Plantar fasciitis - when getting out of bed in the morning is a real pain
Plantar fasciitis is an inflammation caused by excessive stretching of the plantar fascia – the broad band of fibrous tissue which acts as a sheath covering the muscles of the sole (plantar surface) of the foo. This fascia attaches at the bottom of the heel bone (calcaneus) and extends to the bones at the base of the toes and is one of the primary stabilising structures of the (longditudinal) arches on the underside of the foot. The fascia keeps the arch of the foot from flattening completely when the foot is bearing weight, thus providing cushioning and shock absorption when you’re walking, running or standing.
During the ‘toe-off’ phase of gait, when walking or running, the plantar fascia becomes taut. This causes the foot act as a lever and to push off with force. Every time the foot strikes the ground, the plantar fascia is stretched.
Plantar fasciitis - inflammation of the plantar fascia - usually occurs at the point where it attaches to the heel bone, and can cause heel pain, aching arches and heel spurs. It is quite a common complaint for older people who may be prone to stiff joints and restricted mobility, which will put extra strain on the plantar fascia. It can also be the result of overuse in people who do a lot of standing, walking or sporting activities - waiters, hairdressers, runners etc. It tends to be more common in women and in people who are overweight and also in pregnant women.
Key symptom: pain in the morning when taking firsts steps out of bed.
There may be a number of causes including:
* Over-pronation (flat feet) which results in the arch collapsing upon weight bearing
* A foot with an unusually high arch
* A sudden increase in physical activity
* Excessive weight on the foot, usually attributed to obesity or pregnancy
* Improperly fitting footwear
Case study profile
* Female in early 20s
* Sales Exec and part-time waitress
* Generally fit with healthy diet
* Currently not doing any sport
* However, leads very active life holding down two jobs
* Takes brisk walk to and from station everyday
The client presented with pain in the instep of both feet (worse on the left), which was acute first thing in the morning when taking her first steps out of bed. She also experienced pain after a period of rest such as her morning commute. These are classic symptoms of plantar fasciitis. During rest the plantar fascia contracts back to its original shape. Throughout the day it stretches and the pain is likely to subside.
What makes this client’s case less common is that the pain was located in the mid-foot rather than at the point of attachment of the plantar fascia at the heel bone.
A postural assessment did not reveal overpronation of the feet, a leading cause of plantar fasciitis. In fact she has fairly high arches. However, the left foot is slightly longer than the right and the toes are more splayed suggesting a loss of integrity in the medial longditudial and anterior tranverse arches. She has relatively small feet which may also be a contributing factor as the weight bearing surface of the foot is small. As a result the plantar fascia on the left side may be under more stress.
Treatment required
As always, the key to treatment is to determine the cause. In this case: what is causing the excessive stretching of the plantar fascia. In cases of overpronation or unusually high arches orthotics can be very effective.
This client can be treated effectively through massage, stretching and strengthening exercises, and ice therapy.
* Full leg massage to encourage movement of lymph - removal of waste products from the tissues
* Focus on the calf muscles (gastrocnemius and soleus) in particular using stripping techniques and soft tissue release (STR). Releasing tension in this area will take some of the pressure off the plantar fascia which has a fascial connection with the calf muscles via the achilles (calcaneal) tendon.
* Working into the plantar surface - taking care at the muscle attachment site on the heel
* Passive mobilisations to the ankles and tarsels
* Ice therapy for 5-10 minutes eg. crushed ice in a bag, bag of frozen peas, use of small frozen water bottle as a foot roller/massager
* Stretches to calf muscles to take pressure off achilles tendon and plantar surface. This is a good to do before even stepping out of bed in the morning.
* Strengthening exercises could include picking up pencil with the toes
NOTE: Do not apply ice directly to the skin. Stop if skin becomes numb. Keep foot moving slightly while applying ice.
Conclusions
The main cause of the condition in this client’s case was a recent dramatic increase in intense weightbearing activity. Ideally I would like to recommend that she give up the second job. This kind of advice is not always useful. Massage did help to bring recovery in this case. However, self management - through massage, stretches and exercises, plus the application of ice - seems to be the key to keeping this client on her feet.
