The Ultimate Plantar Fasciitis Treatment Guide

Heel Pain

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 will outline 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 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 inflammation
  • 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

What You Need 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 is associated with degenerative changes of these tissues near their attachment to the heel, and not inflammation. 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

  1. Change the way you stand to take pressure off your heel
  2. Increase barefoot activity
  3. Increase ankle flexibility
  4. Start wearing flat, less supportive shoes
  5. Strengthen the muscles in the foot and leg
  6. Stretch and massage the legs and feet

Step 1: Shift Weight Off Your Heels

When you stand, shift your weight forward to balance your weight evenly between the front (ball) of your foot and your heel. The first thing this does is relieves compression under the heel. By shifting your weight forward you increase 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 you walk, 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 you’re 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.

barefootwalking

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

Runner’s 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.

gastrocstretch

Soleus Stretch

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.

soleusstretch

These exercises look similar but both are important because they target different muscle groups. There are two keys to making these ankle stretching exercises work:

  • Keep you feet pointed straight ahead
  • Don’t let your 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 no 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

Flexible Sole

The first priority is finding a shoe that is capable of bending along the entire length of the sole. You can test this out 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 your foot to conform to the motion of the shoe. It should be the other way around. The shoe should match the motion of your 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 limits 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 still can cause issue if you’re standing in them all day.

toespringdemoshoe

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.

archloadArch 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 limits 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.

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 places 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. If you’re used to being in heavily structured, supportive shoes, start slow! Give your body time to adjust. If you’re used to walking barefoot at home the transition will be a little easier.

Step 5: Strengthen

Since plantar fasciitis is associated with degeneration (a.k.a. weakness) of the tissue in the foot, it makes sense that strengthening those tissues should be a priority.

To start, you want to focus on getting the muscles in the underside of the foot some use. This will naturally happen if you’re increasing your barefoot activity, but including some of the following exercises can speed up the process:

Foot Strengthening Exercises

  • Short Foot Exercise: Try to form and hold an arch in your 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 your toes, passing a pen back and for between your feet, picking up marbles, or stacking plastic cups. Use your imagination!
  • Towel Curl: Spread a towel out on the floor in front of you and try to bunch it up by pulling it in with your 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 your toes and then lower down slowly. Focusing on pushing through your big toe as you go 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

Hamstring Stretches:

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.

Towel Stretch

Towel Hamstring Stretch

Standing Stretch

Hamstring Rotation

Downward Dog (Advanced)

DownDog

Foot Stretches:

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:

Plantar Fascia Stretch

Toe Extensor Stretch:

Toe Extensor Stretch

Here is a video that shoes a fairly comprehensive stretching routine:

Massage

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)

Final Notes

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), activity often works better than rest. Overcoming the fear that you are making the condition worse by being active 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!

Comments

    • James Speck says

      I’ve heard good things about Altra shoes. All their shoes are zero-drop with wide toe boxes, so that’s good. Recently though I’ve seen they started making “stability” shoes with firmer midsoles and a removable wedge that their website says is to control pronation. This seems to go against the concept of a minimalist shoe. Maybe they want to capture a larger market, but this just promotes the flawed idea that pronation is something that needs to be controlled by a shoe.

  1. Sean says

    I figured out most of this the hard way. I agree with everything you say, but perhaps it is worth pointing out that in the acute phase of plantar fasciitis it may not be easy always to walk barefoot. I refused sole inserts and made use of MBT shoes which took the weight off the heel and stretched the plantar fascia. Later I used five fingers which are good, but ill-adapted to cold weather and you have to wash them all the time. In the office I go barefoot (i.e. in socks) systematically but it is not practical for shopping, travelling and so on. I also drove barefoot, without which it was near to impossible (using a manual vehicle). So all great suggestions. In addition to tight hamstrings and calf muscles, I have the impression that tightness in the inner thighs contributed to the etiology, by taking weight off the outside of the foot and rotating the ankle inwards. My impression is that the outside of the foot needs to bear the weight of the body in addition to heel and toes in order for the foot muscles to maintain good tone. I would also tend to sympathize with John Sarno’s interpretation of the psychosomatic origin of the condition and I think this is an important complement to stretching the muscles mechanically if the later is to yield sustained improvement in range of motion.

