Plantar Heel Pain : A Soft Tissue Approach
James Barker | Soft Tissue Therapist
Plantar heel pain is a common and often debilitating musculoskeletal condition that affects distinct populations . Epidemiology on plantar heel pain includes an estimated 11- 15 % of all foot complaints in adults presenting for care ( 1 ). Populations most at risk include runners , soldiers , those in prolonged standing positions and females in the 40 – 60-year age group ( 2 ), increasingly so if overweight . In Australia general practitioners are often used as a first healthcare interaction which often includes medication , education , and imaging ( 3 ). With increased knowledge on effectiveness of tendon loading guidelines , exercise and manual therapy are being increasingly utilised in the management of plantar heel pain . Information on management from a soft tissue approach is scarce . In this clinical commentary we will draw on current evidence and clinical experience to provide a working template based on the population and patient presentation .
Anatomy and Function
The plantar fascia , also known as the plantar aponeurosis , is a broad sheet of connective tissue composed primarily of type I collagen . It stretches from the medial plantar surface of the calcaneus attaching to the proximal surface of the metatarsal heads .
Diving a little deeper we can see the fascia is closely connected to the paratenon of the Achilles tendon , more so than to the tendon itself , through the periosteum of the heel . The plantar fascia extends medially and laterally , continuing into the deep fascia enveloping the abductor hallucis and abductor digiti minimi muscles , respectively ( 4 ). Anatomically , the connection to the paratenon decreases as we age .
The aponeurosis functions passively to maintain the longitudinal arch and absorb load as the foot rolls through various stages of the gait cycle . The plantar fascia is active eccentrically during ( hind and midfoot ) pronation and concentrically using the windlass mechanism during toe off . Like tendons , the plantar fascia is essential to store and release energy , increasing mechanical efficiency during gait . Considering the function and anatomy , a stiff strong , aponeurosis is a key factor in a wellfunctioning plantar fascia .
In addition , anatomically the intrinsic foot muscles play a role during gait .
The intrinsic foot muscles have their attachments within the foot itself . The small muscles have been shown to assist damping of energy associated with footground impact and play a critical role in stiffening the foot for propulsion ( 5 ).
One key factor , which has received little research attention to date , is compression , as the fascial connections wrap around the calcaneus . Many of us have seen the patient who presents with posterior heel pain below the Achilles insertion at the calcaneus but well away from the medial calcaneal tuberosity . Could this be a factor to consider when designing a rehabilitation program ?
What is plantar heel pain ?
Plantar heel pain is a localised pain usually confined to the attachment at the medial calcaneal tuberosity and tends not to refer . The condition is common in load-related sports that include running ; however , it is also found in people who are unloaded and sedentary . Those who are overweight often present with co-morbidities which are an additional consideration during the initial consultation and treatment protocol .
JATMS | Autumn 2024 | 15