Plantar Fasciitis

This page has been designed to provide you with the right information about plantar fasciitis (pain in the heel) and the rehabilitation that may help you in your recovery.

What is plantar fasciitis?

Plantar fasciitis involves the irritation of the layer of fascia on the bottom of your foot.

Can you explain that in more detail?

Sure.

Plantar relates to the bottom of your foot in medical language. Fascia is a layer of connective tissue that goes from your heel to your toes and acts a bit like a tendon. The segment ‘itis’ normally mean inflammation in medical language, however recent research has suggested that this might be a little misleading, as inflammation is not typically part of plantar fascia irritation (Buchananon and Kushner, 2020). Sometimes, the same complaint might be called ‘plantar heel pain’ instead, however, most people know it as plantar fasciitis and that is the name we will use for this information page.

 

What is a fascia and why is mine irritated?

Fascia is a normal part of your anatomy and you have it all around your body. Fascia is a form of connective tissue that surrounds things like your organs and helps separate muscles (stops them sticking together). The fascia on the bottom of your foot (plantar fascia) plays a very important role in how your foot works - it does this mostly by supporting the arch in your foot.

Fascia is incredibly strong and yet still very flexible. The plantar fascia is designed to work and sometimes works hard (like when you run, jump or hop) and it normally does this without any issues. Just like any other body part, it can be trained to work harder if you need it to (i.e. the fitter you are, the better it works), but equally, can become less efficient at doing its job if you don’t use it.

Fascia irritation can be caused by many things, but in a lot of cases it is normally caused by one of the following:

1. Doing more than you are used to

2. Doing something new or different that you are not used to

3. Doing either of the two things above but having a period (sometimes a long time) of doing less before

What else might cause plantar fasciitis?

Being overweight is thought to be something that can contribute to the onset of plantar fasciitis and one of the things that can influence how well it may get better.

OK, so what happens to the fascia?

If you think of your fascia as being really good at doing its job (supporting the normal working of the foot), it means it can put up with a lot of work when it needs to. If you find yourself doing more than you are used to, doing something you are not used to doing or more importantly, having a period of doing less activity before, then you can push your fascia’s ability to cope. Most of the time you notice very little, maybe a bit of an ache here and there, but sometimes your body can react and say, “I’m struggling”.

If this happens, you will normally notice some discomfort and may find that moving can be uncomfortable. Think of this as your fascia being an ‘unhappy worker’, now struggling to do its normal day job and complaining about the work it has to do. Most of the time the soreness will settle with time, but sometimes it can last a bit longer, maybe into weeks or months. 

So, what are the common symptoms of plantar fasciitis?

In most cases, plantar fasciitis results in discomfort underneath the heel. This discomfort can sometimes spread into the arch of your foot, or even to the side or back of your heel.

People with plantar fasciitis often find that standing or putting weight on their foot, especially first thing in the morning or after rest, will make their pain worse. Sometimes walking either further or faster will hurt and on occasions, shoes with less cushioning can cause discomfort.

 

Ok, I think I might have plantar fasciitis, but what can I do about it?

Firstly, it’s important that you know that you can feel better. Sometimes, these issues can be really quite sore and can get in the way of things that you would normally take for granted, making you feel that you’ll never get better, however, if it hasn’t settled by itself then physiotherapy can help.

Understanding the issue is often the best place to start. Reading the information above can help you better understand that plantar fasciitis is not a damaging or dangerous problem and that it can get better.

Secondly, there are two important things that can help you on your recovery journey:

1. Calm the problem down

2. Build yourself back up again

What does ‘calm the problem down’ mean?

If you think back to the idea that your irritated fascia/heel is an unhappy worker, then if you keep asking your fascia/heel to do the same job, in the same way that it always has, the fascia/heel will keep being sore. In other words, when something is sore, think of it like your fascia/heel saying “I can’t do that as easily as I used to at the moment”. Making some changes to the things that are sore may help calm the issue down to allow you to move on with your recovery. Think of it as putting the fascia/heel on lighter or amended duties whilst it’s sore.

We have written a whole page on ‘calming things down’ and called it ‘Load Management. You can find it here, along with some homework to try to help your foot’s recovery: Load Management  

 

Can you give some examples of what you mean?

Sure, but remember everyone is different. You will have to do some thinking yourself around how your foot is affecting you and some of the changes you might need to make.

 

Things that are sore

Why is it sore?

