CEU Article Title: Injury Prevention Series: Plantar Fasciitis
Clients enter your realm with several different complaints on any given day. Often, they are small grievances about soreness, tightness, or a pinch here and there that they are concerned about. Many times we nod our heads as fitness professionals, empathize with their complaints and assure them that a good warm-up and stretching routine will help them get through the discomfort just in time for their session to start. But what if the problem is a severe pain underneath their foot or tenderness in the heel?
Chances are they have a case of plantar fasciitis and it can be a showstopper.
Many current clients are keen to understanding plantar fasciitis; either they have been diagnosed by their doctor or they self-diagnose after searching online, and then run to the pharmacy to pick up an orthotic after reading that arch supports will help alleviate the problem and the pain. Many doctors advise clients to change their shoe types to help provide more support. These are common methods to alleviate the discomfort and in some, this may result in a decrease in symptoms or take away the pain completely. However, this form of injury is very common in gym-goers and active people overall and it’s important that you, as a fitness professional, understand the problem, educate the client on some probable causes of the dysfunction, assist to alleviate stress to the affected area, and then determine whether the client should proceed with exercise or sit out a few sessions until the pain subsides.
What it is Plantar Fasciitis?
Plantar fasciitis is simply an inflammation of the plantar fascia, the triangular band of fascia under the foot that helps create the arch of your foot (Figure 1). The definition may be simple, but the cause and treatments for Plantar Fasciitis are multifaceted.
Plantar fascia – connective tissue that can
help disperse mechanical stress. This fascia
runs from the calcaneus (heel) to the toes.
This fascia acts as a truss, helps support a
person’s body weight, and stabilizes the big
toe during the final stance phase of gait.
First, the onset of heel pain or pain under the foot often begins due to overuse, typically an acute strain from excessive loading of the foot. Excessive and prolonged pronation (Figure 2) of the foot has also been shown to increase the stress placed upon the plantar fascia (Smita, Roskowski, et al., 2012). When performed chronically, excessive pronation over extended periods of time can lead to micro-tears in the plantar fascia (Smita, Roskowski, et al., 2012).
Increased activity, heightened amplitude of activity, or constant stress from standing, walking or running are often blamed for the pain and in many cases, clients are advised to stop activity for a while to allow the pain and inflammation to heal (Smita, Roskowski, et al., 2012).
What You Need to Know
A client who comes to you with the symptoms of pain underneath their foot or tenderness in the
heel should first be advised to consult with their doctor. While you may think a client is coming to you
with a case of plantar fasciitis, there are other causes that must be ruled out, such as tarsal tunnel syndrome, which is the entrapment of the first lateral branch of the posterior tibial nerve. Both conditions
have similar symptoms, with a few additional correlated symptoms like numbness or burning pain. In
addition, older patients may be suffering from gout or osteomalacia, all of which should be ruled out
by a physician prior to continuing activity with you. If activity is prolonged, the client can expect to feel
increased pain at night and increased tenderness and stiffness in the morning. Similarly, maintaining
their current level of activity will make the condition worse and could in fact lead to greater issues, like
Achilles tendonitis or rupture, shin splints, knee pain, and even hip pain. Your first responsibility is to inform your client of the potential concerns that may arise from continuing activity and send them to their
physician before your next session.
Gout – a type of arthritis. It occurs when uric acid builds up in blood and causes inflammation
in the joints.
Osteomalacia – refers to a softening of your bones, often caused by a vitamin D deficiency.
If your client has been released from the physician after being given a confirmed diagnosis of
plantar fasciitis and is allowed to begin activity, there are a few important issues to address, exercises to
include, and programming fundamentals that should be applied to help your client avoid any further
pain and even prevent re-injury.
First, the client will require soft tissue work in the form of myofascial release and stretching of the
associated soft tissues (Renan-Ordine, Albuqurque-Sendin, et al., 2011; Digiovanni, Nawoczenski, et al.,
2003; Digiovanni, Nawoczenski, et al, 2006).
• Friction massage or foam rolling can help break down
scar tissue in the soleus and gastrocnemius are imperative to begin helping your client increase ankle range
of motion (Figure 3). Greater dorsiflexion may help to
decrease the onset of over pronation.
• In addition, friction massage or myofascial release of the plantar fascia can help to reduce scar tissue, and stretching of the plantar fascia are important components to begin helping your client alleviate stress on the arch of their foot (Figure 4).
• Once the soft tissue is relaxed and they have worked to reduce scar tissue, which may be shortening or limiting range of motion in the associated muscles, static stretching of the calf complex is imperative to help increase range of motion in the ankle (Figure 5). Hold each stretch for 60 seconds, giving the body time to react to the stretch and relax.
