Plantar Fasciitis, Fasciopathy, and Fasciosis: A Guide for Walkers and Runners

As a sports physiotherapist, I often see walkers and runners side-lined by plantar heel pain caused by plantar fasciitis, or more accurately, plantar fasciopathy or fasciosis. This condition can be frustrating, but with the right understanding and management, you can get back to pain-free movement. In this blog, I’ll dive into the function of the plantar fascia, its windlass mechanism, what goes wrong in fasciitis and fasciopathy, signs and symptoms, contributing factors (including those further up the chain), and evidence-based treatment options. We’ll also explore how we collaborate with podiatrists like Kurt Robertson at Newcastle Podiatry (newcastlepodiatry.com.au) and Foot & Ankle Specialists by Dr Rao (rao.net.au) to provide a multidisciplinary approach to a complex problem.

What is the Plantar Fascia and Its Windlass Mechanism?

The plantar fascia is a thick, fibrous band of connective tissue that runs from the medial calcaneal tubercle (heel bone) to the base of the toes. It acts like a biological spring, stabilising the medial longitudinal arch of the foot and storing and releasing energy during propulsion, such as when walking or running. Made primarily of type I collagen, it’s incredibly strong and elastic, capable of withstanding significant tensile forces.

The windlass mechanism is a key biomechanical function of the plantar fascia. Imagine the plantar fascia as a cable stretched between the calcaneus (heel) and the metatarsophalangeal joints (toes). During the propulsive phase of gait, as your toes dorsiflex (bend upward), the plantar fascia tightens, shortening the distance between the heel and toes. This elevates the medial arch, creating a rigid lever for efficient push-off. This mechanism is critical for dynamic activities like running, where the fascia absorbs and redistributes forces. However, repetitive overloading can stress this system, leading to injury.

Plantar Fasciitis vs. Fasciopathy vs. Fasciosis: What’s Happening?

Historically, plantar fasciitis was thought to be an inflammatory condition (“-itis” implies inflammation). However, research shows it’s more often a fasciopathy or fasciosis, reflecting a degenerative process rather than acute inflammation. Here’s what happens:

• Fasciitis: Early-stage plantar fasciitis may involve microtears and localised inflammation due to repetitive overload, often at the fascia’s insertion on the heel. This is more common in acute cases.

• Fasciopathy / Fasciosis: Over time, chronic overload leads to degenerative changes, including collagen disorganisation, and calcium deposits. The tissue thickens and weakens, resembling tendinosis. There’s little to no inflammation, which is why “fasciosis” is a more accurate term for chronic cases. These changes reduce the plantar fascia’s ability to handle tensile loads, causing pain and dysfunction. For walkers and runners, this often stems from repetitive stress during the windlass mechanism’s activation.

Signs and Symptoms

Plantar fasciopathy typically presents with:

• Heel pain: Sharp, stabbing pain at the medial heel, often most intense with the first steps in the morning (known as “start-up pain”) or after prolonged rest. Pain may ease with activity but worsen toward the end of the day with prolonged weight-bearing.

• Arch discomfort: Pain may radiate along the medial arch, especially during push-off.

• Tenderness: Palpation of the plantar fascia’s insertion at the anteromedial calcaneus (heel bone) is often painful.

• Windlass test positivity: Passive dorsiflexion of the toes (stretching the plantar fascia) reproduces pain, with 100% specificity but lower sensitivity (32%).

• Worsening with activity: Pain increases with prolonged standing, walking, or running, particularly on hard surfaces.

• Chronic cases may lead to reduced weight-bearing capacity, impacting daily activities and athletic performance.

Contributing Factors: It’s Not Just the Foot

While the plantar fascia is the site of pain, contributing factors often originate further up the kinetic chain. These include:

• Tight calf muscles: Limited ankle dorsiflexion (foot up), often due to tight gastrocnemius or soleus muscles (your calf muscles), increases tension on the Achilles tendon and plantar fascia. Studies show tightness in nearly 80% of cases.

• Weak intrinsic foot muscles: Atrophy or weakness in muscles like the abductor hallucis or flexor digitorum brevis destabilises the arch, overloading the plantar fascia.

• Proximal weaknesses: Weak hip abductors (e.g., gluteus medius) or core muscles can alter gait mechanics, increasing pronation or supination and stressing the plantar fascia.

• Excessive pronation or high arches: Pes planus (flat feet) or pes cavus (high arches) disrupt normal foot mechanics, either overstretching or overloading the fascia.

• Obesity: Increased body mass index (BMI) correlates with higher plantar fascia strain.

• Training errors: Sudden increases in running volume, intensity, or walking on hard surfaces amplify repetitive stress.

• Metabolic factors: Diabetics have a fivefold risk of plantar fasciopathy, possibly due to collagen changes from poor blood sugar control.

These factors highlight the need for a whole-body approach to assessment and treatment.

Treatment Modalities: What Works and How

Effective management of plantar fasciopathy requires addressing tissue-level changes, biomechanical faults, and contributing factors. At our clinic, we collaborate closely with podiatrists like Kurt Robertson at Newcastle Podiatry, who emphasise comprehensive assessments and tailored interventions. Below are evidence-based modalities, their tissue-level effects, and how they fit into a holistic plan, with insights from specialists like Dr Pankaj Rao:

1. Calf and Plantar Fascia Stretching

What it does: Stretching the gastrocnemius, soleus, and plantar fascia reduces tension and improves ankle dorsiflexion, decreasing tensile stress on the fascia.

