PT Perspective
with Jason Lau, Doctor of Physical Therapy
Question:
I get a sharp pain in the arch of my foot especially with the first step I take when I get out of bed in the morning. Once I get warmed up, the foot pain is not as bad, and I can exercise or even go running. It has been lingering for several weeks and is not getting any better. What should I do?
Answer:
This is a common description of pain that is indicative of plantar fasciitis. Plantar fasciitis is a term that refers to inflammation in the plantar fascia located on the bottom of our feet. When there is micro trauma of the plantar fascia, the inflammatory response is initiated.
Imagine the plantar fascia as like a rubber hospital glove at the bottom of our foot. For whatever reason, we have over stressed it, and now we have a small tear in the glove. Luckily, our bodies have a way to repair that glove with a “glue” like process. The gluing stage is the inflammatory process that brings all the healing cells to the injured area. If all goes well then the glue is allowed enough time to strengthen and lengthen over time to produce strong and flexible tissue where once there was a tear.
This sounds simple enough, but then why do people have plantar fasciitis that can last years, requires injections, or even a surgery?
The most difficult part about having plantar fasciitis is waiting for the glue to dry. The primary reason for that is the location of the injury. With an upper body injury like a broken arm, we can put it in a cast to keep it immobile and then avoid using it because we have another arm to get us through the day. With plantar fasciitis, resting is a problem because we need both feet just to take two steps. As a result, the wound continues to open before it is healed.
The other problem with this injury is the lack of perceived severity. If you had the choice, would you walk on a broken leg? You wouldn’t because you understand that if you walk on a broken leg before the “glue” is dry, you could misalign the bones during the healing process and end up with a leg that is healed crooked. By contrast, people generally continue to walk and be active on a foot with plantar fasciitis. The pain may be high, but only intermittently. This leads to a condition that often lasts much longer than it should. Thus, the key is to put the condition high on the priority list like we would a broken leg.
The most successful non-surgical treatment I have seen for plantar fasciitis was a combination of physical therapy plus the use of a boot. With this method, the patient’s doctor placed a high priority on resting the foot via a boot that limited motion in the plantar fascia. The physical therapy was then able to gradually build up the tissues in the foot and ankle without ongoing micro trauma to the plantar fascia. This person recovered normal function in three weeks.
The key to avoiding plantar fasciitis is to avoid over stressing the tissue. One way we can reduce stress to the feet is by gradually building up the load that we place on them. By placing a progressive load over time, we allow our tissues time to adapt and strengthen to the new level of activity. This is the rationale behind runners incrementally building up their mileage over time as they train for a marathon. On the other end of the spectrum, sudden weight gain can increase stress to the tissues more abruptly. More weight in a short timeframe means more load without adequate time for the tissue to adapt.
Lastly, we can reduce the chance of getting plantar fasciitis by making the tissue more resilient through stretching and strengthening of the foot and ankle muscles. Imagine taking all the tendons and muscles out of the foot, leaving only the plantar fascia remaining. In this scenario, what is going to take all of the stress? The plantar fascia. Now, imagine a foot with strong and flexible muscles and tendons. These muscles are now able to share the load with the plantar fascia, thus reducing harmful levels of fascial stress.
Practical steps:
If you have the beginnings of what you think is plantar fasciitis…
Avoid the sharp pain. Every time you experience the sharp pain, you are likely reopening the wound that is trying to heal. Before you get out of bed in the morning, do 30 ankle pumps and 30 toe curls (make a fist with your toes). This brings blood to the area, which warms up the tissues and increases their elasticity. After the foot is warmed up, gradually apply weight to the foot. You may need to do some more exercises before you continue with the rest of your day. (This sequence also applies to when you have been immobile for a long period of time.)
Strengthen and stretch. The key exercises to do for the ankle are heel raises and calf stretching. The dosage for the heel raises depends on the individual, but the goal is to challenge the calf enough to strengthen it. With the calf stretch, make sure to hold a static stretch for a minimum of 30 seconds for three to five rounds.
Rest. Don’t underestimate this condition. Worse case scenario, if not addressed properly, this is a condition that can last years and require a surgical solution. Consider getting a boot that limits ankle and foot mobility.
These practical steps should successfully address most mild cases of plantar fasciitis. If you have tried these steps but are not getting the results you need, there may be more specific exercises required or other complicating factors such as foot wear and/or foot structure. If you need more guidance, please feel free to contact me for a complimentary consultation.
Submit your questions for future PT Perspective columns to Jason Lau, Doctor of Physical Therapy at jasonlaudpt@gmail.com