not gender specific. It affects all age ranges,
but most commonly the over 40s.
Anatomy of plantar fasciitis and
its signs and symptoms
A diagnosis of plantar fasciitis is confirmed
when the client presents with the following
signs and symptoms:
• Pain at the medial tubercle of the heel
and along the plantar fascia
• Pain upon first weight-bearing after a long
period of sitting, and the beginning of
weight-bearing activities such as walking*
• As the day progresses, pain can increase
and continue after physical activities
• The nature of the pain has been described
as burning, aching, and occasionally
lancinating
*This is based on the author’s clinical
experience only. If the client does not
experience pain on first weight-bearing,
then I get suspicious that it’s not a typical
presentation, so would dig a little more
diagnostically in order to get a more precise
diagnosis. My advice is, if you have a client
with this presentation, then get the client
to seek specialist assessment, e.g., a
podiatrist, physiotherapist, etc.
Differential diagnosis of plantar
heel pain
Other diagnostic considerations for plantar
heel pain include: calcaneal stress fracture;
rupture of the plantar fascia; and entrapment
neuropathy. Some systemic conditions
can manifest themselves as plantar heel
pain, including seronegative arthropathies,
referred lumbar pain, etc.
Causes of plantar fasciitis
There are several theories as to the
development of repetitive trauma, including
overuse,
over-training,
excessive
bodyweight, biomechanical changes to the
properties of soft tissues, and/or altered
biomechanics.
Although there is no evidence showing
a correlation between plantar fasciitis
and excessive foot pronation, Box 1
has already shown that when the foot is
elongated, the plantar fascia is under
greater tension. The functional relationship
between plantar fascia and the Achilles
has already been acknowledged; evidence
shows a significant association between a
tight calf, i.e., restricted ankle dorsiflexion
(foot points upward) and plantar fasciitis.
Just before heel lift during the gait
cycle, ankle dorsiflexion should be at its
maximum. If this is restricted, i.e., tight
50 | NETWORK WINTER 2019
calves, then the windlass mechanism is
restricted, the foot continues to elongate
(rather than shorten), and tension in the
plantar fascia increases.
Other factors to consider when looking
for potential causes of plantar fasciitis
include occupation. Evidence shows that
individuals on their feet for prolonged
periods, i.e., shifts in excess of eight hours,
are more at risk. Also footwear (shoes that
are totally flat and/or with minimal arch
support), though this is based on expert
consensus only.
Treatment for plantar fasciitis
The treatment options vary greatly, but tend
to group into two categories:
1. Mechanical therapies that are focused on
directly or indirectly reducing the tensile
load applied to the plantar fascia
2
.
Therapies
that
are
focused
on
reducing the symptoms, i.e., pain (in
a comprehensive review, 28 different
therapies were cited, but almost half were
mentioned only once, which suggests
their use is not widespread)
In the first instance, it is agreed among
experts that the first-line treatment is self-
care advice, focusing on the following:
• R
eassurance – most people with plantar
fasciitis will make a complete recovery
within one year
• Symptom relief – the application of ice is
advised (cover the foot with a towel and
apply for 15-20 minutes; this is based on
expert opinion only) – the use of
analgesia, e.g., paracetamol, codeine,
and non-steroidal anti-inflammatory
drugs such as Ibuprofen is advised (but
although they have plausible mechanisms
of action, there are no robust clinical
trials to support their use)
•
Reduce mechanical loading on the
plantar fascia (directly or indirectly):
1. Rest – avoid standing or walking for
long periods where possible, avoid
going barefoot or in shoes that offer
no support (this is based on expert
opinion rather than research studies,
with the logic being based on the
condition being considered an over-
use injury, so resting to allow healing
and recovery to take place would be a
sensible approach to take)
2. Orthoses/insoles – there is some
good evidence to support their use
and they are recommended on the
basis that they benefit foot posture
and reduce the strain on the plantar
fascia (the jury is still out over which is
the most effective type – prefabricated
over the counter or customised – but
NICE guidelines advise that ‘magnetic’
insoles should be avoided)
3. Losing weight – if overweight (to
prevent future episodes)
4. Stretching – this focuses on specifically
stretching the Achilles and plantar fascia
(Box 4) but, again, there is a lack of good
evidence (although this is a therapy that
is perceived by clients as being of the
most benefit and is widely advocated by
most experts)
How personal trainers can help
The advice is to rest and reduce the loading
but, practically speaking, what does that
mean and how do you manage it?
Evidence supports that load management
is a key component in the rehabilitation
process. The Pain Monitoring Model (PMM)
shows that monitoring pain levels during
rehabilitation makes it possible to continue
training, if the pain scores are kept within
certain limits, i.e., below 5 on a 0-10 scale.
Both static and dynamic activities will
load the plantar fascia; it is often presumed
that dynamic activities are more provocative,
but is that really the case? Ask the client:
when is their condition most painful? What
activities set it off? Another option is for you
to evaluate this – monitor their training using
the PMM and record their response, then
use the information to tailor their training.
Additional mechanical-focused
therapies
Taping
Evidence supports its use in the short term,
assisting in off-loading the plantar fascia. It
can also be used as a preventive measure,
i.e., use when undertaking activities that
will place considerable load on the fascia,
e.g., running, heavy weight-lifting. Some
clinicians trial taping first and, if they get a
positive response, will progress to orthoses.
Box 3 illustrates how to self-apply.
Eccentric exercises
These have been shown to be effective in the
treatment of Achilles tendinopathy; there is a
modified version that is effective for plantar
fasciitis (Box 4), however, the reader should
be mindful that this is a considerable amount
of load, so need to consider whether it’s
appropriate for their client. This is where the
PMM can assist in making a client-centred
evaluation. If it’s too much, then consider
performing with the upper-body supported,
i.e., leaning over a worktop so the loading is
reduced, and then evaluate the effect.