Plantar Fasciopathy Rehab Programme
This is an example of a rehab programme for plantar fasciopathy based on clinical reasoning and recent research. It isn't a recipe for
every patient! Here's a quick run through of each exercise;
1) Single leg squat - we start with a simple control exercise that has the added benefit of working into ankle dorsiflexion range. It helps
proprioception and serves as a useful warm up to prepare the foot and ankle for the more challenging exercises.
2) Plantar fascial stretch - research from DiGiovanni et al. (2003) found this stretch to be superior to standard Achilles stretching for
plantar fasciopathy (PF). It may help improve ankle dorsiflexion and great toe extension range, both of which have been cited as
potential risk factors in PF.
3) Modified calf raise - Rathleff et al. (2014) found a progressive heavy loading programme using the modified calf raise (with a towel)
effective in treating PF. The addition of load helps to strengthen the foot and calf muscles, hopefully aiding in load tolerance and
absorption.
4) Strengthening inversion and eversion - tibialis posterior is thought to provide support to the arch of the foot and the evertors have
been found to be weak in patients with PF in a recent study. Strengthening both may assist in supporting the plantar fascia and
improving load capacity of the foot and ankle.
5) Toe flexor strength has also been found to be reduced in patients with PF. Recent research has found that heavy isometric toe flexion
exercises can improve strength and jump performance. We place them at the end as the modified calf raise is also challenging for
these muscles.
Typically a programme like this would be done 3 or 4 times per week with a rest day in between. Please note though that any exercise programme
needs to be designed to suit the individual and this may not be appropriate for those with more irritable symptoms or different rehab needs.
Early rehab where pain is the main issue may require a focus more on isometric exercise and activity modification. Later stage rehab may require
heavier load and exercises to develop maximal strength and power (depending on the goals of the patient).
How to treat plantar fasciopathy
in runners
• Created as a free resource by Clinical Edge
• Based on Physio Edge podcast 062 with @tomgoom
• Get your free trial of online Physio education at [Link]
Pain dominant phase
Pain levels may be influenced by local tissue irritation alongside patient
beliefs and perceived level of threat. Treatment of plantar fasciopathy (PF)
can commence with patient education on the pathology and prognosis to
reduce the threat level. The patients expectations about prognosis and
recovery should be managed at the start to avoid problems later in the
rehabilitation process.
Load management
In a runner with an irritable plantar fasciopathy, running should be reduced
or avoided to allow the symptoms to settle. In highly irritable patients
aggravating factors such as walking and time spent on feet may also need
to be reduced.
Exercise
Isometric toe flexion and isometric mid range calf raises may help to reduce
pain. Ask the patient to score pain during a load test, perform isometric
exercise and then reassess the load test. An immediate improvement in
pain is a positive indication for the use of isometric exercises.
Stretching
Digiovanni et al. (2003) compared a plantar fascia stretching programme
to a calf stretching programme, identifying superior outcomes with plantar
fascia stretching. Plantar fascia stretching can be performed in a non-
weight bearing position with ankle dorsiflexion and great toe extension. The
use of stretching will depend on the irritability of the patients symptoms.
[Link]
How to treat plantar fasciopathy in runners
Taping
Taping techniques may assist in moderating plantar fascia pain and load.
Immediate symptom improvement may indicate the inclusion of taping as a
short term intervention to reduce pain. Taping should not be relied on as
the sole treatment intervention.
Orthotics
Footwear modification can be used before considering the addition of
orthotics. Footwear with a firm arch support may aggravate symptoms,
whereas shoes with a cushioned arch may be more comfortable. Patients
can trial different shoes to identify the most comfortable. If a change in
footwear does not settle symptoms, a gel heel cup can also be used. At this
point if the symptoms have not settled, off the shelf orthotics or referral to
a podiatrist should be considered.
Load dominant phase
Rathleff et al. (2014) studied the use of a heavy slow resistance program
(HSRP) in the treatment of plantar fasciopathy. The HSRP included calf
raises performed barefoot with a towel under the toes to increase plantar
fascia loading. The program increased load from 12 repetition max to 8
repetition max over a period of 12 weeks.
Plantar fascia loading should be started when tolerated in the initial stages
of rehabilitation. Patients may not be able to tolerate the Rathleff et al.
programme initially so the plantar fascia should be loaded progressing from
double leg to single leg calf raises. Once the patient can comfortably
perform single leg calf raises then the Rathleff et al. programme should be
started.
[Link]
How to treat plantar fasciopathy in runners
Impairments
Sullivan et al. (2015) compared 200 people with plantar fasciopathy to a
control group, identifying reduced ankle dorsiflexion, reduced ankle
eversion and toe flexor strength in the plantar fasciopathy group. During
rehabilitation these impairments need to be addressed through a variety of
treatment interventions. Treatment planning should be guided by the
specific impairments identified during the objective assessment. Treatment
may consist of manual therapy to improve ankle dorsiflexion range of
movement and specific strengthening exercises to address any deficits.
When to start running?
There is no recipe for the return to running, however task-based criteria
can be used to help in your decision making. Consider reintroducing
running when the patient is getting less early morning stiffness, can tolerate
walking, able to single leg calf raise and able to tolerate impact testing
(hopping, jumping etc). Rathleff et al. (2015) recommends that the patient
should be able to walk 10km and be pain free for 4 weeks before starting
running.
Run tolerance test
A run tolerance test on the clinic treadmill can be used to identify patient
readiness for return to running. A maximum of 5-10 minutes running is
performed, with patient feedback, distance completed and 24 hour pain
response measured and recorded. If there is no reaction or increase in pain
within the subsequent 24 hours, this distance is used as the starting point
for a return to running programme.
[Link]
How to treat plantar fasciopathy in runners
Links associated with this episode:
Digiovanni et al. 2003. Tissue-specific plantar fascia-stretching exercise
enhances outcomes in patients with chronic heel pain. A prospective,
randomized study.
Rathleff et al. 2014. High-load strength training improves outcome in
patients with plantar fasciitis: A randomized controlled trial with 12-month
follow-up.
Rathleff MS, Thorborg K. 2016 ‘Load me up, Scotty’: mechanotherapy for
plantar fasciopathy (formerly known as plantar fasciitis)
Sullivan et al. 2015. Musculoskeletal and Activity-Related Factors
Associated With Plantar Heel Pain
Previous episodes of interest:
PE #038 Plantar fasciopathy loading programs with Michael Rathleff
[Link]