Guide to Plantar Fasciitis Treatment

Plantar fasciitis is an inflammation and/or degeneration of a thick band of tissue that runs along the arch of your feet from your heel to your toes and aids in stabilization of your arch while you walk and run.

plantar fasciitis pain diagram
  • Often there is pain in the heel area first thing in the morning when starting to walk.
  • Pain also develops after sitting, or standing.
  • It can feel like a pulling or tearing sensation.
  • The pain is also worse when walking barefoot or wearing low-heeled or unsupportive shoe.
  • Pain can be described as, mild or debilitating, chronic or acute.
pain points of platar fasciitis

It is usually under the mid central area of the heel (Green Circle)sometimes on the inner border of the heel and sometimes on the outer border of the heel often radiating into the arch of the foot (Yellow Circle). Occasionally it radiates up into the toes. Usually it affects 1 foot only but sometimes seen in both if not treated.

  • 2:1 Female/Male
  • 70% within 30-50 Age group
  • Frequently in keen sportspeople
  • Frequently in overweight people
  • Those in standing occupations
  • Standing for long periods
  • Change of footwear
  • Change of activity
  • Change of gate following surgery eg. knee replacement
  • Poor foot mechanics eg flat feet
  • Medical conditions eg Rheumatoid arthritis, boney feet

plantar fasciitis anatomy diagram


The plantar fascia is a thickened fibrous aponeurosis that originates from the medial tubercle of the calcaneus, runs forward to insert into the deep, short transverse ligaments of the metatarsal heads, dividing into 5 digital bands at the metatarsophalangeal joints and continuing forward to form the fibrous flexor sheathes on the plantar aspect of the toes. Small plantar nerves are invested in and around the plantar fascia, acting to register and mediate pain. The plantar fascia is made up of 3 distinct parts: the medial, central, and lateral bands.

The central plantar fascia is the thickest and strongest section, and this segment is also the most likely to be involved with plantar fasciitis.

In normal circumstances, the plantar fascia acts like a windlass mechanism to provide tension and support through the arch. It functions as a tension bridge in the foot, providing both static support and dynamic shock absorption.


Biomechanical dysfunction of the foot is the most common cause of plantar fasciitis; however, infectious, neoplastic, arthritic, neurologic, traumatic, and other systemic conditions can prove causative.

The pathology is traditionally believed to be secondary to the development of microtrauma (microtears), with resulting damage at the calcaneal-fascial interface secondary to repetitive stressing of the arch with weight bearing.

Excessive stretching of the plantar fascia can result in microtrauma of this structure either along its course or where it inserts onto the medial calcaneal tuberosity. This microtrauma, if repetitive, can result in chronic degeneration of the plantar fascia fibers. The loading of the degenerative and healing tissue at the plantar fascia may cause significant plantar pain, particularly with the first few steps after sleep or other periods of inactivity.

The term fasciitis may, in fact, be something of a misnomer, because the disease is actually a degenerative process that occurs with or without inflammatory changes, which may include fibroblastic proliferation. This has been proven from biopsies of fascia from people undergoing surgery for plantar fascia release.

Studies have introduced the etiologic concept of fasciosis as the inciting pathology. Fasciosis, like tendinosis, is defined as a chronic degenerative condition that is characterized histologically by fibroblastic hypertrophy, absence of inflammatory cells, disorganized collagen, and chaotic vascular hyperplasia with zones of avascularity.

These changes suggest a noninflammatory condition and dysfunctional vasculature, which may be seen on ultrasound. With reduced vascularity and a compromise in nutritional blood flow through the impaired fascia, it becomes difficult for cells to synthesize the extracellular matrix necessary for repairing and remodeling.

Correct Diagnosis for Your Heel Pain

Plantar fasciitis is by no means the only cause of heel pain. Listed below are just a few of the many causes of heel pain. Getting the correct diagnosis is key to resolving symptoms.


Plantar fasciitis is diagnosed based on your medical history and physical examination. During the exam, we check for areas of tenderness in your foot. The location of your pain can help determine its cause.

Imaging tests
plantar fasciitis xray

Often no tests are necessary. We might suggest an X-ray Ultrasound scan or magnetic resonance imaging (MRI) to make sure another problem, such as a stress fracture, is not causing you pain.

Sometimes an X-ray shows a piece of bone sticking out (spur) from the heel bone. In the past, these bone spurs were often blamed for heel pain and removed surgically. But many people who have bone spurs on their heels have no heel pain.

Sometimes we also order blood tests to exclude inflammatory diseases.

plantar fasciitis ultrasound


plantar fasciitis MRI scan

MRI Scan

Differential Diagnoses

Tarsal Tunnel Syndrome

Tarsal tunnel syndrome is an entrapment of the nerve that travels on the inside of the ankle. This condition can cause heel pain that feels very much like plantar fasciitis.

Calcaneal Stress Fracture

A calcaneal stress fracture is a tiny fracture of the heel bone. It often occurs on the bottom of the heel or the back of the heel. If on the bottom of the heel it is often mistaken for plantar fasciitis and if on the back of the heel is often mistaken for Achilles tendonitis.

Baxter’s Nerve Entrapment

Baxter’s nerve (also called the first branch of the lateral plantar nerve) runs direction under the bottom of the heel. If this nerve gets irritated or entrapped it can mimic plantar fasciitis. Thus it is one of the primary diagnoses that is often mistaken for plantar fasciitis.

Calcaneal Bursitis

A bursa is a small fluid filled sac that occurs throughout our bodies in areas of increased pressure. A bursa under the heel can be mistaken for plantar fasciitis. Often we can visualize bursas on ultrasound examination.

