I’ve both had plantar fasciitis myself, and I’ve regularly treated patients with the condition over the last ten years. I’ve seen a lot of confusing information presented regarding how to treat plantar fasciitis. Most commonly recommended treatments are ineffective, can be costly, and more often than not fail to provide heel pain sufferers with permanent relief.
Effective 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.
This is Part 3 in a three-part series on Plantar Fasciitis.
- Part 1: The Real Cause of Plantar Fasciitis
- Part 2: Why Common Treatments Don’t Work
- Part 3: Treatment Guide for Plantar Fasciitis
Part 1 discussed the factors I believe cause plantar fasciitis. I highly recommended taking a look at that article to better understand the rationale for the treatment approach outlined below.
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 plantar fascia
- It is not caused by running, or spending a lot of time on your feet
Things To Know About Heel Pain
Plantar 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 inactivity.
The 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 length of the foot and insert on the heel in the same area as the plantar fascia. These structures combined provide support to the foot and aid in shock absorption.
Plantar fasciitis has been associated with degenerative changes of these tissues near their attachment to the heel. Part 1 explained why these changes occur, but to briefly summarize:
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 the foot
- 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
Effective treatment of plantar fasciitis means replacing abnormal stress on foot with healthy stress that will promote tissue regeneration. This approach involves:
- Reducing Compression
- Increasing Circulation
- Increasing Flexibility
- Increasing Foot Strength
Plantar Fasciitis Treatment Guide
Below is an outline of the approach I use to plantar heel pain. The steps involved are:
- Change the way you stand to take pressure off your heel
- Increase barefoot activity
- Increase ankle flexibility
- Start wearing flat, less supportive shoes
- Strengthen the muscles in the foot and leg
- Stretch and massage the legs and feet
Step 1: Shift Weight Off Your Heels
In standing, shift weight forward to balance weight evenly between the front (ball) of the foot and heel. The first thing this does is relieves compression under the heel. Shifting weight forward potentially increases circulation to the heel. Injured tissue needs a good blood supply to repair itself.
Taking 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 is one of the key components of treating the condition.
When walking, concentrate on pushing off with the back foot instead of reaching out and landing with a hard heel strike on the front leg.
Step 2: Increase Barefoot Activity
Many of us spend too much 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.
Always walking in shoes, or spending too much time on hard, flat surfaces prevents these actions of the foot. Try to walk barefoot as much as possible, and on as many different surfaces as you can. Grass, dirt, sand etc. Walking barefoot also helps you learn to land softer, with a less impact when your foot strikes the ground.
Step 3: Increase Ankle Flexibility
A lack 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.
There are several ways to stretch your calves, but my favorite is simply walking up a steep hill. It’s simple and effective. The ancient Greek physician Hippocrates said, “walking is man’s best medicine”.
In terms of specific calf stretching exercises, there are two main exercises to focus on:
- Runner’s Stretch
- Soleus Stretch
Lean against a wall with the leg you want to stretch behind you. Keeping your heel down and you back knee straight, lean forward until a stretch is felt in the calf of the leg in back of you.
A 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.
These exercises look similar but both are important because they target different muscle groups. There are two keys to making these ankle stretching exercises effective:
- Keep the feet pointed straight ahead
- Don’t let the arch collapse
Step 4: Change Shoes
I’d like to dispel the myth that the foot needs support 24/7. I suspect shoes are the biggest culprit behind plantar fasciitis. Not because they don’t support the foot, but rather because they often give too much support!
Muscles 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.
Understand that there is very little scientific evidence showing the stability features in shoes help prevent or treat injuries. The following footwear recommendations go against the conventional belief that plantar fasciitis needs to be treated with highly supportive shoes.
The bottom line: just say no to stability and motion control shoes.
Features to look for:
- Flexible Sole
- Little or No Support
- Minimal Toe Spring
- Flat or Low Heel Height
The first priority is finding a shoe that is capable of bending along the entire length of the sole. This can be tested by bending and twisting the shoe. If the sole is stiff or the shoe only bends in certain spots then look for something different.
A sole that is too stiff is going to force the foot to conform to the motion of the shoe. It should be the other way around. The shoe should match the motion of the foot. This is only going to happen in a flexible shoe.
Minimal Toe Spring
Take a 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.
Avoid shoes that curve up sharply in the front. Running shoes often have large toe springs. Minimalist running shoes are somewhat better because that front of the shoe flattens out easier, but these may still contribute to the problem if worn for extended periods during the day.
No Built-In Arch Support
A 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 foot.
Arch supports are 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!
The arch of the foot provides both support as well as shock absorption. Using artificial support changes 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 the position of the built-in arch of the shoe adds compressive stress to the heel.
Low Heel Height
Wearing 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 you to lean backward to stay balanced which then can place more weight on the heels. Look for relatively flat shoes, with little to no difference in height from the heel to the forefoot.
Making 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 my find the transition to be a little easier.
Step 5: Strengthen
Since plantar fasciitis is associated with degeneration of the tissue in the foot, it makes sense that strengthening those tissues should be a priority.
To start, focus on getting the muscles in the underside of the foot some use. This will naturally happen by increasing barefoot activity, but including some of the following exercises may speed up the process:
Foot Strengthening Exercises
- 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.
General Leg Strengthening
- Calf Raises: Raise up as high as you can on the toes and then lower down slowly. Focusing on pushing through the big toe on the way up
- Toe Walking: Stand on your toes and walk 10-15 steps at a time
- Squats: Body 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
- Hip Strengthening: Hip strengthening exercises can improve the mechanics of the foot
Step 6: Stretch
There 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.
Downward Dog (Advanced)
Stretching 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–something they are prevented from doing while inside a shoe.
Many people find these helpful for making the first few steps in the morning less painful.
Plantar Fascia Stretch:
Toe Extensor Stretch:
Here is a video that shoes a fairly comprehensive stretching routine:
Massaging the calves and underside of the foot can promote circulation and flexibility. The two most regularly 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)
It’s 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 don’t get hung up on trying to find the “perfect” shoe. Most importantly find something that’s comfortable, and don’t be afraid of going with less support.
If an 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 gradually resuming regular activity.
When the pain has been going on for months (as is often the case with plantar fasciitis), I’ve found activity often works better than rest. Overcoming the fear that activity will make the condition is an important part of the recovery.
I hope everyone enjoyed this series and found it informative. If you have any questions or feedback, please let me know in the comments below!