Possible solution

 

Standing for a long time

 

Sore fascia will tire more quickly

Try to take more breaks or shift your weight to the unaffected side from time to time

 

Walking (especially uphill or fast)

 

Sore fascia will tire more quickly and they don’t like too much stretch or work

Reduce how far you walk or take more breaks, choose a different route or shorter strides

 

Putting weight on it first thing in the morning

 

Sore fascia sometimes take time to ‘wake up’

 

 

Try some ankle movements before getting out of bed/following rest

 

Being barefoot

Sore fascia don’t like too much stretch and like some cushioning

Don’t walk barefoot; try something cushioned like trainers

 

How long should I work on ‘calming things down’?

This is a little tricky to be specific about and it is probably best to think about what your foot is saying. If you have been really good at adjusting, modifying and looking at the things that make your foot sore, then you should notice some changes within a few short weeks.

 

Ok, what do I do once it feels calmer?

Firstly, well done! Often ‘calming it down’ is the hardest part of your recovery.

Now that your foot feels somewhat calmer, the temptation might be to start going back to your normal activities in the same way you did before your foot issue. Sometimes this can be ok, but equally, sometimes you might find that your foot is not quite ready to return to normal just yet and may get irritated again. It might be best to think that your foot needs to get fit and strong again in order to get back to doing normal things in normal ways.

As we’ve said before, if you consider your sore foot as an unhappy worker, then you’ve adjusted and modified things (put it on ‘lighter duties’) to help calm it down. Now you’ve got to start a gradual or phased return to work (or normal). Jumping in at the deep end and going back to normal might result in your foot becoming grumpy and sore again.

OK, I know I’ve got to build it up and understand it’s got to be done in the right way, but how?

Understanding that it might take some time and that your foot will be more likely to cope better if you do things in a gradual way, is very important as the temptation will be to rush in, especially if it’s less sore than before.

No one is the same, just like no foot problem is the same as the next, therefore there are no ‘formulas' that will be right for everyone. However, we have provided (below) an exercise programme that, if followed, can be effective in helping you move forwards with your foot complaint.

Before I start, I’d like to know what the exercises are trying to do.

Excellent point, as it’s often useful to know what you’re aiming to do before you start.

Firstly, the exercises are aiming to introduce a little bit of work into the foot by asking the muscles, tendons and fascia to do some work. The aim is to start with only a little bit of work (within what is comfortable).

As you move through the exercises (as your heel allows), you will notice that the amount of work/effort and the amount of movement increases.

Lastly, one of the most important things about all of these exercises, is that they are trying to help you regain some trust in your foot. If your foot has been sore for some time, it is only normal to be a little cautious when you start to move back into doing things that caused you pain before. This is why the exercises are done gradually and shouldn’t be rushed too much.

 

What should I expect with these exercises? Will they be painful?

This is a very important question.

If your foot has been sore for some time, it would be a bit unrealistic to expect that it will be pain-free when doing these exercises. However, it is important that you don’t do too much to then upset the problem all over again.

A good marker for how hard to work is that you should feel some discomfort (not too much though), but it should settle within 24 hours. If you are still obviously sore the following day, you may have done too much/pushed too hard, therefore next time you do the exercises, reduce the effort a bit.

 

Will this get better with just adjusting the things that are sore, and exercises?

Although it is impossible to predict how each and every person will respond to rehabilitation, advice and exercises similar to that laid out on this page is considered the most effective way of managing plantar fasciitis (Rathleff et al, 2015).

Apart from these exercises, is there anything else I can be doing to help myself?

Yes, there is - here are just a couple of the most important things.

 

Some people will choose to manage their heel pain with pain relief, whilst some may choose to avoid medication. Applying something cold to your heel may also be useful in helping with some of the pain (do remember to wrap your frozen peas in a towel before applying them to your skin to avoid cold burns).

Weight loss is recommended as something that is important for the management of most muscle and bone issues. Losing weight is difficult and we understand that.

Often, people will think that simply putting more weight through their joints is the reason why they get problems and that being closer to their ideal body weight will simply stop their symptoms. Unfortunately, it isn’t that easy. It is worth knowing that fat cells are very active cells and one thing they do is produce chemicals that can affect pain sensitivity (Tashani et al, 2017).

By looking at diet, exercise, sensible goal setting and establishing a good support network, a weight loss journey is more likely to succeed and the benefits to your foot are more likely to be influenced by the journey you take to lose weight, rather than being lighter.

