What Is The Plantar Fascia?

At the bottom of each of your feet extends a thick band of connective tissue from your heel bone (calcaneus) to the base of each of your toes. It bridges the arch of your foot similar to a string on a bow. It acts as a support for your arches mainly while walking, keeping your arches from collapsing and adding some stability when you push off the ground.

What it’s not supposed to do, is to provide support and take excess strain during propulsive activities like running and jumping. The tissue is not particularly strong or adept at taking that kind of pounding and can become overly stretched, potentially inflamed, and lead to the familiar pain in your heel. Those involved in basketball, soccer, gymnastics, long-distance running, ballet, and tennis are especially susceptible to spawning plantar fasciitis.

Plantar Fasciitis

Plantar fasciitis, aka “Runner’s Heel”, is an overuse injury that affects the plantar fascia and it’s said that one in 10 people will experience it in their life. But what does the name imply exactly? If we reduce the term, we glean that it’s an inflammatory condition specific to the band on the sole of your foot (-itis means inflammation; fascia is Latin for “band”; plantar relates to the sole of the foot). Before we limp our way into the thick of things, let’s clarify a few noteworthy technicalities.

Technicalities

Don’t get too hell-bent on this next portion, but it’s worth noting. The fasciitis piece is a holdover from years ago when we believed it to be an inflammatory response, but studies have shown no presence of inflammatory cells in most cases. There may be inflammation when the tissue is initially aggravated, but it quickly subsides and is not an underlying cause or concern. In fact, numerous studies have found that so little inflammation occurs that some researchers have called to dismiss the term altogether.

The plantar fasciae (plural), instead, tend to demonstrate signs of collagen decay and disorganization in the fiber matrix. All that really indicates is too much damage from constant micro-trauma to your poor fascia. A more accurate term would be plantar fasciopathy (-opathy means disease) or fasciosis (-osis means condition). Fasciosis is a nice blanket expression.

While we’re at it, when referring to this condition, many label it as “fascia”. But is it more specifically an aponeurosis? Fasciae, tendons, and aponeuroses can sometimes be used interchangeably, but I’m a stickler for correct terminology and pronunciations. For example, ASUS is pronounced as “ey-soos”, and a Mac computer IS a PC (personal computer). Damn you marketing for trying to ruin the English language once more and confuse us all.

Fascia

Fascia is a general term for a densely woven (communication) system, mostly made of collagen, covering and penetrating every muscle, bone, nerve, artery, vein, organ, and spinal cord. It envelops all these individual structures like a sheet of cling wrap. It’s important to note that by today’s medical standards and classifications (2020) we deem fascia as a network all its own and the tissues henceforth fall under its holy name. Newer research into fascia is proving it’s far more important and integral to your whole body than we ever thought. It actually used to be thrown away as waste during autopsy. Fascia is more commonly viewed as a tight spider web or sweater throughout your body. Ever wonder why all the water in your body doesn’t just pool at your feet? Tada! Fascia.

Aponeurosis

Aponeuroses are tough, thick, flat, or ribbon-shaped tendons essentially. They are histologically (as if viewed under a microscope) similar in structure to tendons. Fascia is band-like and is similar in that way to aponeuroses, and with aponeuroses technically being a subset of fascia now...things can get murky. Herein lies the confusion for many. There are a few key differences, though. They can provide attachment points for surrounding muscles, for one. Aponeuroses are only sparingly supplied with blood vessels and their fibers align with its direction of pull, like tendons. In its classical sense, fascia has up to 6x more nerve endings than in your muscles themselves and it’s structurally more sporadic. The plantar aponeurosis is actually a deep fascia, commonly referred to as an aponeurotic fascia.

Tendons

Tendons are white, pearly, and glisten-y, fibrous tissues just like aponeuroses, with a few key distinctions. First, tendons are frequently cords or rope-like. Second, they have incredibly high tensile strength (resistance to pulling apart). So much so that during high-velocity movements such as a jump or counter-jump, almost all of the force is applied to it with minimal movement in the muscles of the calf.

That’s why some coaches will admit (jokingly?) to recruiting athletes with little calves and long Achilles. When a muscle contracts, it pulls on the tendon which pulls the bone where the muscle is inserted causing your body to create desired motion.

They, like aponeuroses, lack the type of extreme elasticity you’d expect from something like your skin but are elastic in nature (viscoelastic actually). They are very sparsely supplied with blood vessels and have these cool Golgi organs that wrap around muscle fibers near the tendinous junctions to help alert and defend you against overstretching.

But wait, there’s...more?!

You might be saying, wait a second. I’ll give way to you calling it aponeurosis, or fascia (or whatever), but if it connects two bones, shouldn’t it be called a ligament? Ligaments are practically the same thing as tendons only they connect bone to bone instead of muscle to bone. How astute you are. Well…yeah. Technically it’s also a ligament. Sweet baby Jesus, we just can’t win, can we? Let’s just call it the plantar aponeurotic fascia ligament. Screw it, I guess we can just call it fascia after all since it’s all now a part of that system, sigh.

Heel Spurs

While related, plantar fasciosis is not the same as a bone spur (osteophyte) on the heel. Heel spurs develop as a bony protuberance because of all the added stress the bone receives from the tightness and pulling of the plantar fascia tissue upon it. Calcium is deposited and pooled in response to physical stress, sending calcium to the area to help harden and heal it. So you could say that a heel spur could be an effect of the plantar fasciosis, but not the cause. You may not even know that you have a heel spur because they are often not causes of pain, but you’re likely to still exhibit some swelling or some minor pain due to rubbing of surrounding tissue on the spur or continued pulling on the bone itself.

