A collaborative approach to fascia-related plantar heel pain

Physiotherapist Greg Turpin and Dr Mareeni Raymond discuss management strategies for fascia-related plantar heel pain.

The plantar aspect may be tender (SPL)
The plantar aspect may be tender (SPL)

The plantar fascia is a longitudinally organised fibrous connective tissue which originates on the periosteum of the medial calcaneal tubercle.

It extends into five bands surrounding the flexor tendons as it passes all metatarsal heads, then blends with the paratenon of the Achilles tendon, the intrinsic foot musculature and the skin and subcutaneous tissue.1

Pain in the plantar fascia can be insertional and/or non-insertional. Evidence suggests plantar fasciitis is an inflammatory and a degenerative process.2

It occurs more frequently in females and athletes and overall, one in 10 people experience the condition.3 Ninety per cent of cases resolve with conservative management.4

Potential contributing factors to plantar fasciitis are:

  • Limited dorsiflexion of the ankle
  • High BMI
  • Excessive foot pronation
  • Inappropriate footwear
  • Diabetes
  • A range of biomechanical factors in the spine and lower limbs

GP's perspective

Diagnosis is clinical, based on a subjective history and examination.

History
The patient may describe a feeling like having a stone in their shoe or a burning pain around their heel. Symptoms are usually worse in the morning, on initial weight bearing, ease for a while and gradually increase as the day goes on and the plantar fascia is overloaded.

Patients are likely to report that the pain is worse when they are barefoot than when they wear shoes. Given the increased load on the plantar fascia during barefoot gait, this is unsurprising.

Patients may be walking with an antalgic gait and may stop activities that contribute to their symptoms.

Examination
The plantar aspect of the foot may be tender in and around the origin and/or insertion of the plantar fascia. Symptoms can usually be reproduced on passive dorsiflexion of the ankle combined with MTPJ dorsiflexion to stretch the plantar fascia.

Patients may present with limited dorsiflexion - this can be secondary to ankle arthropathy, such as osteoarthritis or soft tissue restriction.

Management
Given the combination of inflammation and degeneration, identifying the stage of the condition helps to direct initial management strategies. NSAIDs in combination with orthotics and stretching can help with pain in the first two to six months.5

The plantar fascia can be stretched by passive dorsiflexion of the MTPJs in ankle dorsiflexion. This is most easily administered in a seated, cross-legged position.

Stretching the plantar fascia reduces pain more than stretching the Achilles tendon alone.6 Ideally, these stretches should be administered at least three times with 10 repetitions daily, and before taking the first steps in the morning and after prolonged periods of standing.6 A step can also be used to further stretch the plantar fascia in this way, as pain allows.

Orthotics may help, with a heel pad being the most effective option in reducing pain.7 Wearing supportive shoes with a soft heel and reducing weight-bearing activity in the initial stages may also reduce overloading. Evidence suggests that taping can help to provide symptomatic relief in the early stages.8

Who to refer

Patients can often self-manage with the advice discussed above. Those patients who have been compliant but have not responded to stretches, NSAIDs, footwear optimisation and activity modification may need further physiotherapy.

Patients who initially have difficulty understanding or applying the concepts of management may need more time to learn the stretching techniques. Those whose lifestyle appears to be the primary cause may need more time to identify contributory factors and ways to alter them.

Physiotherapist's perspective

A physiotherapist will assess spinal and lower limb mechanics to identify contributory factors.

Modifiable biomechanics, joint stiffness and soft tissue restriction can be improved with manual therapy and home exercise.

Physiotherapists can apply taping techniques to offload the plantar fascias and, in less capable patients, administer stretches and soft tissue techniques where needed. They can also set lifestyle goals if these are a primary driver of the problem.

Working together

GPs are ideally placed to give early advice about stretches and pain relief. Physiotherapists may have an established management pathway and patient information within their department that can be shared with local GP practices.

Identifying those patients who are struggling to comply with management advice and may need further help at an early stage, before the condition becomes chronic, can make plantar fasciitis easier to treat.

Patients who wish to, or who must persist with sport or work that is a contributory factor can benefit from assessment by a physiotherapist, who can help them to modify any aggravating activity.

  • Mr Turpin is a senior physiotherapist, Royal Bournemouth and Christchurch NHS Foundation Trust; Dr Raymond is a GP in east London

References
1. Stecco C, Corradin M, Macchi V et al. Plantar fascia anatomy and its relationship with Achilles tendon and paratenon. J Anat 2013; 223: 665-76.
2. Crawford F, Thomson C. Interventions for treating plantar heel pain. Cochrane Database Syst Rev 2003, Issue 3. Art No: CD000416
3. McPoil TG, Martin RL, Cornwall MW et al. Heel pain – plantar fasciitis: clinical practice guidelines linked to the international classification of function, disability, and health from the orthopaedic section of the American Physical Therapy Association. J Orthop Sports Phys Ther 2008; 38(4): A1-A18.
4. Thomas JL, Christensen JC, Kravitz SR et al. The diagnosis and treatment of heel pain: a clinical practice guideline – revision 2010. J Foot Ankle Surg 2010; 49(3 Suppl): S1-19.
5. Donley BG, Moore T, Sferra J et al. The efficacy of oral nonsteroidal anti-inflammatory medication (NSAID) in the treatment of plantar fasciitis: a randomized, prospective, placebo-controlled study. Foot Ankle Int 2007; 28(1): 20-3.
6. DiGiovanni BF, Nawoczenski DA, Lintal ME et al. Tissue-specific plantar fascia-stretching exercise enhances outcomes in patients with chronic heel pain: a prospective, randomized study. J Bone Joint Surg Am 2003; 85-A: 1270-7.
7. Pfeffer G, Bacchetti P, Deland J et al. Comparison of custom and prefabricated orthoses in the initial treatment of proximal plantar fasciitis. Foot Ankle Int 1999; 20(4): 214-21.
8. Hyland MR, Webber-Gaffney A, Cohen L et al. Randomized controlled trial of calcaneal taping, sham taping, and plantar heel pain. J Orthop Sports Phys Ther 2006; 36: 364-71.

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