  2. Sharon Bridgeman says

    Hi James,
    Fascinating read …thank you.
    I have had the debilitating pain, and as an acupuncturist treated others.

    Recently a naturopath suggested silica as a solution …but don’t know how effective it is.

    Two things I have found fundamental to treatment are:
    1. Massage intensely under the arch preferably daily, especially after a period of rest and prior to weight bearing. The massage should be tear jerking, within days the pain will resolve and usually within a fortnight all but resolved. This was the best advise I received from a colleague, when I had my second bout of plantar fasciitis, because it brought relief and I suspect broke up the congestion which I think underlines the pain.

    2. Also I typically find an imbalance in the pelvis, with a long leg on the same side as the plantar/heel pain. I think this needs to be addressed and have wondered if the long leg means more gravity stress to the effected area?!

    Another comment is about misaligned tendons, starting around the ankle following dis-lodgement following sprained and twisted ankles. In particular the peroneus longus and peroneus brevis tendons can ride up and sit across the medial malleous and are required to be flicked back into place below the ankle bone.

    When the tendons are misaligned it is possible that there will be similar issues around the knee and back up into the pelvis. The lumbars may also be stressed and bulging, causing or reflecting the pelvic twist. It certainly can be a chicken and egg senario, or circular where one misalignment generators compensations throughout.

    Finally, there is no reason why there need be only one cause for the symptoms.

    Regards
    Sharon

    • Lori Rizzuto says

      I am a Bowenwork practitioner and within this particular body of work we have many procedures for plantar fasciitis and balancing the pelvis is key to it being resolved.

      • P. Warring, PT says

        Deep trigger point work in the piriformis/gluteals on the same side as the heel pain was very effective with my own heel pain (worked on piriformis of heel pain side) and relieved heel pain that I had been suffering with for months. Used a lacrosse ball in supine to target the trigger points. Also worked on calves.

  3. Nestor says

    Had plantar fasciitis for a while, and barefoot running cured me pretty quickly. Running in vibrams on the other hand gave me insertional tendinitis, but I cured that by going back to my nikes and warming up my calves before hand. The thing about these injuries is that they’re relatively easy to ignore and power through for months before you realize there’s a problem. So I’m trying to be better about not ignoring my body.

  4. amy says

    Thank you so much. My husband is a Chef and works 12 hours a day always standing. He has been diagnosed with this and the doctor recommended orthotics so this is very helpful. Do you know of any slip resistant shoes that you can recommend? He has worn Birkenstock clogs for years and looks crippled when he wakes up. I’d really appreciate any shoe ideas.

  5. Jane Jones, AP, LMT says

    Thank you for your clear and detailed explanation! I am a long-time Vivobarefoot wearer, impressed with how they have increased the flexibility of my feet…..and not paid to say so!

  6. Miriam Grieve says

    The only thing for me that worked when I had this problem was on a you tube video I watched.
    While just relaxing I’d lift my foot and push my big toe as far back as possible. I knew it was working as I felt the tendon stretching and it was such a relief!
    I now have other foot problems ( not from that lol ) my feet burn when I walk and my calves ache. It all started when I had graves disease which affects the muscles. So I’m back to calf stretches, and leg exercises, hence the research. It was a relief to read that barefoot was so good because it seems so natural to me. I’ve spent a small fortune on “good” shoes in the past couple of years and still my feet and legs hurt. Doctors just look at you silly as if to say big deal but it’s a huge thing when being on your feet is such a pain.
    Thanks for the info, awesome!!!

Leave a Reply

Your email address will not be published. Required fields are marked *