Symptoms

Plantar fasciosis is most common in runners, people who are overweight or sedentary, and middle-aged to elderly populations. It tends to rear its ugly head first thing in the morning for most. After a long night’s sleep, the aponeurosis and surrounding tissues will tighten back up and your body is quite dehydrated.

The first thing you do is place your bare feet on the ground and put all your weight down on this tight and dry mesh. It’s often described as crunchy, and as if stepping on pins and needles, or gravel. Pain is felt primarily at the base of the foot near the heel, on the backside of the arch. This is dependent on the person suffering because the exact location can vary. The pain can be located just about anywhere on the heel or even in the arch itself. As you move around more, the pain normally decreases with blood flow, loosening tissue, and reintroduction of water to the body. It may return after long periods of sitting or standing.

You can do a self-diagnosis by using your fingers and thumbs to press along the inside of your heel and arches to see if you can locate any pain points. It doesn’t radiate, so finding an exact point of contact is relatively simple to do. If you find your pain builds during physical activity such as jogging or jumping around, or you feel discomfort while stretching the bottom of your foot as if performing a calf stretch, that’s a good sign as well.

You can watch someone suffering from plantar fasciosis by looking at their facial expressions when loading and unloading the foot. Watch their gate, foot strike, and where they place their weight on their feet. It’s not hard to tell if someone is in pain or using compensatory measures to avoid pain.

I’ve seen athletes of mine stand barefoot on the ground with all their toes in the air without them noticing, just to keep from putting excess pressure through their plantar aponeurosis. You’ll commonly see over supination (rolling along the outside of their foot) to avoid the pain that would occur when pushing through the ball of their foot and big toe.

What Causes It?

If you have ever been diagnosed with plantar fasciosis (“plantar fasciitis”) or been acquainted with someone who has, you will have likely heard various interpretations as to the cause. In some instances, something to the tune of, a genetic predisposition with your feet, inadequate footwear, weak feet, or overpronation. Feet feet feet! This isn’t to say that it isn’t any one of these or several, but I’ve always found it funny how western medicine quickly turns a blind eye to the rest of the body and narrowly focuses on the symptom instead.

If an onlooker sees you limping around finding it hard to put pressure on your foot, it might be easy to assume you have a foot problem. But that’s merely a symptom of the cause. You could have gotten kicked in the shin, twisted your ankle, shot in the thigh, have a dead leg, have an impingement in your lower back, have weak glutes from sitting all day or even have a crooked neck from when you got whiplash in a game of football a decade ago. While we should examine the source of the pain, we must not rule out a plethora of other regions in our analysis.

The human body is one large kinetic chain, you can actually feel pain in your feet from an issue all the way up in your thoracic spine. The reason you feel it more toward your heel is that the aponeurosis is actually the weakest closest to your heel.

Tight Calves

The most common cause of plantar aponeurosis strain may actually be stiffness of the calf muscles, though not always the case. The large calf muscles pull directly on the calcaneus which is connected directly to the plantar aponeurosis. Other muscles like the peroneus longus, tibialis posterior, flexor hallucis longus, and flexor digitorum longus aid in supporting and run beneath the arch.

Whether or not any of those being tight contributes to plantar fasciosis is a mystery, but it shouldn’t surprise if they do. Even if a more superficial (closer to the surface) muscle like the soleus was taut or inflamed, it could press against any of them leading to a manipulated foot angle (either pronation or supination).

Larger, tight calf muscles can cause an overpronation of the foot. This is because when you are about to push off, your ankle and foot are at maximum dorsiflexion (top of foot pulled toward shin bone). If it can’t flex as it normally would, or should, your body will make an adjustment to get the angle it feels it needs. The only way to do this is to kick your heel bone out which loosens the bones in the foot to allow for a larger range of motion.

While this is a good thing upon initial contact, as it grants adaptation to the surface you’re on, it’s a terrible thing when trying to push off because it’s not rigid and makes your plantar aponeurosis do all the load-bearing and stretching. This results in tearing, inflammation, and thickening of the fascia. While not necessarily the cause of plantar fasciosis, it has been seen as an indicator of the condition.

Progressive thickening of the plantar aponeurosis can be caused by things like scar tissue buildup or hyperplasia, similar to the growth of a callus. This can decrease the effectiveness of the stretch and strength of it. Interestingly, we’ve also seen plantar fasciosis in those with hyper flexibility in the calf muscles, so the saga continues.

Degenerative

We pointed to degeneration and fiber misalignment. In a healthy plantar aponeurosis, the collagen fibers are aligned parallel to each other in a very organized manner, much like loose noodles laid side by side all running in the same direction. When problems occur due to the aforementioned damage taken by that thin band under your foot, repair mechanisms start laying those noodles in all directions in a jumbled mess like a pile of spaghetti.

Aside from overstressing, there are cases of individuals who are predisposed to lax or weakened connective tissue. There are a diverse collection of connective tissue disorders such as osteogenesis imperfecta or Ehlers-Danlos syndrome (EDS) that can be inherited. Also, the older you get the more tissue becomes rigid or brittle, and the healing mechanisms become less capable and prone to errors.

