Plantar fasciitis (fashy-EYE-tis) is a painful inflammation of the foot that affects 10 to 15% of the population. That means that roughly 1 in 10 people will experience it over the course of their lifetime, particularly if you are between the ages of 40 and 60. In fact, it is one of the top reasons we go to the doctor with foot or heel pain.
The Basics of Plantar Fasciitis
Plantar fasciitis is an inflammation of a thick band of fibrous tissue that runs lengthwise down the bottom of your foot, connecting your heel bone to your toes. The band – the plantar fascia – supports the arch of your foot. When the band is overstretched, you can strain or cause repeated microscopic tears occur on the surface of the band. Inflammation and pain follow. Either of these will lead to the foot and heel pain that is common with the condition.
As Doctor of Podiatric Medicine (DPM) William R. Olson says, “Think of the arch of the foot as a hunting bow and the plantar fascia as the bow string. If you put pressure on the top of the bow or arch, it will tighten the plantar fascia and cause it to stretch.”
Of course, the bow is built to bear weight and stretch under use. But if the tension on the bowstring becomes too great or the wood is weak or misshapen, the bowstring runs the risk snapping. The same can be said of your plantar fascia. If you increase the load on your plantar fascia too quickly or you have anatomical biomechanical irregularities such as flat feet or overpronation, you can develop tiny tears on the plantar fascia.
When you have plantar fasciitis, the most common symptom is pain and stiffness on the bottom of your heel. Pain can:
- Be dull or sharp;
- Feel like a deep ache or give off a burning sensation;
- Develop slowly over time;
- Or come on suddenly, particularly after intense activities.
Pain often is notably worse in the morning, and then lessens as the day continues and your foot and arch limber up. However, you will also feel pain:
- After prolonged periods of standing or sitting;
- When going up stairs;
- After intense activities like walking, running, or jumping.
Note: You may think you have plantar fasciitis if your arch hurts, but you probably don’t. The pain from plantar fasciitis is in your heel and not your arch. A sore arch can be a symptom of overpronation or not enough support in your shoes.
Causes and Risk Factors
The plantar fascia connects to the heel, spans across the arch, and attaches to the base of the toes underneath the metatarsal heads (toe bone). If you lift up your toes on your weight bearing foot, you are pulling on your plantar fascia.
Scientists from the University of Kentucky have described this movement as similar to the windlass mechanism in sailing. To pull in or release the sail, you use a winch to wind or unwind the rope wound around a drum. This is the windlass mechanism. In the foot, the windlass refers to when the plantar fascia is wound around the metatarsal head. In this sense, flexing your toes towards your shin is analogous to using the winch to wind the rope. The plantar fascia is the rope, and the metatarsal head is the drum. As you pull your toes toward your knee, you are winding the plantar fasciia on your metatarsal heads.
When there is a problem with this function, inflammation and irritation of the plantar fascia can occur. But what can interfere with this mechanism? We have identified three main causal groups: anatomical; biomechanical, and environmental.
Anatomical Risk Factors
Anatomical risk factors have to do with the actual structure of the foot or body. Certain anatomical conditions put you at higher risk for plantar fasciitis. These include:
Flat feet (pes planus)
- When you have flat feet, the entire bottom of your foot (the sole) touches the ground when you’re standing. Flat feet often occur when your arches don’t develop properly during childhood or if you overpronate. They can also develop as you age or after a foot injury. For women, pregnancy can cause flat feet.
- Low or collapsed arches can stretch the plantar fascia beyond its normal limits.
High arches (pes cavus)
- With high arches you have the tendency to underpronate (more commonly known as supination). As a supinator, your arches don't collapse enough to absorb the shock of walking/running. This puts stress on your feet and can lead to plantar fasciitis.
- High arches also lack the mobility required to help absorb the force of your foot hitting the ground. If you have high arches and heel strike (or the heel lands first when you walk or run), you will have increased load on the plantar fascia.
- Obesity causes well-documented changes in one's gait, including increased pronation. Changes in how your foot rolls when landing can put added tension and force on the plantar fascia.
- As Patrick DeHeer, DPM writes, "evidenced-based medicine supports the intuition that there is a direct correlation between obesity and plantar fasciitis."