Next, focus on muscle strengthening and conditioning of the associated musculature (Smita,
Roskowski, et al., 2012):
- The intrinsic and extrinsic muscles of the foot will need strength and endurance exercise to help
condition them properly. The anterior and posterior tibialis muscles are key to helping control
the mechanics of the foot and will need to be exercised to restore normal function and maintain dynamic support of the arch. Towel scrunching with the toes (Figure 6) along with toe tapping (bringing the toes up towards the shins) and heel raises (Figure 7) (focusing on the eccentric phase of the exercise) will help improve function. One can perform 1-3 sets of 10 to 15 repetitions.
- Balance training has also been shown to help condition the local musculature as well by focusing on the supinator muscles such as the posterior tibialis, flexor digitorum longus and flexor hallucis longus (Smita, Roskowski, et al., 2012). All of which help control pronation. Maintaining a balance position forces the client to eccentrically control the foot, which simultaneously teaches the client to maintain proper supination. For example, having someone balance on one leg and reaching their floating leg out in different directions (front, side, behind, etc.) can be performed to improve balance and control of the foot and ankle complex (Figure 8).
- Secondary to local muscular conditioning, you must look past the foot and ankle complex all
the way up into the hip. Balance training teases this idea since much of our balance can be controlled from the hip. Activating the gluteus muscles, such as the gluteus medius and maximus, can help to decelerate forces, maintain proper alignment at the knee and ankle and reduce stress to the plantar fascia. Strong gluteals may help to decrease excessive pronation and distribute forces appropriately throughout the foot (Smita, Roskowski, et al., 2012). Hip exercises such as hip bridging (Figure 9) or side-to-side tube walking (Figure 10) can help to increase gluteal activation. Advanced balance exercises using proprioceptive-rich modalities, such as a wobble board or BOSU ball can also be effective. These Plantar Fasciitis Exercises should be advanced carefully and progressively so as not to aggravate the condition.
You can experience the impact your hips have on your feet. Stand in front of a mirror. Standing up straight,
with your feet hip-width apart, contract your gluteals and watch what happens at your knees and feel what
happens at your foot. Contracting the gluteals helps to pull the knees laterally and supinate the foot.
Help the client restore normal function:
• Begin by incorporating multi-joint activities that focus on teaching proper deceleration in all planes
of motion. For example a squat to overhead dumbbell press (Figure 11) is a good multi-joint exercise that will help activate the gluteals while contracting the core musculature and teaching the client proper flexion mechanics.
• Slowly integrate low-level plyometric activities in the clients program. At some point the client will want to get back to their previous activities, play sports, run or just be active without pain. They will require re-education of the nervous system to help them control their foot (pronation) in more dynamic situations. Start slow, but progressively increase speed and amplitude to get your client ready for the stress of sport. Exercise examples would be low-level box jump ups (Figure
12), box jump downs (Figure 13) to single-leg hops in multiple planes (Figure 14). Just proceed slowly and keep the exercise program light; this is not the time for significant overload. Stick with a low number of repetitions (5-8) and sets (1-2) in the beginning. Once a client can handle more stress, gradually increase demand. If the client begins to complain of tenderness, stop and go back to balance training until they are more conditioned.
As with any client complaint, assess the situation. Ask the questions necessary to identify the cause:
(Where does it hurt? When does it hurt? What kind of pain are you experiencing: sharp, dull, throbbing?
When did the pain begin?). Always remember to refer your client to an allied health professional to be
reviewed, but if the client is cleared to exercise, ensure they are safe by easing them back into exercise and
addressing the issues, not only at the source, but look globally to uncover possible restrictions in other
joints that may be inhibiting proper form and function. Plantar fasciitis can be a game-changer for clients,
sidelining them from their favorite activities. Help them get back in the game by following the steps
above. They’ll be happy, active and pain-free in no time!
If your clients are out of pain, then it’s time to get your CEUs. Take your quiz here!
Digiovanni, B.F., Nawoczenski, D.A., Lintal, M.E., et al. (2003). Tissue-Specific Plantar Fascia Stretching Exercise Enhances Outcomes in Patients with Chronic Heel Pain. A Prospective, Randomized Study. Journal of Bone and Joint Surgery, 85-A(7): 1270-1277.
Digiovanni, B.F., Nawoczenski, D.A., Malay, D.P., et al. (2006). Plantar Fascia-Specific Stretching Exercise Improves Outcome in Patients with Plantar Fasciitis. A Prospective Clinical Trial with Two-Year Follow-Up. Journal of Bone and Joint Surgery. 88(8), 1775-1781.
Renan-Ordine, R., Albuqurque-Sendin, F., de Souza, D.P., et al. (2011). Effectiveness of Myofascial Trigger Point Manual Therapy Combined with a Self-Stretching Protocol for the Management of Plantar Heel Pain: A Randomized Controlled Trial. Journal of Orthopedic Sports Physical Therapy, 41(2), 43-50.
Smita, R., Roskowski, Jody PhD et al. (2012). Musculoskeletal Conditions of the Foot and Ankle: Assessments and Treatment Options. Best Practice & Research Clinical Rheumatology, 26(3), 345-368