Weight

For obvious reasons, overweight individuals or those who do a lot of heaving lifting put a much higher degree of load on their feet. This will greatly increase your chances of developing foot pain. Aside from attributing to plantar fasciosis, most people around the world have accepted that excessive weight is a major health concern for reasons that are well beyond the scope of this article.

Shoes

Soapbox time! Footwear may be one of the most dominant and overprescribed prognoses. For some, corrective shoes, loose shoes, worn down shoes, etc can be a problem. But one of my biggest complaints as a practicing coach and health professional is the shoe industry as a whole.

Shoes have several benefits, but their ascent to holiness (money and aesthetic) and departure from practicality muddy the water. It’s commonplace for running shoe aficionados to watch your gait and tell you with certainty what shoe you should be wearing. What a load of horseshit (generally).

While you can go to a specialty store and get your run recorded and watched back, most of these “experts” are, again, only watching your feet. Poor ones will watch which way your feet turn and tell you which shoe does the corrective measure needed and to what extent of the slope is required to meet it. That’s nice, I guess, but how does that really help you long-term? If you’re feet hurt when you run, what else do they usually tell you to get?

More cushioning solves everything! My problem with shoes is we continue to worship them as if they are gifts from God and that the perfect shoe is going to help us run faster, longer, and with no pain. No shoe is going to fix a mechanical inefficiency elsewhere in your body.

Photo: Differences between over pronation, Supination, and neutral foot contact [www.klmlabstore.com/]

Extra cushioned shoes disrupt the kinetic chain in the foot muscles and tendons. They put priority on softening the distribution of force to the ground (you want more), increasing energy loss, and create an additional unstable surface for your foot and ankle to adapt to. If you’re a woman, you understand the difficulty of walking in platform boots vs Converse sneakers. [PSA: High heels are some of the worst culprits of ankle problems and plantar fasciosis. It also can cause a shortening of your Achilles tendon, thereby pulling more on your calcaneus which is attached to the plantar aponeurosis.]

There’s less integrity in the foot, takes the many muscles of the foot out of the equation, and weakens your body’s most pivotal support. Custom orthotics are just as bad. Aside from the fact they can bankrupt you, they are stiff enough they won't allow for any proper flexion (curling) of the foot, thus taking the muscles out of play again and causing ligaments to overly stretch. Some studies have shown that the $10 prefabricated inserts may be just as effective but are still ineffective at solving plantar fasciosis. Temporary relief has its own merits, so something like a cork insert, which allows some flexion of the arch but is stiff enough to keep it from collapsing, is a personal favorite.

Shoes are simple. They are a human invention to keep us from stepping on pointy objects. Why take something as extremely evolved and complex as the foot and reduce all its function to a simple lever. The more padding, the more a poor runner/walker will heel strike with more force (no bueno). We say that wearing inappropriate footwear can increase the likelihood of developing plantar fasciosis.

That’s right, over compensatory shoes, excess cushioning, or stiff insoles are a perfect example of “inappropriate footwear”. It’s normal for distance coaches and marathon runners to decree a shoe’s effect on a runner’s efficiency. They’re the first to say things like “If you overpronate then a motion control shoe is best.” Often pointing out your need for arch support. None of which has been proven by the science community to be more than a temporary pain-relieving solution and may seemingly contribute to the problem. Most of which is because you take one of the world’s strongest shapes (the arch) and push right up into its only weak point, as well as create lax musculature.

Sometimes they are right, and it might be simpler, especially for someone peddling shoes, to offer a solution for those who over supinate, for example. By doing this, all that shock is being shot right up through your joints, and it’s the best they can do in the 30 minutes they see you.

Someone with a genetically high arch (pes cavus) could experience plantar fasciosis, and may require more attention to the foot and some short-term cushion support to take away from immediate damage to the ball of the foot (metatarsalgia) and calcaneus. But your feet and that which you choose to put on the ends of them is not the issue in most cases. But all that is for another article, and I, therefore, step down from my soapbox.

Flexibility

I mentioned calf tightness, but what about the rest of your body? If you have tight hamstrings, hips, or glutes, this can increase your risk because of the effect they have on lower limb and foot biomechanics. In direct correlation with the body as a system, we circle back to looking at other imbalances or compensations.

Most of the improvements (decreased discomfort) you’re likely to see from stretching and added flexibility appear to be temporary as well. My guess is simple. When we do a lot of static stretches, where we sit and hold a stretch for 30-60 seconds, we begin to take the muscle fibers beyond their normal range of motion and we pull on the other surrounding soft tissues, like tendons, which are viscoelastic.

This will create lax tissue and take time to return to normalcy. It also weakens them. Once you stop stretching for a day or two, the pain can come right back as the muscles and tendons return to a resting state. We aren’t even completely sure that being more flexible is a good thing. You can read more about that in our article on how to stretch properly.

Hyper flexibility is not ideal. I’ve found that a good number of gymnasts, dancers, and swimmers I’ve worked with who have transferred to track and field by way of pole vault and hurdles, have extensive joint ranges in their hips, knees, back, and feet. Some of that leads to tight calves considering the constant toe pointing involved in each sport, so be wary of that. These are the same athletes who you’ll find every day in the corner with their leg above their head held against a wall, or doing a backbend to the point they are sitting on their own head.