- This occurs when the fat pads on the ball or heel of the foot thin significantly. Without fat pads, the body's weight shifts onto these bones without any protection. Weight is unevenly distributed across the foot, causing the plantar fascia to do more work than it is meant for.
Leg length discrepancy
- When one of your limbs is slightly longer than the other, your weight distribution is thrown off. Physicians from the University of Florida have found a strong correlation between a longer limb and plantar fasciitis pain.
Shortened Achilles tendon
- A shortened Achilles tendon will pull up on the heel bone (calcaneous), which, in turn, pulls on the plantar fascia. This extra pressure can lead to plantar fasciitis.
Any one of these conditions can increase your risk for developing plantar fasciitis.
Biomechanical Risk Factors
While anatomical risk factors are related to structure, biomechanical issues result from how that structure moves and functions. Many biomechanical issues can also lead to plantar fasciitis:
- When your foot overpronates at the heel (excessive subtalar joint pronation), the rolling-out motion over stresses the plantar fascia.
Limited ankle mobility
- If you have limited mobility in the ankle, particularly the inability to flex the toes back towards the shin (limited ankle dorsiflexion or equinus), you are probably suffering from incredibly tight calf muscles. Scientists from the University of Rochester have linked inflexibility in the calf muscles to added strain on the plantar fascia and the development of plantar fasciitis. For stretching the calf muscles, see our advice on stretching and strengthening below.
- Weak calf muscles (plantar flexor muscles) can contribute to the development of plantar fasciitis. Weak muscles will affect how your foot bears your body weight. Your calves need to be both strong and flexible.
- A weak "foot core" (intrinsic muscles of the foot) can lead to instability and injury. While we often focus on the big extrinsic muscles that support the ankle and foot (these generate most of the foot's motion), there are actually 11 small intrinsic muscles located entirely in the foot. These stabilize our foot during strike and push-off. They absorb load and store energy mid-stance. Most importantly, these muscles support the arch of the foot.
- Researchers call these muscles the "foot core." If these muscles are weak, particularly those supporting the arch, the plantar fascia will take up the full load.
- Scientists recommend an exercise called "foot doming." You start with your foot in a neutral position, flat on the floor. Then, shorten the foot by contracting the "foot core" muscles to arch the sole of the foot. Make sure to keep the toes flat on the ground. Start sitting down. As you progress, try standing, on one foot, then hopping.
Environmental Risk Factors
Environmental risk factors are those that are extrinsic or external to your anatomical and biomechanical makeup. These include activities, lifestyle, and footwear. Here are some of the common environmental factors related to plantar fasciitis:
- Swedish researchers publishing in the journal Sports Medicine define traumatic injuries as "sudden, damaging events such as strains and lacerations." Trauma can also refer to intense movements such as running or jumping, which can tear or pull a muscle or even lead to plantar fasciitis.
- While rare, complete plantar fascia ruptures can occur, often when playing sports that require quick movements like tennis or basketball. As Dr. William O. Roberts writes, "Plantar fascia rupture is a relatively uncommon injury and the onset is often associated with a vigorous foot plant. In three words, it really hurts."
- Luckily, most tears or ruptures don't need surgical treatment. They require the same recovery steps as normal plantar fasciitis, outlined below.
- This fancy sports medicine word for being out of shape is a common culprit of plantar fasciitis. When you stop exercising, your lleg and foot muscles lose tone and endurance. If you overdo your exercise comeback, your muscles won't be able to help your bones and feet distribute weight evenly. This stress can overload the foot, particularly the arch.
- If you are trying to get back into shape after a sedentary period, remember to start slow. Mix non-impact sports like biking and swimming with higher impact activities such as running or cross fit.
Barefoot or minimalist running
- If you transition from shod to barefoot or minimalist running too quickly, you can develop plantar fasciitis. It is the most commonly cited injury associated with minimalist running. Think of the extra load the plantar fascia has to bear without the help of an insole or running shoe.
- If you want to transition from shod to minimalist running, does so gradually. This will allow the foot – and particularly the plantar fascia – to adjust to your new stride and the extra load.
- The incorrect shoes can often lead to the development of plantar fasciitis. If your shoes are worn out, don't fit properly, are poorly cushioned, or don't provide arch support, then you are, in essence, running or walking around barefoot.
