The Complete Guide To Plantar Fasciitis

Do you have sharp pain radiating from the bottom of your foot, especially around the heel, when you first step out of bed in the morning? How about when you start to walk after not being on your feet for some time?

If you said yes to both of these questions, then there is a good chance you are suffering from Plantar Fasciitis (pronounced ‘fashee-EYE-tiss’).

The good news is plantar fasciitis can be successfully treated and cured with the right treatment program. In fact, studies have shown that 90% of the cases resolve themselves without needing to resort to invasive surgery [2].

Plantar fasciitis is the leading cause of the heel pain, and affects more than 2 million people in the United States [1]. It is estimated that 10-16% of people will experience this painful condition during their lifetime [5].

Plantar fasciitis afflicts a wide spectrum of people with different lifestyles. It affects both the active and sedentary population. To make matters worse, scientists cannot seem to come to a consensus on the exact cause of plantar fasciitis.

The treatment protocol we provide is based on scientific research and has shown to be effective in clinical settings.

Effective treatment solutions to this nagging condition involve addressing the symptoms, but more importantly, identifying and fixing the root cause of plantar fasciitis. Understandably, relieving the pain is of the utmost concern for most plantar fasciitis sufferers and we will explore the most effective methods to manage the pain. However, our primary goal for this guide is to help you fix the source of the problem that caused the condition in the first place to prevent it from returning with a vengeance.

Traditionally, plantar fasciitis was thought to be an inflammation of the plantar fascia, a thick band of tissue between the heel and toes. However, a recent study has challenged that long-held notion. A study produced by Podiatry Medical Association in 2003 examined plantar fascia tissues and found little to no signs of inflammatory response [6]. What they found instead were degenerated and dead tissue cells.

This does not mean inflammation is not present when you have plantar fasciitis, but rather inflammation is not the underlying cause of plantar fasciitis as it has been traditionally understood. So simply taking anti-inflammatory medicine to combat this issue will not fix the root cause of plantar fasciitis.

As a matter of fact, pain blocking medicines like Non-Steroidal Inflammation Drugs (NSAIDs) have actually shown to delay the recovery process [33].

It is important to understand that inflammation is a body’s natural response to increase the blood flow and other healing agents to help with the recovery process. Suffers tend to want to repress pain, which is why NSAIDs exist in the first place. However, blocking a body’s healing process by taking anti-inflammatory agents may be prohibiting the natural healing process.

With so many myths flying around about plantar fasciitis, it is important to properly educate yourself about the condition to be able to cure it and get rid of the pain once and for all.

The plantar fascia is a thick fibrous bands of ligament tissue that acts like a cable between the heel to our toes. It serves many important biomechanical functions essential to the health of the foot, especially under weight bearing activities like walking, running, jumping, or standing for long periods of time.

 

The plantar fascia also:

• Acts as a shock absorber when standing and moving
• Stabilizes the metatarsal bones during motion
• Creates ‘windlass mechanism,’ tightening of the fascia. This helps promote longitudinal arch stability when walking, running, jumping[3]

You can think of the plantar fascia as a spring that takes all the abuse when you are doing any activity on your feet. It is thought that irritations (micro tears from overuse injuries) to the plantar fascia result in pain at the bottom of the foot, leading to plantar fasciitis.

Plantar fasciitis is often used as a blanket term to describe heel pain. It is often confused with a multitude of other foot disorders like heel spurs, stress fracture, bone bruise, Achilles Tendonitis, Sever’s Disease, etc.

Thankfully, there are some classic signs of plantar fasciitis that can be used to intelligently to rule out other possibilities:

• Sharp, stabbing pain on the bottom of the foot, primarily from the heel area. However, it is not unusual to feel the pain throughout the bottom of the foot.
• No numbness or tingling (parasthesia) is present in most cases.
• Pain after long periods of rest, especially with the first steps in the morning.
• Presence of pain at the beginning of exercise that dissipates during the activity, but returns afterwards.
• Worsening of pain when pointing the toes up.
• The ankle feels tight, often limiting the range of motion of the ankle.
• When walking, pain is worse when pushing off the ground instead of placing the foot back on the ground.
• The pain gets worse when standing on the toes.

