What Causes Plantar Fasciitis?

Physical Therapy Advice For Heel Pain

Girl with plantar fasciitis heel pain

That first step – the burning, stinging pain in your heel stops you in your tracks. It’s been getting worse over the course of the last few months and you hoped it would go away by now. All you want is to be able to live your life the way you used to – to walk and to run pain-free. Plantar Fasciitis can be debilitating and long-lasting, but with the proper treatment, you can improve.

Let’s look more closely at Plantar Fasciitis: what it is, who it affects, and what the best treatment options are…

What Is Plantar Fasciitis?

The plantar fascia is a band of tissue on the bottom of your foot that attaches to the inside of the Calcaneus (heel) bone.

The arch of your foot is mostly supported by the plantar fascia and other static structures like bones and ligaments. EMG studies show that your muscles only come into play when excessive forces are applied1.

Normally, the plantar fascia is about 2 to 4mm thick. However, ultrasound imaging shows people with Plantar Fasciitis can have an increase in thickness to 5 to 7 mm2,3.

Although the cause of Plantar Fasciitis is unclear, a common theory suggests partial tearing and inflammation at the point where it attaches at the heel bone4,5,6,7.

What causes this inflammation? Direct repetitive microtrauma on the heel8.

Who Does Plantar Fasciitis Affect?

Plantar Fasciitis can affect athletes and non-athletes alike.

Some common risk factors for Plantar Fasciitis include obesity, jobs that require a lot of standing, excessive pronation of the foot, reduced ankle dorsiflexion, and heel spurs9,10,11,12,13,14,15.

What a typical case might look like would be a middle-aged, overweight, non-athlete, who stands on hard, unyielding surfaces16.

Another population affected is long-distance runners. In fact, Plantar Fasciitis accounts for about 10% of all running injuries17.

The repetitive forceful loads that occur with long distance running can lead to inflammation, which can then lead to fibrosis (thickening and hardening), degeneration (breakdown), or both18.

Training errors are a likely culprit when it comes to heel pain – sudden increases in mileage (marathon training), running up steep hills, and running in worn-out shoes19.

What are the Symptoms of Plantar Fasciitis?

The typical person with Plantar Fasciitis describes:

  • Gradual onset of pain, not caused by a single traumatic injury
  • Pain on the inside of the heel, often described as burning
  • Pain with weight-bearing
  • Worse pain with coming up on toes
  • Morning pain and stiffness
  • Pain after prolonged inactivity

Most people’s symptoms go away within 10 months. However, about 10% have persistent symptoms that can be disabling20.

20% to 30% of people with Plantar Fasciitis will develop symptoms in both feet21.

What Does Treatment For Plantar Fasciitis Look Like?

As far as what doesn’t work for Plantar Fasciitis treatment: modalities such as ultrasound, phonophoresis, and iontophoresis aren’t of much benefit22.

There are, however, many good options that have their benefits. A recommendation would be to try some or all of them, in any combination that you find most helpful.

In no particular order, here are some treatment options:

  1. Stretch the Achilles: since it’s likely you’ll have limited ankle dorsiflexion with Plantar Fasciitis, you may want to try stretching the Achilles (see photo below). Since the Achilles attaches to the opposite end of the same heel bone as the plantar fascia, stiffness in the Achilles may be causing excessive stress on the attachment point of the fascia – might as well give it some stress relief.

Achilles stretch for Plantar Fasciitis

  • Lean against a wall with the affected foot behind you
  • Keep the back foot straight with the heel on the ground
  • Keep your back knee straight
  • Lean forward until a good stretch in the calf and Achilles is felt
  • Hold this stretch at least 30 seconds

2. Stretch the plantar fascia: non weight-bearing stretching of the plantar fascia (see photo below) has been shown to be superior to Achilles stretching23. My advice: do both – they’re easy and don’t take much time.

Plantar fascia stretch

  • Cross the affected leg over the other leg
  • Place your fingers across the base of the toes
  • Pull the toes back toward the shin until a stretch is felt in the arch or plantar fascia
  • Feel for tension in the plantar fascia
  • Hold this stretch at least 30 seconds

3. Wear Dorsiflexion night splints: they’ve been shown to improve symptoms in 88% of patients and have a 73% satisfaction rate after just 1 month of use24. The downside is that they are a bit on the bulky side and people don’t always stick to wearing them.

