Ouch! My foot hurts! But is it really plantar fasciitis?

It’s 7 o’clock in the morning and you’re just waking up.  You are feeling great, stretching out your arms while simultaneously yawning, it’s going to be a great day!  Then, you put your foot down with a little weight through it and – Ouch! It hurts! Now your day is ruined and you may be worried about what’s going on with your foot. Now, does foot pain normally appear randomly like so? Not really.  Foot pain is typically more insidious in onset, but this story is all too familiar.

Specializing in treating foot pain, it is common for me to have patients come in self-diagnosing themselves as having plantar fasciitis for any sort of foot pain.  I’ve seen patients misdiagnose their metatarsalgia, neuropathic pain, Achilles pain – all for plantar fasciitis.  It’s easy to go onto Google or Web MD and type in “plantar fasciitis” and find out that a symptom is pain on the plantar (bottom) surface of your foot.  Eureka! I correctly diagnosed myself with plantar fasciitis! More often than not, that is the wrong answer. Many times symptoms that act like plantar fasciitis are indeed not plantar fasciitis. The goal of this blog is to help give you more information to understand that the foot can be complex, and may need a physical therapist to help make a diagnosis and treat your pain.

As an evidence-based practitioner, I pride myself on using current research to help my practice.  In 2014, clinical practice guidelines for plantar fasciitis were published in the Journal of Orthopedic & Sports Physical Therapy (JOSPT), one of the most revered journals in the world of physical therapy. In the diagnosis of plantar fasciitis, we find that one must have pain to touch at the insertion of the plantar fascia, limited ankle range of motion and pain following a period of inactivity amongst other things.  There are more complex components involved in the diagnose as well.  This would include ruling out any nerve complications as well as identifying structural foot abnormalities. This is where the provider comes in. As I mentioned previously, plantar fasciitis is non-discriminatory.  We cannot simply say that because our ankle is stiff or that we are overweight that it means we have plantar fasciitis.  Fun fact: according to a systematic review by Lopes et al, running can actually be a risk factor too!

Let’s create a hypothetical situation in which you have read and understood the clinical guidelines. You find that you have pain in your heel or your arch, but the math isn’t quite adding up.  You do not have pain with touching the insertion of the plantar fascia, and you do not have pain with your first couple of steps in the morning. Another day goes by, yet your heel and your arch still hurt. At this point, you are likely blue in the face from rolling your foot on an ice bottle.  What else could it be? Let’s familiarize ourselves a little with myofascial pain.

Myofascial pain is essentially muscle pain derived from contracted fibers of muscle we call trigger points.  These trigger points are typically starved of good oxygen and blood supply given their contracted nature. These are the tender knots that you can feel in your muscles.  If left untreated, over time these trigger points will create referred pain.  Providers who treat myofascial pain are very familiar with the pain referral patterns that these trigger points cause.  Take a look at the following picture; do the red areas of pain look familiar?

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If it does, great! What you are seeing in this image is that trigger points in the gastrocnemius and soleus muscles can cause referred pain that mimics heel pain and plantar fasciitis! Your next question should be, “how do we treat this problem? More rolling on the ice bottle?” Absolutely not! Myofascial pain is effectively treated by functional dry needling, which is performed by Doctors of Physical Therapy.  Not familiar with dry needling? Here’s the definition:

“Dry needling is a technique used to treat dysfunctions in skeletal muscle, fascia, and connective tissue, and diminish persistent peripheral nociceptive input, and reduce or restore impairments of body structure and function leading to improved activity and participation”

-American Physical Therapy Association, 2013

Tekin et al have demonstrated that dry needling is a proven effective treatment to relieve the pain and improve the quality of life of patients with myofascial pain. Now dry needling is a hot topic, and I’m sure you will have many questions, but we will leave that conversation for a future blog post!

So with dry needling and exercises aside, what other options are available to treat this heel and arch pain? In a meta-analysis by Lee et al, it was determined that an orthotic (shoe insert) can be used to reduce pain and improve function in patients with plantar fasciitis. Don’t worry, it gets better! This orthotic does not need to be expensive or custom! In a systematic review by Landorf et al, it was determined that a custom orthotic is no better than a prefabricated orthotic. So there is no need to go out and spend lots of money on a custom orthotic that you will have to wait weeks to be made, when you can get a prefabricated orthotic and leave with it on the same day!

Lucky for you, I know a thing or two about orthotics and dry needling treatment.  I choose to make orthotics for my patients out of prefabricated materials for two main reasons:

  1. It is cheaper for the patient
  2. The patient can leave with it the same day!

So the next time you have heel or arch pain, you should appreciate that there may be a number of things it could be.  All risk factors aside, find a physical therapist that you trust and connect with to help diagnose your pain.  As we have learned, diagnosing one’s foot pain is a little more complex than a search on Web MD!

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