There are many underlying causes to plantar fasciitis which makes it tricky to treat and is the reason there is no singular method that is proven to cure it. Identifying the exact cause of why you developed plantar fasciitis in the first place will give you a better roadmap to understanding the cause and how to treat it properly. More importantly, by figuring out the right cause of your plantar fasciitis, you can prevent it from coming back in the future.

Note that, as you read the list below, you may find you agree with multiple factors. This is common as plantar fasciitis can be triggered by many different factors and no singular cause exists for it.

There is a lot of misinformation flying around the internet about plantar fasciitis. What may sound plausible and even seem like common sense when taken at face value are often flat-out wrong. Whether due to ignorance or bad research, here are some classic myths about the causes of plantar fasciitis that have no scientific evidence to back themup.

1. Excessive pronation

It was once thought that extreme pronation (both under-pronation and over-pronation) was one of the leading causes of plantar fasciitis [13][14]. However, more recent studies have come out that challenge this notion. One study examined the foot posture of professional baseball players and reported that there was no direct link between excessive pronation and low extremities injuries [17]. Two other studies also concluded that “excessive pronation, in and of itself, did not result in lower extremity abnormalities” [15][16].

However, it is important to note that excessive pronation may contribute to structural problems in the lower extremities, notably increased rotation of the tibia. It is thought that problems that can arise from having excessive pronation, when not properly managed, could lead to many problems in the lower extremities.

2. What about heel spurs?
Heel spurs are often mistakenly referred to as plantar fasciitis, leading many people to assume these conditions are one and the same. Heel spurs are also not the cause of plantar fasciitis.

The American Academy of Orthopaedic Surgeons reported that only about 5% of people with heel spurs report foot pain. This contradictors the symptoms of plantar fasciitis, which is always accompanied by heel pain.

How can you tell if you have a heel spur instead of plantar fasciitis? Try walking on your toes. If the pain subsides, then it is more likely to be a heel spur than plantar fasciitis. The pain level will shoot up when you place more pressure on your toes if you have plantar fasciitis.

This guide was created to inform individuals about plantar fasciitis and provide methods of self-treatment for this condition. Remember it is always prudent to visit a doctor to properly diagnose the condition. This guide should be use as a supplement to doctors’ visits.

It is important to start a treatment program immediately upon feeling symptoms. If not treated properly, this condition can quickly escalate to a more severe condition or even become a chronic case of plantar fasciitis, resulting in more doctor visits and at possibly surgery.

First, let’s talk about what you should NOT be doing when suffering from plantar fasciitis.

The following activities can and will aggravate plantar fasciitis, further damaging the tissue, and delay the healing process. By minimizing these activities, the affected and damaged tissue will be allowed to heal and recover.

1.    Stay off of your feet
It is incredibly important to let the plantar fascia heal on its own. It is  not practical to completely eliminate all daily activity, but avoid most if not all activities that require running, jumping, etc. and do not ignore the pain. Pain is the body’s natural response to alert us  when something  is wrong. Simply suppressing it and attempting to ‘power through’ could make the condition worse.

If you hold an occupation that requires you to be on your feet for long periods of time, some things you can do to mitigate the pain and discomfort while improving your mobility include:

• Wear comfortable shoes with plenty of sole paddings that provide proper arch support.
• Try shoe inserts (orthoses) designed to give maximum arch support. Foot orthoses are clinically proven to relief the symptoms of plantar fasciitis.
• Low-dye taping to relieve pain and improve mobility.

2.    Do not walk barefoot
Always wear supportive shoes, preferably ones that provide a lot of cushion and proper support for the arch. Walking barefoot when the plantar fascia ligament is damaged can further aggravate the issue. It is recommended to wear supportive shoes at all times while you have plantar fasciitis.

3.    Avoid hard surfaces like concrete.
If you stand still for a long time on a hard surface, consider investing in a thick rubber mat to reduce stress on your feet. Uneven surfaces should also be avoided, as they will add undue stress to your feet and legs.

1. Non-Steroidal Anti-Inflammatory Drugs (NSAIDS)
Recent studies have dispelled the long-held belief that plantar fasciitis is an inflammatory condition, so it makes little sense to treat the condition with anti-inflammatory agent like ibuprofen and naproxen. Almost all pain-relieving medicines, including NSAIDs, have clinically shown to delay the healing [33].