4. Wear a pre-fabricated over-the-counter shoe insert: when combined with a stretching program, its been shown that these types of shoe inserts produce better results than custom-made orthotics25 (which cost hundreds of dollars). Their purpose is to help correct excessive foot pronation.

5. ICE: try a rolling the bottom of the foot on a frozen water bottle for up to 15-20 minutes – especially after activity.

6. Rest: If you’re a runner, rest is a must. Reduce your miles, slow down, or stop completely. A lot of runners try to run through the pain, which only serves to make symptoms worse. Allow the tissues to heal. Sometimes this means stopping for several months.

7. NSAIDs: may be helpful in acute cases.

8. Local Corticosteroid injections: occasionally, these can be beneficial, but multiple injections is discouraged.

9. Casting: wearing a fiberglass cast for 6 months shows results of 25% of people having a complete resolution of symptoms26.

10. Surgery: this shouldn’t even be a consideration until after a year of persistent symptoms. Even then, less than 50% of patients with chronic heel pain are satisfied with the results of surgery27.

Just remember that improvement is going to be gradual, sometimes taking up to a year. During this time, I’d recommend maintaining fitness and activity by trying cycling or swimming – both activities that aren’t going to put any direct force on the heel.

Once you can tolerate, a gradual return to walking and running is then recommended – working your way from walking short distances, to gradually further, and so on.

Physical Therapy can be beneficial for further education and to guide you through appropriate treatments.

Chronic Heel Pain: An Alternative Theory

We’ve seen what the typical course of Plantar Fasciitis looks like, but what happens when months go by and the pain is still there?  Healing should have taken place by now – could the fascia still be inflamed?

In 2012, a colleague and I conducted a research study28 on individuals with chronic ( >3 months) heel pain. We used ultrasound imaging to measure the thickness of the plantar fascia in these participants and compared the thicknesses to their uninvolved foot.

We found no differences.

We also found no differences in ankle dorsiflexion and big toe extension mobility.

So, in these areas that are traditionally the criteria to diagnose Plantar Fasciitis: thickening of the plantar fascia >4mm and limited ankle dorsiflexion, people with long-lasting heel pain didn’t show any difference when compared to the uninvolved side.

We did, however, find a significant difference in tactile acuity.

To test tactile acuity, we used a 10g monofilament (kind of like a soft needle or firm thread that bends once 10g of force is applied) to apply pressure to the participant’s heel in various places. Without being able to see when we poked them, the person would tell us when they felt the poke.

Tactile acuity testing for plantar fasciitis

A significant loss of tactile acuity was measured in the foot with heel pain.

What this tells us is that true tissue pathology might not be the primary driver of symptoms in people with chronic heel pain. If there are alterations in tactile acuity, perhaps there are alterations in pain modulation, as well.

What to do with this information?

If you do have heel pain, remember that symptoms will typically go away within 8-12 months. Following the recommendations above to stretch, wear shoe inserts, wear night splints, modify or cease running activity, all can help.”

Once you can tolerate it, gradually begin increasing your activity level. This will help to retrain your brain that movement, weight bearing, and pressure on the foot are normal, and not actually a threat29.

Question: What have you found most helpful for heel pain? You can leave a comment by clicking here.

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  • Eran Mangel

    Did anyone think about the real name of the disfunction? There is no inflamation so there is no itis. The name is PLANTAR FASCIOPATHY.
    And with this thought, I found usually that the cause is not in the plantar region but high up along the sequences.

    • Michael Curtis

      Yeah, at the Chronic stage, similar to an Achilles tendinopathy.

  • Rachel York

    Interesting info on the changes with chronic pain. Would it be okay if I shared this article via my clinic’s social media outlets? (giving you proper credit of course!)

    • Michael Curtis

      Thanks Rachel! You are welcome to share any of my content. Anyone is welcome to share. One thing I’d request is that you don’t just copy and paste the whole article – this can actually penalize my website with google. But you can write a little synopsis or use the first paragraph of the article and link to the rest of it on my site. What’s your clinic’s name?