Physio Penrith Plantar Fasciopathy Treatment
Treatment of Plantar Fasciitis (Fasciopathy) at Sydney Muscle & Joint Phsyio Penrith
What is plantar fasciitis (fasciopathy)?
Plantar fasciitis, now called plantar fasciopathy, is caused from repetitive microtrauma where plantar fascia attaches to the calcaneus, reactive and degenerative changes can occur as a result. There is less focus on inflammation in this presentation and this presents the new terminology- planar fasciopathy. Plantar fasciitis (fasciopathy) is also known as painful heel syndrome, chronic plantar heel pain, heel spur syndrome, runner's heel, and calcaneal periostitis.
Histological changes are suggestive of degeneration rather than inflammation. The fascia is usually markedly thickened and gritty. These pathologic changes are more consistent with fasciosis (degenerative process) than fasciitis (inflammatory process), rendering the term ‘fasciitis’ less suitable for broader use and plantar fasciopathy to be more correct.
1. It’s not inflamed so don’t bother with anti-inflammatory medication.
2. Don’t roll it with a frozen water bottle - these injuries hate compression
3. Don’t rest it - as the fascia loves load and movement
What are the common symptoms of plantar fasciitis (fasciopathy)?
1. Plantar (sole) heel pain, whereby pain starts from heel pad or the inside of the heel bone and spreads through the plantar fascia and medial longitudinal arch of the foot.
2. Start up pain - pain on the medial side of the heel, most noticeable with initial steps after a period of inactivity (sitting or rising from bed in the morning and usually lessens with increasing level of activity during the day.
3. Symptoms can be worse toward the end of the day as prolonged weight bearing and an increase in weight bearing activities can be aggravating.
4. Tightness of Achilles tendon is found in almost 80% of cases, which may be suggestive of a weakness in the calf (plantarflexor) muscles.
5. Occasionally the pain may spread to the whole of the foot including the toes. Tenderness can be elicited over the medial calcaneal tuberosity and may exaggerate on dorsiflexion of the toes or standing tip toe.
Obesity, increased foot pronation, difference in extremity length, long standing duration and Achilles tendon tightness are some of the factors which stress plantar fascia and sometimes cause degenerative changes on it. Weakness of intrinsic muscle is also another factor which is thought to be related with plantar fasciitis.
Start up pain feels like you are getting stabbed with a knife and this pain improves after a few steps or 5-10min. A true indication that rest is bad and movement is better for this injury.
What are the risk factors of plantar fasciitis (fasciopathy)?
Some of the risk factors which stress plantar fascia and sometimes cause degenerative changes on it are listed below. If you can manage these factors then it can help in the management and resolution of plantar fasciopathy (fasciitis).
1. Obesity - 5-10% weight loss
2. Increased foot pronation or flat feet - strengthen hip, ankle and foot muscles
3. Difference in extremity length - assess hip and low back contribution to leg length discrepancy
4. Long standing duration - build resilience to tolerate longer standing duration
5. Achilles tendon tightness and weakness of calf muscles - strengthen calf muscles
6. Weakness of intrinsic muscle - strengthen ankle and foot muscles
A 2020 study observed a strong, statistically significant correlation between gastrocnemius tightness and the severity of heel pain in plantar fasciitis.
Other research shows that stretching has minimal effect on muscle lengthening compared with eccentric muscle strengthening.
Diagnosis of plantar fasciitis (fasciopathy)
The diagnosis of plantar fasciitis (fasciopathy) is usually clinical and based on the above symptomatology. Rarely does there need to be further investigations, but x-ray and ultrasound would be first line.
Lateral radiograph of the ankle should be the first imaging study to assess heel spur, thickness of plantar fascia, quality of fat pad, any stress fractures or unicameral bone cysts
Ultrasound examination proves to be significant when the diagnosis is unclear and can also assess thickness of the plantar fascia (normal 2–3 mm). People with chronic heel pain are likely to have a thickened plantar fascia with associated fluid collection, and that thickness values >4.0 mm are diagnostic of plantar fasciitis. Plantar fascia thickness values have also been used to measure the effect of treatments and there is a significant correlation between decreased plantar fascia thickness and improvement in symptoms.
Big truth about plantar fasciopathy (fasciitis):
The injured tissue hates compression. This means poking it, stretching it, rolling it on frozen water bottles, using spiky balls or getting it massaged will IRRITATE it every time.
Our treatments remove compression and we apply progressive loading exercises to help stimulate the tissue to regenerate.