However, during the acute phase of plantar fasciitis, inflammation can be present as a side symptoms. One study was able to treat 79% of patients successfully with NSAIDs [28].

NSAIDs can be effective with management of pain and if the pain is unbearable for you (which tends to be the case during the acute phase of plantar fasciitis). However, understand that it is merely treating the symptoms of it, not the actual cause of the condition.

The key to using NSAIDs properly lies in using it in a consistent matter. Do not exceed the use of NSAIDs longer than 4 weeks. Stop once you are out of the acute phase of plantar fasciitis. An NSAID should be used with caution in elderly patients and avoided all together during pregnancy.

2. Icing

Traditionally, doctors within sports medicine collectively agreed that ice is the key to recovering from injuries. It appeared that icing the pained area would minimize inflammation and numb the pain. But, one study concluded that the only thing ice is good at is numbing the pain [30]. The researchers could not find any evidence to support the traditional notion that icing helps speed up the recovery process [30].

Essentially, applying ice to the injured area blocks healing cells from entering the injured tissue and starting the recovery process.

Dr. Gabe Mirkin M.D. wrote a best-selling Sports-Medicine book in 1978. In it, he coined and popularized the all too famous term RICE (Rest, Ice, Compression, Elevation) as a guideline to help athletes recover from their injury. For decades, this methodology was accepted and passed down as the ultimate truth in the sports and medicine circle. In light of numerous studies that have come out since the publication of this book, little to no evidence that icing helps with recovery process has been shown, and he now cautions the use of ice as part of recovery process. [31][32]

“Since applying ice to an injury has been shown to reduce pain, it is acceptable to cool an injured part for short periods soon after the injury occurs,” recommend Dr. Mirkin.

Virtually in all sports, icing has become a ritual for post-recovery therapy. But by using ice, you are slowing the blood flow and slowing other fluids from moving in and out that are part of the healing process.

So instead of blindly icing your foot, use it strategically. Think of ice as a way for to manage the pain, not as something that will heal plantar fasciitis.

There is no reason to use the following treatment options as a first line of treatment when there are other non-invasive therapies available. They should only be considered as ‘last-resort’ attempts if manual treatment therapy has failed.

1. Corticosteroid injections

Cortisone injection, a powerful anti-inflammatory agent, should almost always be avoided as a first treatment protocol.

There is currently not enough evidence to warrant cortisone injections to be used as the first line of intervention and there are complications that can arise that could worsen and/or create other problems, like sunken arches. It should only be an option if you have tried non-invasive treatment options. Studies do not warrant the use of this treatment to be favored over non-invasive manual therapies that are available.

2. Surgery

Invasive surgery is almost never required. Out of 100 patients, 95 end up resolving plantar fasciitis through non-surgical treatments within a year. Only 5 patients need surgery and those cases tend to be severe and chronic cases of plantar fasciitis. There are many complications that can occur with the surgery and so should be used as a last resort if pain is too severe to continue a normal lifestyle.

The effective treatment protocol is designed to not only attend to the symptoms, but to identify and solve the initial cause for plantar fasciitis so it does not come back. The leading biomechanical causes of plantar fasciitis are poor ankle dorsiflexion as well as tight or weak foot and calf muscles. Proper treatment protocol for plantar fasciitis includes stretching and strengthening exercises.

The goals of the Plantar Fasciitis Treatment are:

1. Allow damages to plantar fascia to heal with rest
2. Relieve pain through stretching exercises and trigger point therapy
3. Improve biomechanical weaknesses by stretching and strengthening the supportive tissues in the feet, ankle, and legs

Dr. Fredericsson, who authored a review article in Physical Medicine and Rehabilitation, states: “Stretching, particular the plantar fascia, and foot strengthening play an important role in the prevention of future foot problems.” He also noted that the most effective treatment for plantar fasciitis includes stretching of the calf muscles and plantar fascia.

Six key components to Plantar Fasciitis Treatment are:

• Rest
• Stretch
• Trigger Point Therapy (Massage)
• Strengthen
• Low-dye taping (optional but highly recommended)
• Weight Loss (For Obese / Overweight Individuals)

These components work together to produce pain relief/management, promote healing to the damaged tissues, and fix the biomechanical issues that caused plantar fasciitis so it does not turn into a reoccurring/chronic condition.

