tennis players, volleyballers, step-aerobics participants, and dancers are also prone to plantar problems, as are non-athletic people who spend a lot of time on their feet or suddenly become active after a long period of lethargy. A recent study found that over 50 per cent of people who suffer from plantar fasciitis are on their feet nearly all day, and many cases of plantar fasciitis seem to occur in 'sofa spuds' shortly after they've made their first trip around their garden with a lawn mower in the spring.<b> </b>The injury is usually near to where the plantar fascia attaches to the heel bone.

<b>Who gets plantar fasciitis?</b>

Plantar fasciitis is quite common. It mainly affects people over 40 and seems to be more common in women. However, it can occur at any age. It is also common in athletes. Situations where it is more likely include the following:

•If you do lots of walking, running, standing, etc, when you are not used to it. Conversely, people with a sedentary lifestyle are also more prone to plantar fasciitis.

•If you have recently started exercising on a different surface. For example, running on the road instead of a track.

•Wearing shoes with poor cushioning or poor arch support.

•Sudden gains in weight or being overweight will put extra strain on the heel.

•Overuse or sudden stretching of the sole. For example: athletes who increase their running intensity or distance; poor technique starting 'off the blocks', etc.

•Tightness of the Achilles tendon (at the bottom of the calf muscles above the heel) causing reduced ability to flex the ankle.

Often there is no apparent cause, particularly in older people. A common wrong belief is that the pain is due to a bony growth or 'spur' coming from the heel bone (calcaneum). Many people have a bony spur of the heel bone but not everyone with this gets plantar fasciitis.

<b>What is the Cause?</b>

The most common cause of plantar fasciitis is very tight calf muscles which leads to prolonged and / or high velocity pronation of the foot. This in turn produces repetitive over stretching of the plantar fascia leading to inflammation and thickening of the tendon. As the fascia thickens it loses flexibility and strength. So repetitive small injuries to the fascia with or without inflammation or by biomechanical faults that cause abnormal pronation are likely to contribute.

Some practitioners think you will see pronation by dropping and rolling in of the arch. This is not always the case. Sometimes it can only be seen with foot scans, especially if the patient has a high arched foot.

Other causes include high arch or low arch feet (pes cavus / planus) and other biomechanical abnormalities including over-supination which should be assessed by a podiatrist / physiotherapist / biomechanist.

<b>The 'red zone of tautness’</b>

Why does the fascia flare up? Although it is a fairly rugged structure, the plantar fascia is not very receptive to stretching, and yet stretching occurs in the fascia nearly every time the foot hits the ground. Studies indicate that the fascia can unkink itself to no more than 102 per cent of its normal length without suffering at least some tearing, but the force equal to almost three times body weight which passes through the foot with each step forces the fascia to come close to this 'red zone of tautness' 90 times per foot per minute during the act of running ('Anatomy and Biomechanics of the Hindfoot,' Clinical Orthopaedics, vol. 177, pp. 9-15, 1983). So, it's not surprising that plantar fasciitis occurs fairly frequently, nor is it a surprise that the damage - and pain - often tend to occur near the heel, where stress on the connective tissue fibres is greatest, and where the fascia itself is the thinnest (it tends to broaden out as it reaches toward the toes).

Why are some people troubled by plantar fasciitis, while others remain relatively plantar fasciitis free? Research suggests that plantar fasciitis is often associated with a change in activity (like a sudden increase in the volume or intensity of training or a simple expansion of the total time you spend on your feet). Using worn-out shoes, especially while running on pavement or hard ground, also seems to increase the risk Individuals with flat feet are said to be at higher risk for plantar fasciitis, and - somewhat paradoxically - so are people with high arches. A sudden increase in hill training may also spark a bout of plantar fasciitis, and pregnancy and plantar fasciitis go together like hand and glove.

Gaining weight or being obese is also a strong risk factor for plantar fasciitis. A recent study determined that 77 per cent of its sample of 411 plantar fasciitis (heel spurs) patients were overweight. Another study found that 23 per cent of overweight women had plantar fasciitis (heel spurs) compared to 8 per cent of the normal body-weight group. The additional body mass simply places increased stress on the plantar fascia.