If you would like some support to help you with your weight loss journey, please contact our partners at Feel Good Suffolk or Active Norfolk.

Getting the best out of your diet is important to support your training programme. There are lots of different opinions on what is best, but generally it is agreed that if you want to build muscle, you should look to increase the protein in your diet. 1.5 grams of protein to every kilogram of your body weight is often suggested as a good starting point. More advice about diet can be found here: Eat Well

Sleeping well will help your recovery and support your training programme. More advice about sleeping better can be found here: Sleep Well

Frequently asked questions

 

A: Scans (MRIs or ultrasound scans) are very useful in a lot of cases; however, they are not normally needed for the assessment or management of plantar fasciitis. If your GP or physio decides they would like to arrange a scan for you, it is likely they are checking for something in particular, but the treatment (outlined above) remains the same and the most effective way of managing plantar fasciitis.

A: A steroid injection for plantar fasciitis is an option, however, like most drugs, steroids come with side effects and some of these can cause problems in the future for your heel (particularly the tendons and fat pad on the bottom of your heel). Often, injections only help in the short-term and exercise and advice remains the most effective option for most people (Rathleff et al. 2015).

A: This is something that your heel will dictate. If you have reached a stage in your recovery where the pain is settling and things that used to hurt are less sore, you might want to try some gentle training-type exercises (see phase 6). It is strongly advised that any return to sport is done gradually to allow you the best chances of success.

A: Firstly, ask yourself if you tried the ‘calm it down’ approach first. If you didn’t, then that might be the reason why you haven’t moved forwards. If you have, ask yourself if you did everything you could do and really commit yourself to adjusting/modifying all the things your heel was telling you it was struggling with.

A: Often, these types of problems take a long time (weeks into months) to settle, so be patient with yourself. If you have been dedicated to the ‘calm it down’ work and the exercises, as well as being patient and giving it time and still you feel no better, do discuss this with your physio as they may be able to discuss other options with you.

Exercises

Phase one:

 
Exercise tip: Use a rolled-up towel or something soft but firm under your toes. Raise up slowly (3 seconds), hold at the top of the movement (2 seconds) and slowly lower down again (3 seconds). Repeat 12 times for 3 sets (rest for 1 minute between sets). Aim to complete the exercise every other day.


Move onto the next phase when these exercises start becoming too easy.

Exercise 1

Phase two:

 
Exercise tip: With a heavy backpack (loaded with books/bottle or bricks) on your back, use a rolled-up towel or something soft but firm under your toes. Raise up slowly (3 seconds), hold at the top of the movement (2 seconds) and slowly lower down again (3 seconds).


Repeat 10 times for 4 sets (rest for 1 minute between sets). Aim to complete the exercise every other day.

Move onto the next phase when these exercises start becoming too easy.

Exercise 1

Phase three:

 

Exercise tip: With a heavier backpack on your back, use a rolled-up towel or something soft but firm under your toes. Raise up slowly (3 seconds), hold at the top of the movement (2 seconds) and slowly lower down again (3 seconds).


Repeat 8 times for 5 sets (rest for 1 minute between sets). Aim to complete the exercise every other day.

Move onto the next phase when these exercises start becoming too easy

 

Exercise 1

Phase four:

 
Exercise tip: With this phase, you can start to play around with speed. Try adding some speed to the second, as shown in the video. This section is important to help your foot regain its ability to tolerate high level fast movements.

Exercise 1

Need more help? Refer yourself here.

References:

Buchanan, B.K. & Kushner, D. (2020) Plantar fasciitis. Available from: https://www.ncbi.nlm.nih.gov/books/NBK431073/ (last accessed 18/01/2021)

Rathleff, M.S.,  Mølgaard, C.M.,  Fredberg, U.,  Kaalund, S.,  Andersen, K.B.,  Jensen, T.T., Aaskov, S., and Olesen, J.L. (2015). High-load strength training improves outcome in patients with plantar fasciitis: A randomized controlled trial with 12-month follow-up. Scandinavian Journal of Medical Sports Science: 25: e292–e300 doi: 10.1111/sms.12313 (accessed 18/01/2021).

Tashani, O.A., Astita, R., Sharp, D. & Jonhson, M.I. (2017). Body mass index and distribution of fat can influence sensory detection and pain sensitivity. European Journal of Pain. 21(7):1186-1196.

 doi: 10.1002/ejp.1019 (accessed 16/12/2020).