By now, you should have a pretty good idea of what may have caused your plantar fasciitis. It could be that you are a runner that increased your duration and intensity too quickly or you may be working a job that requires you to stand on your feet all day. Whatever the case may be, it’s important to recognize the pattern that led you to have plantar fasciitis.

During the acute phase of plantar fascia, it is imperative that you limit your activity as much as possible. In one study, rest was considered to be the most effective form of treatment in 25% of the patients [29].

If you are an athlete, avoid any physical activity that requires you to be on your feet during the acute phase. This includes running, jumping, climbing stairs, etc. Unfortunately, our body does not work well without rest, especially our plantar fascia, which receives little blood flow to begin with.

Essentially, the key is to limit the movements that cause pain and lead to plantar fascia.

It is not unusual to initially feel pain when exercising and for it to dissipate during exercise. Just because the foot doesn’t hurt during physical activity, it does not mean it is acceptable to continue to aggravate the injury.

When the pains and symptoms subside

you can start to gradually reintegrate into your normal exercise programs. This means decreasing the duration, intensity, and frequency of your normal fitness program.

Limit the time you spend on hard surfaces like concrete and other hard surfaces. If you must stand on your feet for an extended period of time, as your job may require, make sure you are wearing a pair of shoes that are well fitted and provide you with adequate arch support and cushioned soles.

Though complete rest is not practical, nor entirely desirable, come to a solution that will allow you to function normally while limiting the strains on your foot while you recuperate. Swimming is a great alternative to running while you are recovering from plantar fasciitis.

Dr. Perry H Julian, foot specialist for the 1996 Olympic games, noted, “One of the most common causes of plantar fasciitis is tightness of the calf and Achilles tendon.” A study concluded that 83% of patients who performed stretching exercises experienced successful relief. Stretching, thus, has become a key component to improving heel pain.

Incorporating a stretching regimen into your routine is one of the key pieces to healing and recovering from plantar fasciitis. Stretching the proper muscle groups and tissues linked to plantar fasciitis is key to providing pain relief, as well as improving the flexibility and range of motion in the feet and ankles.

There are two types of stretches  to perform when suffering from plantar fasciitis: plantar fascia stretch and calf stretch. Both have proven to be effective in reducing pain and helping with the recovery process by gently promoting healing in the damaged tissues [40]

1. Plantar Fascia Stretch

The goal of plantar fascia stretch is to loosen up the tissues that were damaged through micro-tears and trauma in the fascia ligament. Although it is named the plantar fascia stretch, this is effectively stretching out the Achilles tendon using your toes as anchors. This stretch will engage the windlass mechanism, making the stretching even more effective.

By performing the plantar fascia stretch, you will relieve strains and tightness in the plantar fascia, thus reducing irritation and creating an environment for healing to take place [38].

2. Calf Stretch

Numerous studies have demonstrated the effectiveness of calf stretching as part of the treatment regimen for plantar fasciitis. Calf stretches will not only provide pain-relief, but also improve the flexibility in the calf muscles, as well as increasing the ankle’s mobility.

Tight calf muscles will pull on the Achilles tendon and, correspondingly, create tightness in most of the foot structure, including the ankle as well as the plantar fascia. As we discussed earlier, poor ankle dorsiflexion is one of the leading causes of plantar fasciitis.

By stretching out the taut calf muscles, you are fixing this biomechanical faults, and reducing the aggravation of the tissues in your feet. Patients reported a reduction in pain and faster recovery time when they included calf stretching as part of their treatment regimen [39].

Trigger points are tight knots that form in our muscles that are palpable and highly irritated. These knots prevent other surrounding muscle groups from relaxing and recovering properly. There are 126 ligaments, muscles, and tendons cohesively working together in our feet and trigger points can wreak havoc in this delicate environment by pulling and aggravating them.

Trigger point therapy using a tennis ball by massaging and releasing the trigger points in our feet (particularly the arch), is one way to achieve pain relief and recovery. This can also be done by usin ga water bottle that has been frozen, providing the pain relief from the ice and trigger point massage at the same time. Trigger point therapy has been proven to be more effective when combined with stretching. A study showed higher efficacy in recovery when stretching and deep tissue massage were combined versus stretching alone [35].