<b>What are the Symptoms of plantar fasciitis?</b>

Pain is the main symptom. This can be anywhere on the underside of the heel. Commonly, one spot is found as the main source of pain. This is often about 4 cms forward from the heel, and may be tender to touch.

The pain usually eases on resting the foot, but is often worst when first used in the morning or after long periods where no weight is placed on the foot. Gentle exercise may ease things a little as the day goes by, but a long walk often makes the pain worse.

Sudden stretching of the sole of the foot may make the pain worse. For example, walking up stairs or on tip-toes. You may limp because of pain. Some people have plantar fasciitis in both feet at the same time.

<b>What is the Treatment?</b>

The traditional remedies for plantar fasciitis are - at best - quite weak. Stretching the calf muscles is often recommended, as are massage, decreasing one's training, losing weight, purchasing better-fitting shoes (with a raised heel and arch support), using special insoles, relying on thick heel pads, icing the sore heel, and gulping down prescription-type doses of ibuprofen.

The trouble with most of these nostrums (e. g., stretching the calf muscles, getting a massage, cutting back on training, hitting the non-steroidal anti-inflammatories, and icing) is that they don't really address what's going on. Stretching out the calf area is often a step in the right direction (tight calf muscles put extra strain on the plantar fascia), but there are many other strengthening and stretching routines which work more effectively (we'll describe them later). In addition, you can refrain from training, employ ice packs, and wash down dozens of ibuprofen caps over a period of many months, but when you get back into full-fledged training again, plantar fasciitis is very likely to recur with full fury. As is the case with any injury, you have to understand why plantar fasciitis cropped up before you can really rehab yourself and make the impairment a distant memory. You also need to increase the strength and resiliency of the plantar fascia and the other muscles and connective tissues of the foot - and stabilise and strengthen the entire leg - before you can expect to stay away from plantar fasciitis in the future. The exercises outlined below do just that.

<b>Exercises to recover from and prevent plantar fasciitis</b>

Our plantar fasciitis routines are divided into two types - those that emphasise stretching and those that stress strengthening:

<b>I. Stretching Routines</b>

A. The Rotational Hamstring Stretch
To carry out this stretch, stand with your weight on your left foot and place your right heel on a table or bench at or near waist height. Face straight forward with your upper body and keep both legs nearly straight. As you stand with your right heel on the table and your left foot on the ground, rotate your left foot outward (to the left) approximately 45 degrees, keeping your body weight on the full surface of your left foot (both heel and toes are in contact with the ground). You are now ready to begin the stretch.

Lean forward with your navel and shoulders until you feel a steady tension (stretch) in the hamstring of your right leg. Don't increase the stretch to the point of pain or severe discomfort, but do maintain an extensive stretch in your right hamstring while simultaneously rotating your right knee in a clockwise - and then counter-clockwise - direction for 20 repetitions. As you move the right leg in the clockwise and counter-clockwise directions, stay relaxed and keep your movements slow and under control.

After the 20 reps, remove your right leg from the table and rest for a moment.

Then, lift your right leg up on to the table and repeat this clockwise and counter-clockwise stretch of the right hamstring, but this time keep the left (support) foot rotated inward (to the right) approximately 10 degrees as you carry out the appropriate movements. Perform 20 repetitions (clockwise and counter-clockwise) before resting.

Finally, repeat this entire sequence of stretches, but this time have the right foot in support and the left foot on the table for the repetitions (do 20 clockwise and counter-clockwise reps with the left foot on the table and the right (support) foot turned out 45 degrees, and 20 more reps with the right foot turned in).

<b>Why is this stretch valuable? </b>

Tight hamstring muscles (which cross both the knee and hip joints on the back of the leg) can lead to limited extension and exaggerated flexion of the knee during the running stride (they tend to pull the lower part of the leg backward). This over-flexion at the knee actually increases the amount of dorsiflexion at the ankle during the landing phase of the running stride (remember that the entire leg functions as a kinetic chain; change one thing, in this case hamstring flexibility, and that change will 'ripple' right down the leg to the ankle joint). Increased flexion of the ankle creates an inordinate amount of stress on the Achilles tendon (the Achilles tendon's 'job' during running is to control dorsiflexion of the ankle), which in turn pulls on the heel bone (calcaneus) and plantar fascia. The rotational hamstring stretch ensures that hamstring flexibility is developed in the transverse (rotatory) plane as well as the sagittal plane. The hamstrings undergo movement stresses in both of these planes during the running motion and therefore must have flexibility in both planes to avoid over stressing the plantar fasciae.