- If you don't stretch enough and have resulting tight calf muscles this can cause plantar fasciitis. Brian Fullem, DPM, describes the connection as the following: "If there is not enough motion in the ankle joint due to a lack of flexibility [in the calf muscles], then there will be extra strain on the fascia."
Who is Most Affected by Plantar Fasciitis?
If we look at the three categories of risk factors (anatomical, biomechanical, and environmental) that lead to plantar fasciitis, we can identify certain groups of people who are more likely to develop the condition:
- Runners and ballet dancers;
- People who are between the ages of 40 and 60;
- People who are at least a little overweight;
- People with sudden weight gain;
- People who wear shoes with inadequate support;
- People who have flat feet or high arches;
People who overpronate.
It may seem like everyone is at risk for plantar fasciitis. But if you take care of your feet by buying the correct footwear and insoles and maintain a healthy lifestyle, you can avoid this common ailment.
Preventing Plantar Fasciitis
If you could see inside your foot, you would see a shelf on the inside of your heel bone, towards the rear of your arch. This is the “calcaneal shelf.” The plantar fascia connects to the bone just below the shelf. Providing structure to the heel bone will stabilize the foot, spread the fascia's shock-absorbing capacities evenly, and prevent plantar fasciitis.
Support of the calcaneal shelf is the best way to prevent plantar fasciitis.
- An orthotic insole provides support under the calcaneal shelf and controls pronation.
- Spreading the support forward into your arch provides an even weight distribution over the entire foot.
- Firm support will provide needed structure to the heel, arch, and fascia. The best insole for plantar fasciitis is firm, with a spring-like feeling. An accurate fit is necessary to ensure that the insole is completely comfortable.
Plantar Fasciitis - Treatments
But if you have already developed plantar fasciitis, any veteran sufferer will know that a 3-prong approach works best in treating the condition.
Stretch and strengthen the ankle, foot, and calf muscles.
Protect the plantar fascia from further trauma.
Step 1: Reduce Inflammation and Relieve PainThe inflammation and pain caused by plantar fasciitis can be excruciating. Podiatrists and orthopedists recommend employing various methods to combat the problem.
Ice several times a day for 15 minutes each time. We recommend the following methods:
- Fill a paper cup with water and freeze it. When ready, peel off the top part of the paper and rub the cup along the arch and heel.
- Rest the arch and heel on an ice pack.
- Frozen vegetables such as peas or corn work well as they contour to the heel and arch.
- You can also place your foot in contrast baths – going back and forth between hot and cold water. You should always end with cold water as heat may aggravate the pain. Heat makes your blood vessels enlarge and cold causes them to shrink. When you switch between hot and cold, your blood vessels change size. This means your body will pump more blood to and from your feet. Changes in blood movement can help reduce inflammation and swelling. It can also help improve overall range of motion in the area.
Non-Steroidal Pain Relievers (NSAIDS)
Take over-the-counter pain relievers.
- Ibuprofen (Advil) reduces inflammation and pain. This acts quickly and doesn't stay in the body too long.
- Naproxen (Aleve) also reduces inflammation and pain. This is a longer-acting drug than ibuprofen, and thus you don't have to take as many for the same results.
- Acetaminophen (Tylenol) is not the best choice for treating plantar fasciitis as it doesn't affect inflammation.
This splint stretches your calf muscles and maintains your foot (and plantar fascia) in an extended position with your toes pointed up while you sleep.
- Keeping your foot in this position overnight applies an extended gentle stretch to the plantar fascia and Achilles tendon (see Stretching section below).
- It also maintains the plantar fascia, Achilles tendon, and calf muscles at their functional lengths. Normally, your toes curl and your foot relaxes while you sleep (plantarflexion position). This shortens the plantar fascia. When you wake up, your foot automatically straightens out, causing the plantar to stretch suddenly and bring on pain (post-static dyskinesia). By keeping the foot straight overnight, the splint decreases the stress sudden movement places on the plantar fascia.
- In the beginning, it is helpful to wear a night splint every night for up to two months. If your symptoms go away, gradually reduce the nights you wear the splint.
