both had plantar fasciitis myself and have regularly treated patients with the
condition. I’ve seen a lot of confusing information presented about how to
treat plantar fasciitis. Most commonly recommended treatments are generally
ineffective, can be costly, and more often than not fail to provide heel pain
sufferers with permanent relief.
treatment requires treating the cause and not just the symptoms of heel pain. This article outlines a step-by-step
plan based on the current understanding of how plantar fasciitis develops.
is Part 3 in a three-part series on Plantar Fasciitis.
Part 1 discussed the factors I think
can likely contribute to plantar fasciitis.
Part 2 reviewed the lack of effectiveness of
conventional treatment approaches such as arch supports, cortisone injections,
and night splints.
Common Misconceptions About Plantar Fasciitis
It is not caused by wearing
shoes that don’t have enough support
It is not caused by a tight
It is not caused by running,
or spending a lot of time on your feet
Things To Know About Heel Pain
fasciitis is a painful condition characterized by a gradual onset of pain on
the bottom of the heel near the inside of the foot. The pain is usually the
most intense with the first steps in the morning or after periods of
plantar fascia is a thick band on the bottom of the foot, running from the toes
to the heel. Deep to the fascia there are muscles that also span
the length of the foot and insert on the heel in the same area as the
plantar fascia. Together, these structures provide support to the foot and aid
in shock absorption.
contributing factors to the development of plantar fasciitis:
Compression on the heel leading to increased
load and reduced circulation
Footwear that alters the normal function of
Weakness of the foot muscles that transfers
load to the plantar fascia
Abnormal stress on the arch from decreased
ankle flexibility, pronation, or a high BMI
Goals of Plantar Fasciitis Treatment
treatment of plantar fasciitis likely involves replacing abnormal stress on
foot with healthy stress that will promote tissue regeneration. This approach
Increasing Foot Strength
Plantar Fasciitis Treatment Guide
is an outline of the approach I use for plantar heel pain. The steps involved
standing posture and habits to take pressure off your heel
less supportive shoes
the muscles in the foot and leg
and massage for the legs and feet
Step 1: Shift Weight Off The Heels
shifting weight forward to balance weight evenly between the front (ball) of
the foot and heel relieves compression under the heel. Shifting weight forward
also potentially increases circulation to the heel. Injured tissue needs a good
blood supply to repair itself.
weight off the heel and placing it more on the forefoot also allows the toes
and the front of the foot to engage the ground. This activates the muscles that
run along the bottom of the foot and attach on the heel bone. Increasing the
strength of these muscles may be one of the key components of treating the
walking, concentrating on pushing off with the back foot instead of reaching
out and landing with a hard heel strike on the front leg may also alter the
stresses on the foot in a beneficial way.
Step 2: Increase Barefoot Activity
of us spend most of our time walking around in shoes on perfectly flat
surfaces. The foot is capable of bending and twisting in many different ways.
This flexibility allows the foot to conform to whatever surface we are walking
on. There are also many muscles that allow the foot to make quick adjustments,
as well as sensory receptors that continuously supply information to the brain.
walking in shoes, or spending too much time on hard, flat surfaces
limits these actions of the foot. Walking barefoot as much as possible,
and on as many different surfaces can help change this. Grass, dirt, sand etc.
Walking barefoot can also be used as a tool to learn to land softer, with a
less impact forces when the foot strikes the ground.
Step 3: Increase Ankle Flexibility
of ankle flexibility is one of the most reliable risk factors for developing
plantar fasciitis. Decreased ankle dorsiflexion range of motion alters the
mechanics of the foot and can cause abnormal forces under the heel.
are several ways to stretch your calves, but one of my favorites is simply
walking up a steep hill. It’s
simple and effective. The ancient Greek physician Hippocrates
said, “walking is man’s best medicine”.
terms of specific calf stretching exercises, there are lots of option. Two
common ones are:
against a wall with the leg to be stretched in back. Keep the heel down and the
back knee straight, lean forward until a stretch is felt in the calf.
similar position to the runner’s stretch, except this time the leg in front
will be the one getting stretched. Keeping the heel of the leg in front flat,
lean into the wall while bending the front knee until a stretch is felt in the
back of that leg.
exercises look similar but both are important because they target different
muscle groups. There are two keys to making these ankle stretching
Keep the feet pointed straight ahead
Don’t let the arch collapse
Step 4: Change Shoes
like to dispel the myth that the foot needs support 24/7. I suspect shoes are
in many cases the culprit behind plantar fasciitis. Not because they don’t
support the foot, but rather because they often give too much support!
and connective tissue need movement and activity to remain healthy. At the time I developed plantar
fasciitis I was wearing stability running shoes with insoles everyday for 8-9
hours. The heel pain went away a short time after I switched to more flexible
shoes with less arch support.
that there is very little scientific evidence showing the stability features in
shoes help prevent or treat injuries. There is no one size fits all approach to
selecting shoes, but the features I consider important are:
Little or No Support
Minimal Toe Spring
Flat or Low Heel Height
prefer shoes that are capable of bending along the entire length of the sole.