Tissue-level effect: Stretching promotes collagen realignment, reduces adaptive shortening, and enhances tissue flexibility, aiding healing of microtears.

2. Strengthening (Intrinsic Foot and Proximal Muscles)

What it does: High-load strength training, such as single-leg calf raises with toes dorsiflexed (windlass raises), induces tensile forces across the plantar fascia, stimulating collagen repair similar to tendinopathy protocols. Strengthening hip abductors and core muscles improves gait stability.

Tissue-level effect: Controlled loading promotes tissue remodelling, increases collagen synthesis, and strengthens supporting muscles to reduce fascia strain.

3. Video Analysis of Walk/Run Technique

What it does: Analysing gait via video helps identify biomechanical faults, such as overpronation, excessive heel strike, or poor push-off, which overload the plantar fascia. Correcting these reduces stress on the windlass mechanism.

Tissue-level effect: Optimising mechanics minimises repetitive microtrauma, allowing the fascia to heal without ongoing strain.

4. Orthotics and Footwear

What it does: Custom orthotics or heel pads, as provided by experts like Kurt Robertson, control pronation, support the arch, and redistribute forces. Proper footwear with adequate cushioning reduces impact on hard surfaces.

Tissue-level effect: Orthotics decrease excessive fascial strain, allowing degenerative tissue to recover by reducing mechanical overload.

5. Platelet-Rich Plasma (PRP) Injections

What it does: PRP involves injecting concentrated platelets from your blood into the plantar fascia to stimulate healing. Studies, including those cited on rao.net.au, show PRP improves pain and function at 3 months compared to corticosteroids, with fewer risks like fat pad atrophy.

Tissue-level effect: PRP delivers growth factors that promote angiogenesis, collagen synthesis, and tissue regeneration, addressing the degenerative changes of fasciosis.

How to do it: Performed under ultrasound guidance by a specialists like Dr Rao, PRP typically requires 1–2 injections, with 70% of patients reporting significant improvement.

6. Extracorporeal Shock Wave Therapy (ESWT)

What it does: ESWT delivers high-energy sound waves to the plantar fascia, with focused shock wave (FSW) showing pain relief in some studies. It’s useful for chronic cases resistant to conservative care.

Tissue-level effect: ESWT stimulates neovascularisation and collagen remodelling, breaking down scar tissue and promoting healing.

How to do it: Administered by a podiatrist like Kurt Robertson & Co at newcastlepodiatry.com.au over several sessions, ESWT is non-invasive.

7. Manual Therapy and Dry Needling

What it does: Soft tissue mobilisation and dry needling target trigger points and fascial restrictions, improving flexibility and reducing pain.

Tissue-level effect: These techniques enhance blood flow, reduce myofascial tension, and stimulate local healing responses.

How to do it: A physiotherapist performs deep massage or inserts fine needles into trigger points, often combined with stretching.

8. Activity Modification and Education

What it does: Reducing steps (e.g., under 5,000 daily in early stages) and avoiding aggravating activities like forefoot running prevent further fascia overload. Education on load management is critical.

Tissue-level effect: Rest allows microtears to heal, preventing progression to chronic degeneration.

How to do it: Use a step counter and gradually increase activity. Work with a physiotherapist, like those at Up N Adam Performance Training & Physiotherapy, to plan a return-to-sport timeline.

9. Night Splints

What it does: Night splints (e.g., Strassberg Sock) maintain the ankle in dorsiflexion, preventing fascial shortening overnight and reducing morning pain.

Tissue-level effect: Passive stretching promotes tissue elongation and reduces tensile stress during first steps.

Collaborating with Experts

At our clinic, we partner with podiatrists like Kurt Robertson at Newcastle Podiatry, who specialise in biomechanical assessments, custom orthotics, and footwear advice. Their expertise complements our physiotherapy interventions, ensuring a tailored approach. Similarly, Specialist life Dr Pankaj Rao highlight the role of regenerative therapies like PRP, which we integrate for recalcitrant cases. This multidisciplinary approach addresses both symptoms and root causes, maximising recovery.

Take-Home Message for Walkers and Runners

Plantar fasciopathy is a complex condition driven by degenerative changes in the plantar fascia, often exacerbated by biomechanical faults and overload. By understanding the windlass mechanism and addressing contributing factors—like tight calves, weak glutes, or improper gait—you can prevent and manage this condition effectively. Start with conservative measures like stretching, strengthening, and orthotics, and consider advanced options like PRP for persistent cases. Collaborate with physiotherapists and podiatrists to create a personalised plan, and you’ll be back to pain-free walking or running in no time.

Need help? Contact us at Up N Adam Performance Training & Physiotherapy to schedule a biomechanical assessment or connect with Newcastle Podiatry for expert podiatric care.

This is APA Sports Physiotherapist, Darren Glendenning, signing off for now!

You can book an appointment with Darren or Newcastle Knights Physiotherapists Katie or Hayd'n at www.upnadamptphysio.com

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