Although a professional deep tissue sports massage is preferred, self-massage options have shown to be just as effective. Massaging the plantar fascia is a commonly accepted protocol but calf massaging is just as important as this region is ripe to form knots, which tug at the tissue in the foot.

Stretching and massaging are both effective and preferred methods to treating plantar fasciitis by most foot specialists and physical therapists.

However, those two are not enough. You need to strengthen the muscles in and around the feet to address the root of the problem and prevent plantar fasciitis from coming back. Strengthening the muscles and tissues in our feet and calves have shown evidence of the beneficial effects to a faster recovery from plantar fasciitis [44].

Dr. Patrick McKeon, the author of the study, also added “The plantar fascia has to passively stabilize the foot with every stride and strong foot muscles reduce the demand by adding an extra layer of support.”

The British Journal of Sports Medicine produced a study in 2013, which emphasized the importance of strengthening the ‘foot core’ when treating for plantar fasciitis. The article states, “While temporary arch support may be needed during the acute phase of plantar fasciitis, it should be replaced as soon as possible with a strengthening program just as would be carried out for any other part of the body.”

Strengthening exercises for intrinsic foot muscles, such as picking a towel off the floor with your toes, should be initiated as soon as you are out of the acute phase of plantar fasciitis. It will take one to two months to start seeing tangible benefits from strengthening exercises.

Remember also, that

Plantar fascitis can cause an altered gait pattern

affecting both the hip and the knee. A case study done of a runner with plantar fascitis actually resolved the symptoms within 8 weeks by strengthening the hip abductors and external rotators. This can easily be done at home by laying on the nonaffected side and lifting the affected leg up in the air (side leg lifts for hip abductors), as well as tying an exercise band around your knees while sitting to resist bringing the knees away from each other (hip external rotators).

In the study, they also positioned the patient on a treadmill with a mirror so that she could see that her knee was turning in when she ran. The therapist would then cue her to keep her knee straight. While it is optimal for a therapist to further assess a running pattern, this could be initiated in the gym if treadmills are in front of mirrors. If placement of feet or positioning of knees is not equal from side to side, that can be self corrected. [52]

Also known as calcaneal taping, low-dye taping was created by Dr. Ralph Dye, a podiatrist, to treat pain arising from foot injuries. This method is designed to support the arch of the foot, correcting the faults in biomechanics in the foot.

For plantar fasciitis, low-dye taping effectively takes the load off of the plantar fascia, enabling healing to take place. It also provides short-term pain relief, lasting 7-10 days [45]. Another study demonstrated that low-dye taping, when used in conjunction with stretching, provided considerable reduction in pain versus stretching alone.

Low-dye taping is an optional part of the treatment protocol, but is highly recommended if you must be on your feet as part of your occupation. It will help to minimize the pain and increase the mobility.

As plantar facitis is asscociated with a BMI greater than 27, it would make sense that weight loss would reduce the load put on the plantar fascia, promoting healing. There are many different ways to accomplish this goal, but as activity may be somewhat limited secondary to pain, this may be best done with management of diet. If you are unsure of how to do this, it would be best to consult your physician or dietician.

There are many products claiming to help provide relief for plantar fasciitis and to even cure it. Because plantar fasciitis almost always accompanies excruciating pain, it is no wonder these products have come flooding into the market promising high hopes for people suffering from this painful condition.

So which plantar fasciitis products work and which do not?

Following are the top products that have been shown to be effective in reducing the pain and improving mobility.

A good pair of shoes can relieve painful symptoms of plantar fasciitis. Proper footwear should have a well-padded sole designed to absorb shock and lessen the strains placed on your plantar fascia. Good plantar fasciitis shoes should also provide proper arch support for your foot type. Well cushioned shoes will reduce the tension to micro-trauma that are present in the plantar fascia, helping you to relieve pain.

A worn out, poorly constructed shoe will irritate the plantar fascia, furthering causing damage to the tissue, leading to more pain and prolonging the condition.

Worn out shoes should be replaced. Inspect the paddings, treads, and heels and if they are worn out, they should be replaced immediately.

It is estimated that running shoes should be replaced every 350-500 miles.

For non-athletes, a good pair of walking shoes can last up to 9 months, which comes out to be 1,000-1,500 miles when walking 4-5 miles a day on average.