There’s a notion that needs to die, and that is that the more flexible you are, the better. Stretching needs to be done correctly and understood, as it’s a cruel and misunderstood mistress. When you are too flexible in areas, it can cause not only an imbalance in others but further concerns with regard to joint instability and tissue irritation, and impingements.

Rare Instances

Speaking of impingements, there are rare instances where a nerve is pinched, in particular the Baxter’s nerve which is a branch of the lateral plantar nerve that runs right under the heel. I’ve run across this speaking with podiatrists and doing a little research through the magic of Google. It can exhibit similar symptoms to plantar fasciosis. I’ve read articles involving doctors who thought they were dealing with a fasciosis, and after trying and failing at a multitude of treatments, determined this nerve be entrapped.

If you think you might have this, you’ll find that you won’t have the same “first step” pain in the morning, but you will experience pain that worsens throughout the day, especially if on your feet a lot. You might even find that the pain doesn’t go away after you quit for the night. Much like a pinched nerve, if you step on it incorrectly, you’ll likely get a shooting pain through the edge of your foot or up your ankle.

The only way I’m aware of testing for Baxter’s neuritis (swelling of the Baxter’s nerve) is by using ultrasound imaging, or perhaps numbing the nerve and testing the person’s pain afterward to see if it still exists.

Flat Feet or High Arches

Flat feet (pes planus) can be caused by the overpronation of the foot. This is to say, the foot rolls inward. You can routinely lump flat feet with plantar fasciosis because they tend to be present in many cases. So it’s not difficult to point to them as a root issue. They don’t necessarily go together though. I’m of the same mindset as a good number of other coaches, online blogs, and researchers who think it’s another fancy word people like to throw out and use as a scapegoat to sound smart and earn confidence.

Just because there is a correlation doesn’t mean there’s causation. Just because you can say something, doesn’t mean you need to. “I love lamp!”

We love to define things with absolution using sophisticated words or blanket statements because it’s easy, fun to do, or because we can point out one of many glaring observations. To have a collapsed arch or a high arch for that matter is but one symptom for most. If I kick someone hard in the nuts, their bruised testicles are one symptom of many, potentially. Aside from the pain and depending on how hard I kicked, you may also have a bruised ischium or broken pubic symphysis. Where is the pain radiating from and how might that be affecting the way you walk?

Another concern of mine is, who’s to say what overpronation or over supination is? Is neutral foot position quantifiably better? Let’s not forget that the body will adjust to just about anything you throw at it with enough time, even if that means it causes other problems up and down the kinetic chain.

Are the people diagnosing you giving good evidence as to either’s effect on your foot pain, or are they just saying you have flat feet so we should get some arch support and you’ll be good to go? Ian Griffiths pointed out on Kinetic Revolution that two different people can have maximally pronated feet but present pain on opposing sides of their ankles. If that’s the case, are supportive or corrective shoes going to be the end-all-be-all solution? Obviously not.

It’s useful to know in diagnosis, but it’s unfortunately not going to tell the whole story. While it will fix some who need the support, it’s a half-assed approach to prescribing medical advice. Never allow someone to dictate your shoes based on their interpretation of your arch alone.

Remedies

I want to quickly address a few potential treatment options. Some are worthwhile, some don’t have enough data to support their worth, some are poor overall, and some might just be too expensive. Either way, while not a comprehensive list, there are many to look into. When in doubt, try more than just one or two.

Inserts

Far more often than I’d like to see, sufferers are prescribed extraordinarily expensive, custom orthotics. This isn’t my first time mentioning this today, but worth noting my particular distaste for them typically. They are designed to help distribute pressure to your feet more evenly and give additional arch support for cases where a weak and collapsed arch may validate their use.

Unfortunately, like many “solutions”, they have only been found to be temporary pain relievers. Podiatrists have commented on how custom inserts can vary drastically from one physician to the next which should be alarming to you reading this. If someone takes a cast of your foot, shouldn’t they be pretty damn close to the same pattern?

Depending on the stiffness of the material used, they can be good at almost immobilizing the arch and much of the rest of the foot. In doing so, this could be a less bulky option to the big boot down below, though they are not made to truly be the same. Overly soft foam ones are nearly useless, but stiffer ones like cork and plastic are more redeemable. Research has also given rise to the use and approval of those cheap arch support inserts you can buy for $10 at your local grocery store. There’s not enough difference, especially given the sporadic custom orthotics you can get from your doc.

Verdict: Might be useful to some, but the data is inconclusive when it comes to healing as opposed to simple pain relief.

Immobilization (boot)

The purpose of a boot cast is to, again, immobilize. In particular, it does more than just stabilize the bottom of the foot and adjacent structures, but also the ankle. What this does is takes out just about all forces that would be applied to the plantar aponeurosis. The bottom of the boot is actually curved to allow greater dissipation of force as well as aid in a normal walking motion. It’s seen as an extreme measure to those suffering from severe pain to the point they can’t continue everyday activities on their feet, but need to remain mobile.

With any treatment where you render a part incapable of motion, you take away its ability to work as well after use. You must first ask yourself if the disability is extreme enough to call for a boot, and how much you plan to use it. Letting tissue stagnate is a surefire way to atrophy the muscles that support the foot and hinder their ability to handle even the most basic stressors.