Guideline-based treatment of plantar fasciitis (fasciopathy)
At Sydney Muscle & Joint Clinic Penrith our physiotherapists use guideline-based treatments when manageing patients with plantar fasciitis (fasciopathy). This means the treatments are proven to work and are best practice. Non-surgical treatment for plantar fasciopathy (fasciitis) includes explaining to patients that pain and irritability will settle over time, progressive load is needed to stimulate cellular regeneration and specific education and advice is required to manage patient expectations. Some treatments focus on the proximal insertion of the fascia, while others address the relationship between gastrocnemius tension and weakness and the plantar fascia during weight-bearing activities.
Orthoses and splints
Mechanical treatments affecting loading of the plantar fascia have been extensively used for the treatment of plantar fasciopathy (fasciitis). Foot orthoses aiming to decrease pronation and off-load the proximal insertion of the fascia have been studied. A randomised, controlled study comparing over-the-counter shoe inserts with customised shoe inserts found no significant difference in pain relief between the two groups at 12-month follow-up. Nocturnal splints are applied to stretch the fascia to prevent morning stiffness and pain. Several high-level studies support the use of night splints, but poor patient tolerance may be an issue for compliance.
One or more injections of cortisone and local anaesthetics may result in variable responses and duration of relief. Multiple injections may increase the risk of rupture of the plantar fascia and fat pad atrophy. Controlled, randomised clinical trials demonstrated low-quality evidence of moderate short-term positive effects of cortisone injections when compared to a placebo, but they usually lasted no more than 1 month. Potential complications of fat pad atrophy and plantar fascia rupture together with limited results are in contrast with the wide use of cortisone injections for PF worldwide. Other injection therapies that have also been shown to have short-term and variable benefits include hyperosmolar dextrose, botulinum toxin A, and autologous blood.
Platelet-rich plasma (PRP)
A recent systematic review of published literature for studies comparing PRP injections and corticosteroid injections for plantar fasciopathy (fasciitis) shows PRP injections were associated with improved pain and function at 3-month follow-up when compared with corticosteroid injections. But there was no information regarding either relative adverse event rates or costs. The authors concluded that large-scale, high-quality, randomised controlled trials with blinding of outcome assessment and longer follow-up were required.
Extracorporeal shock wave therapy (ECSWT)
Some well-designed clinical studies have shown ECSWT to be effective in the treatment of plantar fasciopathy (fasciitis). In a recent meta-analysis on the efficacy of the different variants of ECSWT, nine studies involving 935 patients were included. It was suggested that focused shock wave (FSW) can relieve pain but no firm conclusions of general ECSWT and radial shock wave (RSW) effectiveness can be drawn. Radial shock wave is dispersed from the applicator and does not concentrate on the tissue as FSW does. However, other authors showed there was a considerably lower success rate of ECSWT in patients with gastrocnemius shortening. There are also concerns regarding availability and costs of this therapy, and as a result Sydney Muscle & Joint Physio Penrith does not utilise ECSWT.
At Sydney Muscle & Joint Physio Penrith our focus is on strengtha nd building capacity in the tissue. Atrophy of intrinsic foot muscles has been associated with symptoms of plantar fasciopathy (fasciitis) in runners by destabilising the medial longitudinal arch. In a randomised controlled clinical trial, patients with plantar fasciopathy (fasciitis) were allocated to one of three treatment options – extrinsic and intrinsic foot muscles; abductor and lateral rotator hip muscles; and stretching alone – for an 8-week period. All three protocols led to improvements at 8-week follow-up in pain and function in patients with plantar fasciopathy (fasciitis). However, in a systematic review of the literature regarding strength training for plantar fasciopathy (fasciitis), it was not possible to identify the extent to which strengthening interventions for intrinsic musculature may benefit symptomatic or at-risk plantar fasciopathy (fasciitis) populations.
There is evidence that increased plantar fascia strain is associated with increased calf tension. Calf-stretching exercises with eccentric loading, widely considered to be the most effective conservative treatment for non-insertional Achilles tendinopathy, also work well for recalcitrant plantar fasciopathy (fasciitis). A recent study compared two calf-stretching regimens for plantar fasciopathy (fasciitis) and it was confirmed that Achilles stretching alone was an effective treatment. Several other clinical studies demonstrate the efficacy of home-based plantar-fascia-specific stretching.
In a recent meta-analysis, although several therapies (ECSWT, laser therapy, orthoses, pulsed radiofrequency, dry-needling, and calcaneal taping) seemed effective when compared to placebo, improvements were very small, and quality of evidence was low or moderate for most interventions and no conclusions were drawn to be considered in clinical practice. At present the use of eccentric calf stretching (as popularised by Alfredson et al) with additional stretches for the fascia is possibly the first-line choice in non-operative treatment for chronic plantar fasciopathy (fasciitis). At Sydney Muscle & Joint Physio Penrith we use eccentric loading to lengthen muscles, rather than static stretching.