William E. Morgan D.C.

The Plantar Fascia
The plantar fascia is a wide band of tendon that attaches to the heel and helps to support the structure of the foot.

The most common cause of heel pain is plantar fascitis The term plantar fascitis literally means inflammation and thickening of the fibrous sheet of tissue on the bottom of the foot. This condition may be caused by a sudden increase in activities such as running, incorrect footwear or from an acute injury. Plantar fascitis is characterized by the following symptoms:

• Pain localized on the bottom of the foot, most commonly on the heel
• Pain that is worse when one begins walking after getting out of bed in the morning or after periods of inactivity
• Pain that diminishes with light activity, but worsens with vigorous activity
• Pain that is commonly worse when walking barefooted
• Pain described as a pulling sensation with walking or a deep bruise when standing
• Pain that is worse with low-heeled shoes

Heel Spur Formation

Chronic stress and irritation may cause calcification of the attachment of the plantar fascia to the heel. The calcification of the plantar fascia will appear like a "spur" on X-ray. The spur itself is not usually the cause of pain, but the result of chronic irritation.

What conservative treatments are available?

On the surface it seems that treatment of plantar fascitis would be simple: rest. But, it is difficult to rest the plantar fascia if one continues to walk, bike, stand or perform virtually any weight bearing activity. The following is a synopsis of the various conservative treatments that are available for this problem.

Modification or Reduction of Provocative Actions

• Swim instead of run for exercise.
• Change from running on hard surfaces to soft surfaces.
• Cycle with a stiff bicycle shoe instead of an unsupportive shoe.
• Avoid going barefoot.

Manual Myofascial Treatment

Manual soft-tissue manipulation and "release" of fascial adhesions often helps to relieve plantar pain. This chiropractic technique uses manual deep tissue techniques to reduce restrictions and fascial thickening.

Myofascial Treatment
Release and mobilization of connective tissue adhesions in the plantar fascia is accomplished by treatment with Graston™ instruments or with a chiropractor's hands.

Manipulation

Each foot is composed of 26 bones. These bones are connected by joints, and if these joints are not moving freely, then the force of walking or running is transmitted to the plantar fascia rather than being dissipated by normal biomechanics. Manipulation by a trained manual practitioner maintains normal joint mechanic. The word chiropractor literally means "manual practitioner."

Manipulation
Chiropractic adjustment (manual manipulation) of the foot, a treatment to restore and maintain normal joint motion

Proper Shoes

Shoes should be comfortable and allow unrestricted foot motion, while providing comfortable support. I even recommend that patients have supportive footwear next to their bed so that they can slip them on for even the first few steps of each new day.

Orthotic

Orthotics are specialized arch supports that fit into your shoes. These supportive arch supports will reduce plantar pain in some patients. Orthotics are available over-the-counter for $20-50. For persistent plantar pain, custom molded orthotics are recommended. Orthotics custom molded to your foot are available for $100-$300. I recommend starting with a non-rigid orthotic.

Heel Cushions

Soft heel cushions may reduce the heel pain associated with plantar fascitis.

Ultrasound

Therapeutic ultrasound sends sound waves into the fascia. These sound waves soften and warm the connective tissues of the plantar fascia. The use of ultrasound is intended to breakdown adhesions that contribute to inflammation and thickening of the fascia.

Ultrasound Application
Therapeutic ultrasound uses ultra high-frequency sound waves to treat plantar fascitis.

Stretching

Stretching is important in elongating shortened tissues that can contribute to plantar fascitis. As we age, our connective tissues become shortened, less pliant, and less resilient to physical stresses. Stretching the calves and the plantar fascia is a good preventive measure as well as a treatment.

Stretching the Calf Muscles
From a lunge position with your palms pressed against a wall, push your back heel toward the ground until a stretch is felt. To increase the stretches, get into a deeper lunge position. Perform for 30 seconds with each leg.

Seated Calf Stretch
Using a band of rubber tubing, a belt, or a towel, pull your foot into a stretched position while keeping the knee straight. You should feel a gentle stretch on the calf.  Hold this stretch for thirty seconds with each foot.

Stretching the Plantar Fascia
Grasp the base of the big toe.  Gently stretch it back and hold for thirty seconds. You should feel a stretch on the bottom of the foot. To modify this exercise, you may grab lower on the toe.

Strengthening Exercises

Strengthening the muscles of the calf has been show to decrease the severity of plantar fascial pain.

Calf Strengthening
Calf-raises and the use of rubber therapeutic bands are good ways to strengthen the calf muscles.

Massage

Massage stimulates blood flow and has been purported to mobilize restricted soft tissue structures. Massaging the bottom of the foot provides at least temporary reduction in pain. Self-massage can be accomplished by rolling your foot on a firm ball or a bottle while in a sitting position. Do not perform this maneuver while standing. I recommend using a tennis ball for this type of massage, but golf balls and baseballs work well, if you do not apply too much pressure. Perform the massage for five minutes once or twice a day.

Ball or Bottle Massage
Tennis balls, golf balls, or even baseballs can be used for massaging the bottom of an irritated foot.

Ice

Icing the heel can reduce inflammation of the plantar fascia.

Ice Massage:

1. Place a Styrofoam cup filled with water in the freezer.
2. After the water has frozen, peel back a portion of the Styrofoam to expose ¼-½ inch of ice.
3. Grasping the Styrofoam cup, massage the heel and bottom of your foot with the ice for five minutes.

You may also combine ice and massage by freezing a soda bottle and placing it on the ground. Roll your foot on the ice cold bottle for five minutes while sitting.

Of course, patients with diabetes or other conditions characterized by decreased circulation or sensation should avoid the use of ice.

Night-Time Splinting

Night-time splints maintain a constant gentle stretch on the plantar fascia to elongate the tissues and prevent the fascia from healing in a shortened position.

Splints
Splints can be used to keep the fascia from shortening.

Taping

Plantar taping for athletic events is certainly a good idea, but I also have found that taping is also a good treatment for non-athletic patients with persistent plantar fascitis. By correctly taping the plantar surface of the foot, you allow the planar fascia to rest. Some doctors will have their patients leave the tape on for three to four days at a time.

My main concern with taping is circulation. Never tape in such a way as to restrict circulation; check the circulation (distal pulses, color and temperature) often. I recommend that you do not tape around the circumference of the leg or foot; this could create a tourniquet effect.

Other Treatment Options

NSAIDs (non-steroidal anti-inflammatory medications) are the primary medical treatment for plantar fascitis. Protracted use of NSAIDs carry the risk of gastrointestinal bleeding and kidney damage.

If these conservative measures do not help your condition, then more extreme measures may be required; less conservative treatments include the use of oral steroids, steroid injections, and surgery.

Dense connective tissue, such as the plantar fascia, has a poor blood supply and that lends toward a slow healing process. This poor blood supply and the difficulty in resting these tissues combine to make this a source of frustration. While there are no guarantees that conservative treatments will relieve foot pain, they should always be used before using treatments that have greater risks attached to them. Everyone is different and will respond differently to these conservative measures. Remember that the advice in this article is not a substitution for advice from your health care provider.