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​​​​​​​Plantar Fasciopathy is a common condition that contributes to 15% of foot injuries in the general population and affects up to 17.4% of the running population (Rhim et al, 2021). Largely known as plantar fasciitis, plantar fasciopathy is a more accurate term for this condition. The suffix itis usually refers to acute inflammation, but in this instance, it is not thought to be the main cause of symptoms. This blog will explore the role of the plantar fascia, the cause of plantar fasciopathy and evidence-based treatment options grounded in current guidelines.

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What is the Plantar Fascia?

Formed of collagen, the plantar fascia is a strong fibrous band that runs along the sole of the foot, from the heel bone (calcaneus) to the base of the toes (metatarsals). Its role is to maintain the medial longitudinal arch of the foot by providing tension between these two points. 

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• Body weight generates downward force through the tibia.

• Ground reaction forces push upwards at the calcaneus and metatarsals during contact with the ground.

• Opposite forces are created, which tend to flatten the arch.

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To counteract the flattening and maintain the integrity of the arch, the plantar fascia provides tension. The plantar fascia works like a cable to prevent flattening during dynamic movements such as walking and running. This is commonly referred to as the windlass mechanism (Bolga and Malone, 2004).

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• As the heel lifts during gait, the toes remain in contact with the ground and dorsiflex (bend upwards).

• The fascia tightens, winding around the metatarsal heads.

• The medial arch is elevated, creating stability and a lever for propulsion.

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What Causes Plantar Fasciopathy?

 

During the windlass mechanism, the plantar fascia is subjected to high levels of stress. Repetition of loading can cause microtears at the fascia’s origin (calcaneus). This induces an inflammatory response where cells called fibroblasts lay down new collagen. However, this collagen is often disorganised and weak, contributing to the thickening of this structure (NICE, 2024). As this tissue undergoes further mechanical loading and stress, the cycle continues, which can result in pain and tenderness under the heel. This pain may be more noticeable when weight-bearing after periods of rest.

 

A recent study by Barreto Rabelo et al (2023) found that individuals with plantar fasciopathy had reduced stiffness in the plantar fascia and Achilles tendon on the symptomatic side. This reduction may reflect structural changes in the tissue and the effect this has on the posterior chain. Ultimately, this can contribute to poorer performances in functional tests such as the heel raise test.

While the exact cause of stress is uncertain, established risk factors are known (NICE, 2024):

• Age: most commonly affects people aged 40-60 due to decreased tissue elasticity.

• Obesity: BMI greater than 30 increases plantar fascia loading

• Sedentary lifestyles: reduce plantar fascia adaptability

• Prolonged standing, walking or running: puts the plantar fascia under repetitive stress

• Structures in the foot: 

  • High foot arches 

  • Excessive foot pronation 

  • Tight Achilles tendon or calf muscles

• Poor footwear support: Poor arch support/cushioning increases strain

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Plantar Fasciopathy treatment:

 

Managing Load: 

• Initially, reducing time spent on your feet and switching to supportive footwear can help disrupt the cycle of load and stress. In fact, custom orthoses have strong evidence for pain relief, particularly when tailored to support the foot’s arch and offload the tissues around the heel (Morrissey et al, 2021).

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Extracorporeal shockwave therapy (ESWT)

• With growing evidence for use in musculoskeletal disorders, ESWT produces acoustic waves that induce microtrauma and stimulate a healing response. This includes pain modulation, formation of new blood vessels and activation of tissue regeneration cells (Wang, 2012; Moya et al, 2018). Importantly, combining ESWT with an exercise program is shown to enhance outcomes compared to either modality alone (Moya et al, 2018; Burton and Cormack, 2022).

• Guidelines suggest that radial or focused SWT should be administered every 1-2 weeks until 5 sessions are completed and intensity tailored to your pain response (International Society for Medical Shockwave Therapy, 2023).

• Focused SWT: 1500-2500 pulses per session. 

• For radial shockwave: 2000-3000 pulses per session

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Exercise Prescription: 

• While stretching offers short-term symptom relief (Morrissey et al, 2021), evidence suggests that high-load strength-based exercise is superior for promoting physiological adaptation. 

• One randomised control trial compared a stretching and strengthening program, finding that the strength approach led to better outcomes (Rathleff, 2015). Due to its composition, the plantar fascia responds to high loads via collagen synthesis, which normalises tendon structure and improves functional outcomes at the 3-month mark. 