<b>What other treatments are there for plantar fasciitis?</b>

There is no one specific treatment that appears stand out as the best. A combination of different treatments may help.

<b>Rest the foot</b>

This should be done as much as possible. Avoid running, excess walking or standing, and undue stretching of the sole. Gentle walking and exercises described below are fine.

<b>Footwear</b>

Do not walk barefoot on hard surfaces. Choose shoes with cushioned heels and a good arch support. A laced sports shoe rather than open sandals is probably best. Avoid old or worn shoes that may not give a good cushion to the heel.

<b>Heel pads and arch supports</b>

You can buy various pads and shoe inserts to cushion the heel and support the arch of your foot. These work best if you put them in your shoes at all times. The aim is to raise the heel by about 1 cm. If the heel is tender, cut a small hole in the heel pad at the site of the tender spot. This means that the tender part of the heel will not touch anything inside the shoe. Place the inserts/pads in both shoes, even if you only have pain in one foot. Orthoses should always be broken in slowly.

<b>Painkillers</b>

Painkillers such as paracetamol will often ease the pain. Sometimes anti-inflammatory medicines such as ibuprofen are useful. These are painkillers but also reduce inflammation and may work better than ordinary painkillers. Some people find that rubbing a cream or gel that contains an anti-inflammatory medicine onto the heel is helpful.

<b>Injections</b>

A steroid (cortisone) injection is sometimes tried if the pain remains bad despite the above measures. It may relieve the pain in some people for several weeks but does not always cure the problem. It is not always successful and may be sore to have done. Steroids work by reducing inflammation. Sometimes two or three injections are tried over a period of weeks if the first is not successful. Steroid injections do carry some risks including (rarely) rupture of the plantar fascia.

<b>Splint treatment</b>

Some people benefit from wearing a special splint overnight to keep the Achilles tendon and plantar fascia slightly stretched. The aim is to prevent the plantar fascia from tightening up overnight. In very difficult cases, sometimes a plaster cast or a removable walking brace is put on the lower leg. This provides rest, protection, cushioning and slight stretching of the plantar fascia and Achilles tendon.

<b>Extracorporeal shock-wave therapy</b>

High pressure sound waves directed at the plantar fascia may be used to stimulate healing if other treatments have failed. However, there are some uncertainties as to how effective this treatment is, mostly because of a lack of large, well-designed clinical trials to prove this. Also, there is a possibility of side effects from the treatment. These include damage to the bone, pain, damage to the Achilles tendon or a blood-filled swelling called a haematoma. You should discuss the treatment fully with your doctor if it is available.

<b>Other treatments</b>

Various studies and trials have been carried out looking at other possible treatments for plantar fasciitis. Such treatments include injection with botulinum toxin and treatment of the plantar fascia with radiotherapy. These treatments may not be widely available.

<b>Surgery</b>

This may be considered in very difficult cases. Surgery is usually only advised if the pain has not eased after 12 months despite other treatments. The operation involves separating the plantar fascia from where it connects to the bone and is called a plantar fascia release. It may also involve removal of a spur on the calcaneum if one is present. Surgery is not always successful. It can cause complications in some people so it should be considered a last resort. Complications may include infection, increased pain, injury to nearby nerves, or rupture of the plantar fascia.

<b>Can plantar fasciitis be prevented?</b>

There are certain things that you can do to try to prevent plantar fasciitis, especially if you have had it before. These include:

•Regularly changing trainers used for running or walking.

•Wearing shoes with good cushioning in the heels and good arch support.

•Losing weight if you are overweight.

•Regularly stretching the plantar fascia and Achilles tendon (see exercises above), especially before exercise.

•Avoid exercising on hard surfaces.

*Contributed by Martin Haines, Managing Director of Brytespark, Specialist Biomechanics Coach™, Chartered Physiotherapist.

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