Don’t forget to reacquaint your feet and ankle with normal usage here and there and there might be some good to come of it in conjunction with other treatment options below. There’s not a ton of definitive research here either, though rest is about as good a solution as you’ll find for all cases generally.

Verdict: Use in extreme cases only. It can be useful in instances where long-term rest is called for, but I caution its use as it can produce other unwanted weaknesses counter to its original purpose for this condition.

Ultrasound

Ultrasound is an interesting one because just about every physical therapist at every major university and physicians still prescribe its use. Yet, there has not been any conclusive evidence in the technology’s ability to revitalize injured tissue, especially in the plantar aponeurosis, and seems to be debunked at every corner for the good part of a decade. Its use is sold much like snake oil. Don’t get me wrong, there are other benefits to ultrasound and those are heavily backed by the science community.

There’s some indirect evidence from some out there, but even if it did show promising results, it’s still expensive for the average sufferer. For an average portable home unit, you’re looking at several hundred dollars and these are very basic, while more professional units can cost in the thousands.

I myself have a portable unit that I have used off and on for years. I can admit that I have not really seen any noticeable difference in healing or pain management unless a minute placebo effect or from the gentle massaging of the head against the affected area. It’s also a hard tech to understand for most people and difficult to determine its influence because at most you’re going to feel a little heat in the area and maybe some tingling, all of which can be a symptom of the massaging.

Verdict: Inconclusive data both scientifically and personally. I have yet to find any solid evidence that it can produce good results with respect to injury repair, especially that of plantar aponeurosis.

Night Splints

Night splints are a pretty basic and commonly recommended piece of equipment for plantar fasciosis patients. The idea is sound. If you have tight calves and plantarflex heavily, stretch the calves and arch of your foot while you sleep! Our savior, the night splint. Sadly, not a lot been has shown to benefit over placebo groups, but it doesn’t help that the research on night splints and this condition, in particular, are sparse, to say the least.

There is some promise and might be worth trying out though. This is something that’s not going to harm to try. We do know that calf stretching, especially when more than just the big gastrocnemius is hit, has shown some signs of at least temporary relief.

Verdict: Inconclusive but worth trying. While the clinical evidence is minimal, there are some subjective reports of them relieving stress and pain in the area of the bottom of the foot.

Shockwave Therapy

The following three therapies are based on a treatment therapy doctors have been using for decades on kidney stones (lithotripsy). The end goal is the same for each but the way they are administered and designed is different. Their claim is that they send acoustic shock waves into bone or soft tissue, in effect causing microtrauma to stimulate a repair and breaking up scar tissue that affects tendons and ligaments. By doing so, you allow the body to regenerate bone and soft tissue cells along with blood vessels in the area.

Radial shockwave therapy (RSWT) penetrates the skin sending low-energy acoustic pulses to the target area directly onto the skin itself. In simpler terms, it’s like a mini jackhammer that physically delivers a shock wave to the skin that radiates into the body. Because it’s low frequency, it hurts less but also doesn’t penetrate deep tissues. I’m not sure if it’s any more beneficial than using one of those massage guns with the right attachment.

Extracorporeal shockwave therapy (ESWT), extracorporeal meaning “outside the body”, is another noninvasive electro shockwave. It administers a very high frequency with short intense pulses. They are not quite as painful as the older technology used in lithotripsy which caused patients to ask for anesthesia to knock them out, but I do hear they are not the most enjoyable thing. It’s credited as inducing tissue repair and regeneration in orthopedics. I have seen it used as a treatment for everything from tendonitis to erectile dysfunction as of late.

It has shown some potentially positive results in reducing pain or perhaps even assisting in aiding tissue growth through better circulation, with plantar fasciosis...maybe? There’s just no research that backs it well. The FDA approved its use on “plantar fasciitis” back in 2000 citing benefits, but the real-world outcomes don’t seem to really parallel the study effectively.

I’ve seen several osteopaths toting the benefits such as increased circulation, it being easier than surgery, and no need for medications or anesthesia. While these are all indeed great benefits, they are weighed upon alternative options and not based on the results of the treatment itself. The research is far too limited and weak to recommend it as a treatment option at this time, I think. It doesn’t help that it’s said to be relatively uncomfortable and expensive.

On the other hand, there’s also intracorporeal pneumatic shock therapy (IPST) which uses a small probe that goes into the skin and emits shock waves to break up things like heel spurs. It requires local anesthesia, but minimal downtime. One double-blind clinical study conducted claimed it was predominantly safe and effective. Of the few studies cited here, such as the one done by the medical faculty at Mustafa Kemal University, they claimed a 92% success rate in reducing pain using the procedure.

So a few studies exist to support its efficacy, but even less on plantar fasciosis particularly, even though there are some. In fact, Googling it as a keyword will net you very little information of what it even is or how it works, at the time of this writing.

Again, it seems that almost all of these find success by comparing them solely to how well they produce results to those who do nothing. It’s the ol’ “Better than nothing at all”.

Verdict: Not worth it for plantar fasciosis. There’s not enough evidence to support its use, it’s expensive, and in some instances can be painful to deal with.

Taping

Taping acts like a sling for your foot and provides stable arch support. This is a temporary solution, as it will only work while you’re taped up. Can be good for unloading but it can also be irritating, tight, and painful to take off.

Verdict: Use sparingly and when needed during initial treatment, especially if you can’t rest completely.