• Within the strength program, participants completed heel raises with a towel placed under their toes to engage the windlass mechanism while loading the Achilles tendon. Progressive loading was achieved by increasing the weight over time.​

 

As with other injuries, staged progression may be needed:

• Bilateral to unilateral heel raises 

• Slow to fast tempo

• Controlled reps 

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Overall, plantar fasciopathy can be persistent and frustrating, but understanding the cause and treatment is key to recovery. At Prime, we are here to support your journey! Book in with one of our Physiotherapists or Sport Rehabilitators today for further help.

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Reference List:

 

Barreto Rabelo, D., Coelho Figueira Freire, A.P., Colen Milagres Brandão, F., Oliveira Melo, S., Ocarino, J.M., Saldanha dos Anjos, M.T., Schleip, R., Souza, T.R., Simoneau, G. and Zambelli Pinto, R. (2023). Myofascial stiffness of plantar fascia and Achilles tendon in individuals with plantar fasciopathy: An observational cross-sectional study. Musculoskeletal Science and Practice, [online] p.102781. doi:https://doi.org/10.1016/j.msksp.2023.102781.

 

Bolgla, L.A. and Malone, T.R. (2024). Plantar Fasciitis and the Windlass Mechanism: A Biomechanical Link to Clinical Practice. Journal of Athletic Training, [online] 39(1), p.77. Available at: https://pmc.ncbi.nlm.nih.gov/articles/PMC385265/.

 

Burton, I. and McCormack, A. (2022). The Effectiveness of Combined Extracorporeal Shockwave Therapy and Exercise for Plantar Heel Pain: A Systematic Review. Exploratory Research and Hypothesis in Medicine, 000(000). doi:https://doi.org/10.14218/erhm.2021.00059.

 

Charles, R., Fang, L., Zhu, R. and Wang, J. (2023). The effectiveness of shockwave therapy on patellar tendinopathy, Achilles tendinopathy, and plantar fasciitis: a systematic review and meta-analysis. Frontiers in Immunology, [online] 14, p.1193835. doi:https://doi.org/10.3389/fimmu.2023.1193835.

International Society for Medical Shockwave Therapy (2023). ESWT Guidelines. [online] Available at: https://shockwavetherapy.org/wp-content/uploads/2024/01/ISMST-Guidelines-for-ESWT-_-engl-20240103.pdf.

 

Morrissey, D., Cotchett, M., J’Bari, A.S., Prior, T., Griffiths, I.B., Rathleff, M.S., Gulle, H., Vicenzino, B. and Barton, C.J. (2021). Management of plantar heel pain: a best practice guide informed by a systematic review, expert clinical reasoning and patient values. British Journal of Sports Medicine, [online] 55(19). doi:https://doi.org/10.1136/bjsports-2019-101970.

 

Moya, D., Ramon, S., Schaden, W., Wang, C.-J., Guiloff, L. and Cheng, J.-H. (2018). The Role of Extracorporeal Shockwave Treatment in Musculoskeletal Disorders. Current Concepts Review, pp.251–263.

 

NICE (2024). What are the causes and risk factors? [online] NICE. Available at: https://cks.nice.org.uk/topics/plantar-fasciitis/background-information/causes-risk-factors/.

 

Rathleff, M.S., Mølgaard, C.M., Fredberg, U., Kaalund, S., Andersen, K.B., Jensen, T.T., Aaskov, S. and Olesen, J.L. (2015). High-load strength training improves outcome in patients with plantar fasciitis: A randomized controlled trial with 12-month follow-up. Scandinavian journal of medicine & science in sports, [online] 25(3), pp.e292-300. doi:https://doi.org/10.1111/sms.12313.

 

Rhim, H.C., Kwon, J., Park, J., Borg-Stein, J. and Tenforde, A.S. (2021). A Systematic Review of Systematic Reviews on the Epidemiology, Evaluation, and Treatment of Plantar Fasciitis. Life, [online] 11(12), p.1287. doi:https://doi.org/10.3390/life11121287.

 

Wang, C.-J. (2012). Extracorporeal shockwave therapy in musculoskeletal disorders. Journal of Orthopaedic Surgery and Research, 7(1), p.11. doi:https://doi.org/10.1186/1749-799x-7-11.

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​If you would like to know more about Plantar Fasciopathy and it's treatment, please contact us on 01949 485084