This can be tested by bending and twisting the shoe.
that is too stiff or one that only bends in certain spots is going to force the
foot to conform to the motion of the shoe when really it should be the other
way around. The shoe should match the motion of the foot and this is only going
to happen in a flexible shoe.
look at Part
1 for an in-depth
review of the effect a toe spring has on the foot. Basically, the toe spring
keeps the toes elevated off the ground for the majority of the time when
standing or walking. This alters the normally functioning of the foot and can
potentially limit the shock absorbing capacity of the arch. Though it’s almost
impossible to find shoes without large toe springs, some minimalist running
shoes or barefoot style shoes are lower in the front and flatten out easier.
Built-In Arch Support
structural arch gets its strength from the ends, not in the middle. In the case
of the foot, the two ends of the arch are the heel and the toes. These are
the parts of the foot that need to be in contact with the ground to support the
supports seem like the wrong way of supporting the foot because they prop the
arch up from the middle. If you saw an arched doorway in a building you
wouldn’t call up the architect who designed it to tell him he should have put
more support in the middle!
natural arch of the foot provides both support as well as shock absorption.
Using artificial support can alter the foot’s ability to cushion impact forces.
To some degree using an arch support closes off that space underneath the foot
where muscles, nerves, and blood vessels pass. In some cases I suspect the
position of the built-in arch of the shoe adds compressive stress to the heel.
a shoe with a raised heel is the same thing as standing on a ramp facing
downhill all day. The result of this is adaptive shortening of the muscles in
the calves and Achilles. A raised heel also tips your body forward. This forces
the wearer to lean backward to stay balanced which then can place more weight
on the heels. I look for relatively flat shoes, with little to no difference in
height from the heel to the forefoot.
the switch. For
someone used to wearing heavily structured, supportive shoes, the key is to
transition slowly! The body needs time to adjust. A person used to walking
barefoot at home may find the transition to be a little easier.
Step 5: Strengthen
plantar fasciitis is often associated with degeneration of the tissue in the
foot, it makes sense that strengthening those tissues should be a priority.
A recent study out of Denmark found a strength training program
consisting of single-leg heel raises with a towel inserted under the toes
resulting in better outcomes than a plantar fascia stretching program.
results suggest getting the muscles in the underside of the foot some use
should be a priority. This will naturally happen by increasing barefoot
activity, but including some of the following exercises may help the
Short Foot Exercise: Try to
form and hold an arch in the foot. Hold for 5 seconds, relax, and repeat (video)
Foot Gymnastics: This
can include any activity that requires foot dexterity. Some options are
grabbing a pen with the toes, passing a pen back and for between your feet,
picking up marbles, or stacking plastic cups. Imagination is the limit!
Towel Curl: Spread
a towel out on the floor and try to bunch it up by pulling it in with the toes
but without moving the rest of your foot (video)
Imaginary Beach: pretend
you are gripping sand with your toes, picking it up, and then dropping it.
Calf Raises: Raise
up high on the toes and then lower down slowly. Focus on pushing through the
big toe on the way up
Toe Walking: Stand
on the toes and walk 10-15 steps at a time keeping the heels off the ground
weight squats are a great way to build leg strength and
increase ankle flexibility
Single Leg Balancing: Practice
balancing on one leg to increase ankle and lower leg strength
is some evidence that tight hamstrings, like
tight calves, play a role in causing plantar fasciitis. I found the following
stretches helpful when I had this injury.
the foot is important for promoting flexibility and circulation, as well as
adding stress to the tissue to encourage healing. These stretches bring the
toes through a full range of motion. Many people find these helpful for
making the first few steps in the morning less painful.
is a video that shoes a fairly comprehensive stretching routine:
the calves and underside of the foot can promote tissue health, though the
exact mechanisms involved are not yet understood. Two of the most commonly used
self-massage techniques for plantar fasciitis are:
Rolling a tennis or golf ball under the foot
Using a foam roller to massage the
calves–many runners swear by this (video)
really difficult to make specific shoe recommendations because of the
variability in styles that each brand makes. I tend to think the more
structured a shoe is, the more likely it will interfere with the mechanics of
the foot. I don’t think a complete switch to minimalist shoes is necessary. The
guidelines in the article are a good starting point for what to look for, but
I’ve come to realize there is no such thing as the “perfect” shoe. Finding
something that’s comfortable is important, as well as understanding that there
is very little evidence to suggest the support features built into shoes have
any beneficial effects.
athlete’s heel pain just started, it’s not a bad idea for them to take a week
or two off from your normal training. I also like the concept of “relative
rest” which means substituting a new activity for the one aggravates the
symptoms. The relative rest period is a good time to work on strength,
flexibility, and mechanics in preparation for a gradual return to regular
the pain has persisted for several months (as is often the case with plantar
fasciitis), I’ve found that activity is often better than rest. Overcoming
the fear that activity will make the condition worse can also be an important
part of the recovery.
everyone enjoyed this series and found it informative. If you have any
questions or feedback, please let me know in the comments below!