Massage

Massage directly to the foot may be one of the least effective methods of treatment if you speak to a podiatrist. It generally provides modest relief and only seems to be short-term. One of the places it can help is in using massage for delayed onset muscle soreness (DOMS).

The highest potential for basic relief is probably whatever you think feels good, but typically podiatrists won’t recommend rolling over a ball, for instance.

Something hard that pushes up into the aponeurosis might cause more damage to a tissue that has poor blood flow than you want, but this is all conjecture. There may be some better results if it feels good to do it, using a softer ball like a tennis ball. I tend to like the idea of its ability to at least spread out across the tissue and help with squeezing the fascia apart.

There’s some belief that trigger point therapy can work, but we don’t know why and we don’t know if it actually does anything long term. Part of that is likely because we don’t even know what little knots in tissue are. The scientific community believes they may be sets of hypertonic (tense or partially contracted) muscle fibers and you can force them to relax via manual stimulation. My guess, via autogenic inhibition, though this usually pertains to the Golgi tendon organ within tendons.

Graston Technique

Because of specific tooling that allows for tight spaces and working around edges, it’s been seen as useful. The desired outcome is much like the electroshock therapy above. Using dull-edged blades to scrape across the surface of the skin instead, you can induce damage to the fascia and improve circulation, thus kickstarting your body’s natural tissue repair mechanisms.

I’ve never heard of this actually working for this particular condition, but I have athletes who swear by it (likely a placebo). It should be stated that every one of them cries like a baby when getting it done. It hurts! I’d say that most of them use it on their calves more than anything else. The science behind it is relatively weak, and I’ve never personally been one to endorse it, but there may be some potential in relation to research on fascia rehydration specifically where I’ve seen it shine more prominently.

Friction Massage

Here’s another alternative (so many choices!). There are big differences though between it, and Graston. For one, you don’t need as much pressure or pain. You take your hands, or whatever else you have to use, and massage across the fibers back and forth. Imagine playing the violin across the width of your foot, not along the length.

Ice Massage

Same as most of the above, but with ice. Some people will use a bottle with frozen water in it and roll their arches on it -- that I don’t recommend, for the same reasons I don’t recommend rolling them on a ball. We still classify the condition as plantar fasciosis rather than fasciitis because we don’t see real evidence of significant inflammation of the plantar aponeurosis. If so, then ice is not more useful than any other material to utilize.

We’ve written quite a bit on the subject of icing and how its use is overhyped, overrated, and generally not a recommended method of repair. If you want to learn more about why we don’t generally recommend it, check out why cryotherapy or ice for injury might be a poor choice.

Verdict: Exercise at your own risk. If the pain is unbearable, don’t do it. If it feels good, what’s the harm? Massage is something that we still don’t fully understand and can be more or less effective depending on the individual’s needs.

Drugs

When in doubt, pop ‘dem pills. Before jumping in, I want to say that if your pain is severe enough that you have to bury the pain in drugs, you need to see a doctor. While non-steroidal anti-inflammatory drugs (NSAID) such as Ibuprofen and Alieve are great at reducing pain, remember they are not only temporary but create problems of their own, as well as only mask the problem rather than fix it. Let’s remember that pain is a very useful signal to our brain that there’s an issue somewhere and to make adjustments to avoid damage. If you drown the pain, you could be creating worse damage.

Pain pills can be a cheap and effective short-term solution to plantar fasciosis. It has no other effect on healing the problem, only masking the symptoms. Be careful when using them, as pain pills can become addictive, lose effectiveness over time, and cause stomach and liver problems. There’s also research that has shown that long-term usage of NSAIDs specifically, can hinder muscle growth via suppression of satellite cell differentiation and proliferation...potentially.

Voltaren Gel

As I don’t spend much time looking into or using pain medication or other masking agents, this product was new to me. It’s called Voltaren Gel, this is a topical solution (applied to the skin), not its pill form. I only just learned about it through Paul Ingraham over at PainScience.com. If you haven’t checked his books out, he’s got an even MORE in-depth review on plantar fasciitis on the site, so go check him out!

Voltaren Gel is similar in use to things like Bengay, Icy Hot, Tiger Balm, or Biofreeze. Biofreeze still being one of the best topical solutions you can use today. Most topical creams and gels work by combining menthol and methyl salicylate which works by causing the skin to feel cool and then warm. They react in this way to “distract you” from feeling aches and pains.

Voltaren Gel is actually an NSAID, as it contains only one active ingredient - diclofenac diethylamine. Diclofenac is nothing new, and in fact, has been used medically in the U.S. since the late 1980s. It has been scientifically proven to reduce inflammation and pain in muscles, relieving pain quickly and helping increase blood flow locally. Diclofenac has also been shown to increase your risk of heart attack and stroke, but I’m not certain how its topical solution differs in that respect to its oral form.

Some obvious benefits to the Voltaren topical route include how quickly it takes effect as it directly absorbed into the skin, at the site of application, and it doesn’t have to travel through your bloodstream.

Verdict: Use if needed, and as directed, in conjunction with other treatment options. They likely will do nothing for healing and are only intended to cover up pain primarily. Be wary of long-term or heavy usage of NSAIDs in general. Voltaren, or even Biofreeze, may be more promising than your oral medications.