Step 2: Stretch and Strengthen
Think of the plantar fascia as a big rubber band that stretches from the heel to the toe, supporting the arch of your foot. Both it – and the other rubber bands it connects to – need to be flexible to avoid snapping.
The tendons and muscles that connect to the fascia also need to be flexible. The Achilles tendon connects the fascia to the calf muscles (gastrocnemius and soleus). If any of these are tight, they will pull on the plantar fascia. In fact, almost 80% of people who suffer from plantar fasciitis have tight Achilles tendons or “heel cords.”
The following stretches will help loosen the fascia, tendons, and muscles that all contribute to plantar fasciitis. We recommend that you perform these exercises 2 to 4 times per day.
Fascia stretch – From a seated position, stretch the unaffected leg straight out in front of you. Bend the other leg and put your foot against the inside of your extended knee. Pull your toes back towards your shin bone for 10 to 15 seconds. You should feel a stretch in your arch. Repeat on the other side. If you are flexible enough, stretch both legs straight out in front of you with your heels on the floor. With your toes pointing straight up, grab the toes and pull them back towards the shin bones.
Achilles tendon stretch – Stand on a step. Relax your calf muscles, and slowly let your heels down over the edge of the step for 10 to 15 seconds. You should feel the stretch along the Achilles tendon.
Calf muscle stretch – Stand with one foot about a foot in front of the other. Point the toes of the back foot towards the heel of the front and lean towards a wall. Keep your back leg straight and bend your front one, keeping both heels firmly planted on the floor. Hold for 10 to 15 seconds. Repeat on the other side.
As Joy Rowland, DPM, says: “Stretching is a big part of treatment for plantar fasciitis. We have to allow that ligament to stretch rather than pull.”
Step 3: Protect the Plantar Fascia
Because biomechanical irregularities such as flat feet, high arches, and overpronation can lead to plantar fasciitis, correcting any underlying foot problems and supporting the arch are key to avoiding the pain caused by plantar fasciitis. Strong arch support is critical to both recovery and prevention. Scientific studies have found that insoles – whether over-the-counter or custom-made – reduce pain levels related to plantar fasciitis.
Insoles can both help treat and prevent the development of plantar fasciitis:
Treat – Insoles with strong arch support will reduce the weight bearing load of the in the plantar fascia, allowing it to heal.
Prevent – Insoles that properly support the arch lengthwise prevent overpronation, which can lead to plantar fasciitis.
Not all insoles are made the same. While your foot may be screaming for comfort, what it really needs is structural support. Soft, cushioned insoles will provide temporary relief. But they won't correct the overpronation that leads to plantar fasciitis.
When to Seek Medical Help for Plantar Fasciitis
If you are experiencing any of the symptoms outlined above and they don't go away after several weeks of home remedies, it is probably smart to go see a podiatrist or orthopedist. Remember, the faster you accurately diagnosis the pain and begin a treatment regimen, the sooner you can get back to your normal lifestyle.
An informed physician will conduct a thorough physical exam, may take an X-Ray, and will probably give you a non-invasive treatment plan similar to what we have outlined above. They might proscribe an orthotic or ask to you purchase over-the-counter models.
95% of people with plantar fasciitis are able to recover within 6 months of onset with the use of home treatments. While half a year may seem like a long time, it's nothing when compared to the recovery time of more invasive treatment strategies like surgery.
Sometimes, however, plantar fasciitis will not go away with home remedies. More aggressive measures such as steroid injections, extra-corporeal shock wave therapy (ESWT), and even surgery are only considered if you have been suffering from plantar fasciitis for more than 6-12 months and none of the normal interventions have improved symptoms.
Preparing for Your Appointment
Before your appointment, it will be helpful to write down a list of your symptoms and when they started; any personal information such as activity level and type; all the medications and supplements you take; and questions to ask your doctor. In addition, it's helpful to bring in your running shoes, or the shoes you wear to work (if you stand all day), so your physician can assess if they are the correct model for your feet and lifestyle.
Be prepared for the following questions from your physician:
- At what time of day do your symptoms most often occur?
- What footwear do you usually wear?
- Do you run or participate in other sports that involve running? If so, how often/long?
- Are you on your feet during your job? Does your job require intense physical exertion?
