Plantar heel pain (PHP), commonly known as plantar fasciitis, is a prevalent condition that affects the underside of the foot, particularly the area near the heel. It is characterized by pain in the plantar fascia, a thick band of tissue that connects the heel bone to the toes. It can significantly impact an individual's daily activities. Fortunately, advances in research have led to evidence-based management strategies that effectively address this condition.

1. What causes plantar heel pain?

Like most musculoskeletal injuries, PHP is commonly caused by a discrepancy between load and capacity. The tissues in your body (muscle, tendon, ligament, and even bone) adapt to whatever you do most often and the plantar fascia is no exception. For example, during the winter months, many people increase the time they spend engaging in sedentary behaviours such as sitting. In this case, the plantar fascia is not asked to adapt to much load or weight bearing. Enter an unseasonably warm spring in Vancouver, and many folks find themselves inspired to run! If done gradually, most people will do quite well, and won’t experience PHP. For some, their running program was a classic case of “too much too soon”. This discrepancy between load and capacity can also be seen when people gain weight during pregnancy which is likely why some people that are pregnant experience PHP. You can read more about the root cause of pain and injury in this blog post (please hyperlink 1st blog post).

2. Accurate Diagnosis and Assessment

Accurate diagnosis and assessment are important for developing an effective management plan. A physiotherapist can conduct a thorough examination which will include a comprehensive history and physical examination. This will help to rule out any other causes of heel pain.

3. Physiotherapy management

The first line treatment of plantar heel pain typically involves conservative, non-invasive approaches delivered by a physiotherapist. A 2021 best practice guideline recommends a core treatment approach of plantar fascia stretching, education, and taping. If there is no improvement in four weeks, folks can decide if they want to move onto other interventions, such as custom orthotics. Importantly, the core approach is meant to continue until symptoms resolve, even if other interventions are incorporated. Based on this best practice guideline, along with other high-quality research, we recommend the key interventions below:

Activity modification

Since PHP is usually caused by a discrepancy between load and capacity, it can be helpful to temporarily decrease load to allow the plantar fascia to settle down. When feasible, a temporary break from aggravating activities and a gradual return can be useful. For example, in the case of runners with PHP, a temporary deload followed by a gradual return to previous running distance, time, frequency, and/or intensity will help. That said, many people have work or life demands that will require them to be on their feet, and there are other ways to decrease the load described later.

Physiotherapy Led Stretching and Strengthening Exercises:

While you work to temporarily decrease the load, you can also build the plantar fascia’s capacity. Targeted exercises that stretch and strengthen the plantar fascia and other tissues around the foot and ankle can lesson symptoms and promote recovery. A physiotherapist can help you identify any deficits in muscle strength, muscle length, or joint range of motion. This study demonstrates that high load strength training of the calf muscles is effective for plantar heel pain. This may be because the calf muscles and the plantar fascia are continuous, so when you strengthen the calves, you also strengthen the plantar fascia, which increases its capacity to handle loads.

Soft-tissue Work and Manual Therapy

Manual therapy refers to soft tissue mobilization, joint mobilization, and joint manipulations performed by qualified therapists. This systematic review does demonstrate that manual therapy is effective at reducing pain and improving function when used as an adjunct treatment. Manual therapy performed by a registered massage therapist, physiotherapist, or chiropractor can temporarily provide pain relief that may allow you to engage more with your rehabilitative exercises. If you have someone at home that can rub your feet, that can be relieving, too!

Taping, Orthotic Devices, and Footwear Modification.

Fortunately, there are several clever ways you can offload the feet while continuing life as usual with the use of taping, orthotic devices, or footwear modifications. With the risks of sedentary behaviour being well documented, it is worthwhile to use the strategies below to allow you to continue to move your body.

Taping: The low dye taping technique has been shown to be quite effective in relieving pain for people with PHP. This is likely because taping the feet changes the way that forces are distributed in the feet, giving tender structures a bit of a break. After a physiotherapist tapes your foot the first time, you can learn to tape them at home.

Orthotic Devices: custom or prefabricated orthotic devices, such as shoe inserts, can give the plantar fascia a break in the same way that tape can but some folks might find orthotic devices more comfortable. Dr. Alexa Dykun at can help you with custom orthotics!

Footwear Modification: Wearing appropriate footwear with adequate cushioning and shock absorption can alleviate symptoms. Like taping and orthotic devices, we’re just playing with force distribution. If you’re choosing footwear because you have PHP, get something comfortable with lots of cushion! As a fun aside, it is quite possible for most people to adapt to all sorts of footwear, including more minimalist shoes, when they are not experiencing tenderness in the plantar fascia or other foot/ankle pain.

PHP has an excellent prognosis, and most people recover fully. For people that have failed with the above interventions and have ongoing disabling symptoms, their physiotherapist can collaborate with their doctor regarding medical treatment options, which are generally considered a last resort.

In short, people experiencing plantar heel pain should seek guidance from a physiotherapist for an accurate diagnosis and the development of an individualized management plan. By incorporating the principles discussed in this blog post, you can enhance your recovery, reduce pain, and regain quality of life.

References:

Fraser, J. J., Corbett, R., Donner, C., & Hertel, J. (2018). Does manual therapy improve pain and function in patients with plantar fasciitis? A systematic review. The Journal of Manual & Manipulative Therapy, 26(2), 55–65. https://doi.org/10.1080/10669817.2017.132273

Morrissey, D., Cotchett, M., Said J’bari, A., Prior, T., Griffiths, I. B., Rathleff, M. S., Gulle, H., Vicenzino, B., & Barton, C. J. (2021). Management of plantar heel pain: a best practice guide informed by a systematic review, expert clinical reasoning and patient values. British Journal of Sports Medicine, 55(19), 1106–1118. https://doi.org/10.1136/BJSPORTS-2019-101970

Rathleff, M. S., Mølgaard, C. M., Fredberg, U., Kaalund, S., Andersen, K. B., Jensen, T. T., Aaskov, S., & 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 Medicine & Science in Sports, 25(3), e292–e300. https://doi.org/10.1111/SMS.12313

Evidence-Based Management of Plantar Heel Pain: A Guide