Contrast and ice baths

Here’s one I can probably chalk up to a single shrug emoji. Like a lot of newer fad treatments, there’s not a lot supporting it yet. Much like ice baths at one time (and still to this day), contrast baths might make you feel a little better, but the science is still very much out for an extended lunch.

Coldwater submersion will result in a slowing of blood circulation as it reserves it for the most vital organs of your body to function. When you remove yourself from the cold and either air out or hop in a warm bath, the body will then increase the speed of blood circulation, effectively boosting circulation and bringing fresh oxygenated blood to the tissue. At least that’s one of the theories behind it.

Also, being cold causes muscles to contract and quiver to generate heat. Once out, the muscles relax and are metabolically warmed and primed to release those waste products back into the bloodstream to be washed away. Hopping into a heated pool of water further helps with blood circulation and relaxation. The blood vessels first constrict, and then open back up when you contrast like this.

Anecdotally, many who have chosen to partake in ice and contrast baths emerge feeling fresher. But why? No one effing knows for sure. It could be because the cold dampens nerve impulses since ion channels across the neuron open more slowly when cold, causing the speed of the action potential to travel down the axon slowly in response. Or…maybe it pulls your attention from site-specific pain by changing the stimulus and increasing the area. I like to imagine an old midwife slapping a woman giving birth, drawing her immediate attention away from the pain of childbirth to the pain in her face.

One of the problems with the cold is that there’s plenty of scientific evidence that cold therapy is not useful in any way to tissue repair and recovery. There’s actually strong evidence that it can hinder it, contrary to popular belief. I go over the ice treatment in our myths debunked series. Cold likely prevents chain reactions that lead to the changes in growth/regrowth you are striving for. In short, ice baths may restrain them gains!

We know that using ice after a hard workout inhibits natural healing mechanisms. It restricts blood flow by constricting blood vessels, thus slowing down the rush of white blood cells to the area in need of repair, and the release of insulin-like growth factor, fibroblast proliferation, etc. Does that mean that you should not do ice baths particularly? For the sake of this article’s premise, it might not be the best method to choose, but perhaps if paired with a heated bath it may be more beneficial.

There’s not much to gain or to lose, but if it feels good or you see benefits in another way, I say keep on keepin’ on. Physical muscle recovery, for example, is only one particular adaptation. There may be other benefits psychologically, or for other systems in your body.

Verdict: *Shrug*. There could be some benefit or there could not be. I don’t think there’s much to lose by doing it. You may gain some unknown benefit outside of a physical tissue repair mechanism, but the evidence for it otherwise is lackluster and remains inconclusive.

Steroid injections

Photo: Corticosteroid injection directly into the plantar aponeurosis [https://healingplantarfasciitis.com/]

Corticosteroid injections are not something I usually suggest, and I won’t here. They offer short-term relief only, and while they work well in the interim, there are numerous health risks associated. There are confirmations that these injections into tendinous tissue lead to inhibitory effects on collagen synthesis (creation of collagen), cell death, and atrophy. Does that sound productive to you? There’s no indication that they can help with plantar fasciosis and may create further negative effects.

Verdict: No. Just no. Save this treatment and the next as an extreme and final therapy option.

Surgery

Surgery for plantar fasciosis is the absolute last option you have. Something I will not recommend under any circumstances apart from the person having truly exhausted every option and put in the time (months, perhaps a year) to treat it. The problem I have with it is I think it’s often something people are too quickly referred to as a corrective measure. Surgery is expensive, the recovery times and methods may be more restrictive, and there’s no guarantee it will actually work. It does work for some, but for more, the last recovery method below is more effective (most effective) and it’s free.

The process involves local anesthesia and anything from shaving down your heel bone to lengthening your achilles to cutting the aponeurosis. Imagine, if you will, cutting one side of a suspension bridge off from one of the pieces of land it adjoins...seem like a very useful bridge anymore?

Verdict: Not a very viable option unless every other option has been thoroughly depleted and the issue remains. When something involves the modification of your internal parts, don’t be hasty in making decisions.

Rest

Rest is the ultimate key for most all problems the human body can experience. If all other methodologies did not exist and you were a caveman, you would have nothing but rest to fall back on. While it may be more time-consuming, painful, or difficult to adhere to in today’s day and age, it’s the one thing you can count on a majority of the time.

There may not be a magic way of truly speeding up recovery. What your body does naturally, and your body is unique, might be what you have to work with. For more cases than not, I would venture to say that rest was the main ingredient, the determining factor to the recovery of plantar fasciosis. It may not work for you, but I will recommend it be used in juxtaposition with a few of the other treatments above for best results. Also, understand that when I say rest, I don’t mean to rest for the day. It’s likely that even resting a week will not produce life-changing results, but perhaps a month or several months if need be.

Tissues, as such, do not heal quickly. They have limited blood flow and are positioned in two of the most heavily utilized parts of your entire body. I understand that taking significant time off is wildly unlikely in most cases, but finding a way to not only stay off the feet or keep the pressure off the aponeurosis is your smartest choice. This may be something runners, in particular, are going to dismiss as a choice, but if you want to potentially get back to normal running, you might think it over. This is an overuse injury, so it’s logical that continuing to overuse it will garner poor results.

Remember that there are plenty of ways of building strength and endurance without using your arches. Play around with alternatives that don’t involve stretching it or bearing your full weight. See our article on rehabilitation exercise options for a few ideas.