Shoes must fit your feet properly. It is a myth that some shoes require a break-in period. If any shoe causes pain and claims this will get better as you “break it in,” avoid them. A good pair of shoes that provides proper arch support and is well cushioned should feel comfortable immediately.

Avoid footwear like high heels and flip flops that do not provide an adequate support structure for your feet.

Many studies support the effectiveness of orthotics in reducing pain and improving mobility [21] [22]. Also often known as shoe insoles/inserts, orthotics are designed to correct improper foot mechanics and reduce the stress placed on the tissues in the foot. It is particularly effective in reducing the strains on plantar fascia when you are pushing off on your feet to start the movement [23].

Dr. Fredericson, who published an article in Physical medicine and Rehabilitation, noted “Good evidence exists that foot orthotics may be useful as a treatment.” As a part of treatment for plantar fasciitis, combining stretching with foot orthotics has produced more effective results.

A study observed that patients who used orthotics with physical therapy, like stretching and strengthening exercises, experienced significantly higher rates of pain reduction and recovery time compared with groups who only received the physical therapy [42].

Which are better: prefabricated or custom orthotics?

There seems to be no evidence to support that custom orthotics are any better than shoe inserts available over the counter [25]. A long-term clinical study conducted on the effectiveness of foot orthosis concluded that there was no difference between the two in reducing pain and relieving the symptoms of plantar fasciitis [26].

With custom orthotics being cost-prohibitive (running anywhere from $200-$500), there is no reason to prefer them over products available for purchase in retail stores for less than $50. However, it is still important to make sure that the over the counter orthotic that you choose provides the support that you need. Keep in mind, that if you have fallen arches an orthotic that provides good arch support will not immediately be comfortable. It will take a few days to become acustomed to having support. In fact, it may be best to limit the time you spend on your feet for a few days to allow time for your feet to adjust.

Avoid magnetic shoe inserts, which have not been proven in clinical trials to be effective. Any relief or benefits claimed from them are anecdotal at best, likely due to a placebo effect [19][20].

When asleep, the feet are usually pointed downward. This contracts the plantar fascia, leading to the shortening of the tissue. This effect is one of the leading causes of morning pains that are synonymous with plantar fasciitis.

Soft night splints are designed to mitigate this by maintaining a neutral 90 degree foot to leg angle, which gently stretches the plantar fascia ligaments, promoting rest and healing to the damaged plantar fasciitis and relieving the tension and pressure, leading to pain relief.

One study concluded that after only using night splints for one month patients with chronic plantar fasciitis had an 88% improvement in their condition [44].

Night splints are often used for cases of plantar fasciitis where the symptoms last longer than 6 months [27]. The typical protocol for night splints requires continuous use of the splints for one to three months. However, those who use them earlier will often find that it significantly reduces the pain in the morning. The use does not need to be continuous after the symptoms of plantar fasciitis have dissipated.

There are primarily three types of night splints: posterior, anterior, and sock-type. Studies do not favor one type over the others. The problem with night splints is from patient compliance, due to discomfort. Many people seem to have trouble using the night splint every night for consecutive weeks.

If you decide to use a night splint to treat your stubborn cases of plantar fasciitis (cases lasting longer than 6 months), pick a splint that provides maximum comfort. The key is to use it in a consistent manner every night until the pain is no longer present.

If conservative treatment does not greatly eliminate the pain, there are other options that will be completed by a physician.

This has shown significant reduction in symptoms. Essentially an electroshock treatment will be applied to the heel- in the study this was done over 5 visits. Pain was reduced in 81% of the patients after 6 weeks, 88% of the patients after 16 months and in 96% of the patients 72 months post treatment. [48]

This is a very common treatment done in a doctors office. This is an injection of a coricosteroid into the area of the plantar fascitis. Research, however, does support the use of corticosteroids, but the effects only last 4-12 weeks. [49]

This is generally not the best option for treatment of plantar fasciitis, but it is still something some chronic suffers of plantar fasciitis choose. A recent study comparing endoscopic plantar fasciotomy vs. open plantar fasciotomy found that compared to the open approach, the patients who had received endoscopic surgery experienced less pain and had a greater satisfaction with the surgery. [50]

However, the long term outcomes of surgery are not positive. Another study published in Foot and Ankle international found that typically outcomes of surgery were poor and there was a long recovery period. Outcomes were even worse in patients that had had prior corticosteroid injections. [51]