- Have you had previous foot injuries, and if so when, what type, and for how long?
- Do certain activities or remedies improve your pain? Worsen it?
Here are some questions you may want to ask your physician:
- What's likely causing my symptoms?
- What are other possible causes?
- Do I need extra tests, and if, so, which ones?
- Is this a temporary or chronic condition?
- What's the best course of action?
- Are there any alternative approaches towards treatment?
- Do I need to modify my activities or follow any restrictions?
Because podiatrists, orthopedists, and sports medicine physicians are highly trained in treating plantar fasciitis, we recommend skipping your general practitioner and going straight to a specialist. Most people will benefit from seeing a podiatrist, who specializes in all types of foot injuries. However, if you're an athlete, a sports medicine specialist is probably the best choice, as they will also look at your overall biomechanics and your training plan. Moreover, if you are older and have degenerative bone or soft tissue conditions, an orthopedist – someone who specializes in the entire skeletal system, including its associated muscles, joints and ligaments – would be a better choice.
Tests and Diagnoses
In addition to asking you the questions outlined above, your doctor will perform a physical exam of your feet. This should always include watching you stand, walk, and hop.
Usually this is enough to diagnosis the condition. However, if your physician suspects a stress fracture, bone cyst, or other bone-related issues in the foot or ankle, she might take an X-ray. While X-rays don't show ligaments clearly – and thus won't show if you have plantar fasciitis – they will rule out any bone-related injuries that might be causing the same pain. Depending on your demographic group and lifestyle, your doctor might perform an X-ray preemptively. If you are a 23-year-old woman with a history of an eating disorder who is training for a marathon, your physician will want to make sure you aren't experiencing something more serious.
For the rare few, your physician might ask for other tests including MRIs, blood tests, bone scans, and vascular testing. The last test will analyze blood flow to the foot and lower leg. These tests are rare, and usually occur only when the patient has followed several months of rigorous treatment without improvements.
If six months have passed and nonsurgical treatment isn’t helping – and plantar fasciitis is affecting your daily activities – your doctor may recommend surgery. If you are one of the few that requires surgical intervention, the primary surgery is called plantar fascia release. This involves cutting part of your plantar fascia ligament to release tension and relieve inflammation.
During the plantar fascia release surgery, your doctor will numb the area with a local anesthetic. Your surgery can either be performed endoscopically – with instruments inserted via a small incision – or through a traditional open surgery. Make sure you talk to your physician about all the options surrounding your plantar fascia release.
Following surgery, you will begin a gradual strengthening and flexibility program. Expect that you won’t be allowed to run or jump for at least 3 months post surgery to give your foot time to fully recover. 75% of people who have plantar fascia release surgery have less pain after the surgery than they did before.
If you’re dealing with plantar fasciitis on top of another reason for heel pain – a bone spur for example – you may want to think about having an additional surgery at the time of the plantar fascia release.
One option would be to remove the heel spur. Another surgical option is the gastrocnemius recession, or the surgical lengthening of the calf muscles (gastrocnemius). Tight calf muscles put extra stress on the plantar fascia. If you have gone through a year of calf stretches and you still have trouble flexing your foot, talk to your doctor about this surgical option.
Plantar Fasciitis - Painful, but Curable and Preventable
If you've had plantar fasciitis in the past, you know how big of a drag it can be. But once your symptoms go away, you can go back to your normal lifestyle. Here are some tips to keep in mind, so that the injury doesn't reoccur.
- Take care of your feet. Buy well-fitting shoes with plenty of support and stability. Supplement their existing arch support with orthotics or over-the-counter insoles.
- Maintain flexibility. Even if you're not an athlete, you should stretch your calves and Achilles tendon daily.
- Maintain a healthy weight. If weight was a factor in the development of plantar fasciitis, this is extra important.
- Exercise regularly. Make sure you find time in your busy schedule to exercise. But remember, always start a new plan gradually and wear correct gear. If you tend to only run, try mixing-up your workout routine. Add a couple days of swimming or biking to offset the wear and tear your feet experience while hitting the pavement.
Plantar fasciitis can be painful – and annoying – but with the proper treatment and the implementation of preventative measures, you won't have to experience it again.