Using a boot or orthotics or taping could be a form of recouping if used properly. If you just take pills and throw on some tape and go out and run 10k, you’re slapping bandaids on it. If you are willing to put lots of time, energy, and focus into getting in shape, it can take just as much to get healthy. So allow yourself the same time and commitment to put yourself in a position to do so.

Tissue needs to be mechanically stressed to not only grow but to relearn how it is intended to move. To regain its normal range of motion, it has to make changes and be told to create and redistribute fibers parallel to the direction of the pull. In other words, you don’t necessarily have to get off your feet for a few weeks and wheelchair around the house because that will not serve you in strengthening the arches either.

Verdict: 100% utilization required. This should always be your first choice and the basis of all your recovery methods. Add any other methods on top of it for potentially better results.

Strengthening

Heel raises

These next two exercises are simple to employ just about anywhere. Heel raises require that you essentially raise your body up by pushing through your arch and contracting your calves (stand up on your tippy-toes for reps). Adding strength to the arch and calf muscles has shown good results.

Heel drops

Heel drops are a personal favorite. There’s not as much to be said for its effectiveness in the treatment of plantar fasciosis, but I use eccentric exercises for just about everything and everyone in my training menu. The reason being, you create a stretch through the contraction which creates more trauma, which is useful in facilitating growth through the standard ranges and types of forces athletes put upon their tissue during competition. This may help kick off the body’s repair process in the aponeurosis. It may also allow the individual better control and stabilization through the exercise.

Find something elevated to stand on (a stair or a book will suffice) and start on your toes with your heel hanging over the edge. Slowly lower yourself down until your heel is at a level lower than your toes. From here, use either your opposite free foot or a rail to carefully lift your body back up to the starting position and repeat. You can do either of these exercises on one foot or both, just let your body tell you if one is too easy or too difficult.

Barefoot

Photo: Potential benefits of running without the aid of shoes [https://fearlessmen.com/]

Because those little muscles and tendons in your feet are often neglected and weakened by shoes and superfluous arch support, it can be worthwhile to give them a bit of a workout like you would do for any other body part. I’ve been a huge proponent of barefoot walking and running for about a decade now. From experience, just by adding it into a daily warm-up routine, I’ve not once had an athlete come to me with shin splints or foot problems who didn’t already have them.

Now, that said, there’s not much on the clinical side that necessarily supports the fad. After books like “Born to Run” came out, the shit hit the fan. Articles, books, shoes, and every coach and athlete ran with it. Remember Vibram Five Finger shoes? While I personally believe there is a place for it and it may help with alleviating foot strike issues and strengthen the foot, there are negatives as well especially if done the gung ho American way. Even then, research doesn’t support it much.

Walking around your house or backyard barefoot a little every day might be a good prescription. Will it help with your plantar fasciosis? The evidence is severely lacking and the jury is still out.

Verdict: Worth testing each as a part of your regimen. There’s some better science and conjectural evidence here than other treatment options for not only helping to heal but some reduced pain after multiple sessions.

Conclusions

As Smokey Bear used to always say, “Only YOU can prevent forest fires!” Well, only YOU can dictate the outcome and potency of your healing as well. Don’t half-ass it, give up, and decide to get back to full-blown activity if your body isn’t ready.

Plantar fasciitis, or more aptly “plantar fasciosis”, is an overuse condition that is not fully understood and, truthfully, a bit more involved when compared to other typical injuries. Before you avert too much attention to working on your feet, you MUST look at your body as a whole. Biomechanical issues have a cascading effect through the body, and something that you feel in your feet could be by virtue of a problem or imbalance far from the site of pain (your middle back is an example). Seeing a licensed chiropractor for a head-to-toe assessment, or a good physical therapist might be of particular use to help see things that you don’t or can’t.

Rest alone may help significantly for a large subset of people, especially those who only recently changed their routine or have no history of other problems. A combination of several, or all, recommended treatment options is going to be the best prescription. Remember that if it hurts, don’t do it. If it feels good, you’re probably fine to perform unless otherwise not recommended.

It may take anywhere from weeks to years to fully resolve, but don’t let that deter you from doing the work. Just because I say it could take that long, also doesn’t mean that it will. If the issues persist after months and persistent care, it would be a good idea to speak to a physician and talk about other options. It could be worthwhile to get an MRI or x-ray to determine if there’s another cause such as a prominent bone spur.

Here are a few small things you can do every day just as standard precautionary measures.

Everyday to-do list

Untuck your sheets at the bottom of your bed to keep your toes from pointing down and shortening your calf muscles all night. If we have to, get you a simple pair of foot splints to have you wear for a week or two to start while you sleep.
Slowly warm up your feet by moving them around and stretching your toes gently back with your hands a few times each morning before your feet even hit the floor.
DRINK LOTS OF WATER! Your muscles, tendons, and fascia are like a sponge, and if they aren’t well-hydrated, they can crack and tear like a dry sponge.
Heel walks and resistance band pulls (using a resistance band to resist you as you pull your toes toward your shin) for reps may help in lengthening the calves and strengthening the opposing muscles that keep your toes up (anterior tibialis)
Get off your feet. When you don’t need to be on your feet, don’t be. It could also be useful to walk around a softer surface barefoot such as a patch of grass or your carpeted floor to help build your foot strength.

16 Remedies You May Need to Try for Plantar Fasciitis

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