Plantar fasciitis is an all-too-common pathology that orthopaedic physiotherapists assess and treat regularly. This condition has a variety of causes that include, but are not limited too:
- Biomechanical issues such as over-pronation or a ‘flat foot’, restricted ankle and toe dorsiflexion (bringing your toes towards you), and tension in the achilles tendon (1,2)
- Repetitive strain (over-use and/or training errors) (1,2)
- Poor footwear (1,2)
- Weight gain (1,2)
Despite its prevalence in society and our awareness of the causative factors, it can be tricky to treat. Anecdotally, I most commonly see two groups of people presenting with this injury:
- People starting a new running program or runners who significantly increased their weekly running mileage abruptly
- People that have had it for ‘years’ with no history of repetitive strain or trauma. These people often saw benefit initially through the prescription of a foot orthotic but are now experiencing the same or worse pain and are now unable to walk in their home without supportive footwear.
Luckily, ‘group 1’ will more often than not see benefit from physiotherapy intervention which includes a combination of activity modification, home exercises for lower extremity strengthening, and manual therapy. Unfortunately ‘group 2’ is not so lucky and as a result must commit to a longer road to recovery. Who is to blame for this? I’ll tell you who, your healthcare providers! Your physiotherapist, or chiropractor, or family doctor, or pedorthist, or orthotist… or whoever sent you down the one-way road to the passive treatment known as foot orthotics. Now don’t get me wrong, foot orthotics can be helpful, but knowing what we know (see the above causes of this type of pain) leads me to believe that we probably mis-educated our client or were unable to identify an important contributing factor to their foot pain. I don’t want to paint all healthcare providers with the same brush, but this DOES happen out there. For the record, recent evidence suggests orthotics may benefit people with plantar fasciitis pain in the short-term (less than one year) and NOT the long-term (3), so don’t throw them out yet.
So why does the pain progress this way? It is probably multi-factorial (again, see the above causes of this type of foot pain), but one problem I commonly see which has also been identified in the literature is foot muscle weakness (2). The following is definitely more of an opinion than proven fact, but I think that long-term use of orthotics for plantar fascia pain contributes to reduced foot muscle strength in exchange for increased passive reliance on the orthotic. The longer you use it, the weaker your foot muscles get (basically they get lazy), until all of a sudden you wake up one day in running shoes because you can’t bare to walk anywhere without those cushiony pillows supporting your feet.
So what can we do about it? Let’s maybe try exercise this time around! To date, a number of studies have evaluated the effect of exercise on foot muscle strength which is implicated in plantar-fascia pain and over-pronation (…which is a cause of plantar-fascia pain) (2,4,5,6). As you may suspect, the results of these studies show either improvements in foot strength (…weird, right) or reduced plantar fasciitis pain through the use of specific foot exercises. One study in particular was also able to identify weakness in toe flexor strength in participants with a two month history of plantar fasciitis pain (2). One of the important takeaways from this research is not only the results, but also the protocols. Exercises were implemented for a minimum of 8 weeks in the study that measured the change in plantar fasciitis pain with exercise (4). So what does all of this mean? It means your feet are probably weak, and you need to complete the exercises regularly because immediate changes may not occur.
What do the exercises look like? Here are two beginner foot strengthening exercises that may help to soothe your sole:
- The ‘short foot’ exercise: https://www.youtube.com/watch?v=iy1Qxt2mnsE
- The ‘towel toe curl’ exercise: https://www.youtube.com/watch?v=ORaq6ls9EXA
Interestingly, a recent study came out that has shown that walking in minimalist shoes results in similar changes to foot muscle strength as compared to specific foot strengthening exercises (6). Care must be taken as to how long you walk in this style of shoe each day, but this may be an option for some people that find the above exercises difficult.
Finally, remember that we have discussed only one contributing factor to plantar fasciitis pain, and that not every person with plantar fasciitis pain is the same or responds to the same treatment. If you have concerns regarding your foot pain, coming in for a detailed biomechanical assessment will bring you one step closer to being pain-free and avoiding future injury. Highlighting and resolving biomechanical and strength deficits is something that can’t be done by reading this blog, so please use our expertise appropriately.
Jordan Fortuna, Manager of Clinical Services
Jordan is a graduate of the University of Toronto Physiotherapy program and has since been practicing in orthopaedic settings. He has developed an interest in sports physiotherapy through his many years as an athlete, participating in baseball, golf, snowboarding, and more recently rock-climbing, cycling, and strength training. He has worked with a variety of clientele including athletes from disciplines such as competitive dancing, running, rock-climbing, and mixed-martial arts, as well as non-athletes of a wide age range and ability. Regardless of activity level, he is dedicated to improving mobility, optimizing function, and strengthening to help achieve your goals through the use of an individualized exercise prescription and manual therapy. He also has additional training in acupuncture and sports taping.
- Krivickas, LS. Anatomical Factors Associated with Overuse Sports Injuries. Sports Med. 1997; 24(2): 132-146
- Allen, RH, and Gross, MT. Toe Flexors Strength and Passive Extension Range of Motion of the First Metatarsophalangeal Joint in Individuals With Plantar Fasciitis. J. of Ortho. & Sports Physical Therapy. 2003; 33(8): 468-478
- League, AC. Current Concepts Review: Plantar Fasciitis. Foot Ankle Int. 2008; 29: 358-366
- Kamonseki, DH, Goncalves, GA, Yi, LC, and Lombard, L. Effect of stretching with and without muscle strengthening exercises for the foot and hip in patients with plantar fasciitis: A randomized controlled single-blind clinical trial. Manual Therapy. 2016; 23: 76-82.
- Jung, DY, Kim, MH, Koh, EK, Kwon, OY, Cynn, HS, and Lee, WH. A comparison in the muscle activity of the abductor hallucis and the medial longitudinal arch angle during toe curl and short foot exercises. Physical Therapy in Sport. 2011; 12: 30-35
- Ridge, ST, Olsen, MT, Bruening, DA, Jurgensmeier, K, Griffin, D, Davis, IS, and Johnson, W. Walking in Minimalist Shoes Is Effective for Strengthening Foot Muscles. Medicine & Science in Sports & Exercise. Published ahead of print.