Calcaneal Cyst

A bone cyst is a weak or thin area of bone. This can lead to both dull and sharp heel pain. Bone cysts can be be diagnosed with x-ray, CT scans or MRI scans.


A radiculopathy is a nerve entrapment in the back. In some patients this can result in pain that presents under the bottom of the heel.

Rheumatoid Arthritis, Psoriatic Arthritis and Other Systemic Arthridities

There are a number of diseases that can present with heel pain. Often patients spend years being treated for plantar fasciitis when the problem is actually a systemic condition. Besides those listed above these can include conditions such as ulcerative colitis, reactive arthritis and Sjogren’s syndrome.

Plantar Fascial Tear

A tear or rupture of the plantar fascia can occur near the heel bone. While the area of the is the same as plantar fasciitis the pain itself is usually more substantial and it can even be difficult to bear weight. Sometimes bruising can be seen after the injury occurs.


While many people think gout primarily affects the big toe joint it can, in fact, cause pain at the heel. Usually causes severe pain with redness and increased temperature in the area.

Soft Tissue Mass

There are a number of different soft tissue masses that can occur under the heel or just in front of it. These include fatty cysts, ganglion cysts, varicose veins and tumors.

Heel Fat Pad Atrophy or Displacement

There are some conditions that result in the loss of the fatty padding underneath the heel. This can be when there is a direct loss of the fatty padding (eg Some Rheumatoid diseases) or sometimes it is displaced because a lack of integrity of the soft tissue that binds the fat family under the heel (Hypermobility syndromes). This can lead to increased pressure on the under surface of the calcaneum (Heel Bpone) with the possibility of developing bone bruising, stress reactions or fractures of the calcaneum.

Treatment Plan for Plantar Fasciitis

When treating plantar fasciitis I follow this protocol:

For tissue to heal you must first stop damaging it so it has a chance to heal.

There are two types of force that affect the plantar fascia:

  • Tension: When the arch of the foot flattens out, it gets longer. As it gets longer, tension increases on the fascia. To allow the plantar fascia to heal you have to stop tugging on it.
  • Pressure: Every step you take puts 3 – 5 times your body weight through your heel. To allow the plantar fascia to heal you have to stop pounding on it.
insoles image
  • Orthotics and Arch Supports: Custom orthotics or prefabricated arch supports that conform close to the arch of the foot will both reduce tension on the plantar fascia AND transfer pressure off of the heel onto the mid-portion of the arch..
  • Proper Shoes: Some shoes will reduce force on the plantar fascia while others can increase it. The best shoe for your foot will vary with your foot type and your activities. We will guide you to the best shoes to reduce force on the plantar fascia.
boots and braces image
  • Boots and braces: These can be used in the short-term (usually a couple weeks) to maximally reduce force on the plantar fascia to allow the tissue to rest and jump start healing.
  • Taping: There are taping techniques that can reduce tension on the plantar fascia. We often teach our patients to tape in order to facilitate healing
  • Modification of Activity: If you are athletic or exercise a lot we absolutely want to keep you active and we will work with you so you can maintain your fitness. You will, however, often need to modify activity so you are not pounding so hard on your heel and arch.
man stood on scales
  • Weight Loss: Being overweight can dramatically increase force on the heel. Losing weight will almost always help plantar fasciitis heal.

Home stretching programs are often the first line of treatment and can be very effective. There are many suggestions for home stretching programs involving numerous stretching exercises.

Based on current research and your individual considerations, we may recommend one or more of the following:

  1. Stretching Exercise: Direct Stretch of the Plantar Fascia

    plantar fasciitis stretches

    Studies have shown that this stretching technique is the most successful form of stretching for plantar fasciitis. It has been shown to be very effective when combined with orthotics and anti-inflammatory therapies and can help to reduce pain significantly.

    This new stretch targets the plantar fascia more effectively than the standard stretch that was long used.

    We recommend this stretch be performed before taking the first step in the morning and again after prolonged sitting so that it’s done at least three times per day.

    To Perform the direct Plantar Fasciitis Stretch:

      Cross one leg over the other.

      Hold the base of toes of the affected foot.

      Gently pull the toes back towards the shin until you feel a stretch in the arch.

      Hold the stretch for 10 seconds and slowly release.

      Repeat 10 times.

  2. Continuous stretch: Using a night splint

    A number of studies have shown that night splints can be beneficial in helping to treat plantar fasciitis and Achilles tendonitis. Although they have not been shown to be effective if used as the only treatment for heel pain, they seem to work well in conjunction with other therapies.

    One 1998 study showed that 80% of patients using night splints saw significant improvement in just one month. And a 2007 study also showed significant improvement with the use of night splints. By maintaining a gentle stretch on your foot while you sleep, a night splint can prevent night time contraction of the tendon and decrease inflammation that causes morning heel pain.

    plantar fasciitis stretches

    Night splints are one of the best ways to treat morning heel pain. Although night splints are intended to be worn while sleeping, many of our patients find it difficult to sleep while wearing the splint. As an alternative, you can benefit by wearing a night splint during the day for 30 minute intervals while watching TV, reading or working on your computer to speed healing. Plan on using the night splint for the first three to four weeks of treatment.

    If both feet hurt, we suggest you initially purchase only one night splint. Even patients that can sleep with one night splint on find it a challenge to sleep wearing two. Those that are back or side sleepers may be more comfortable sleeping while wearing night splints while those that sleep on their stomachs tend to find them less comfortable.

    Choosing a night splint – our recommendations

    I have reviewed a number of night splints and the following one I find most effective, comfortable and affordable. Click to view

  3. High load stretching and strengthening to progressively increase the ability of the plantar fascia to handle greater loads.

    one legged heel raise

    Perform one-legged heel raises on a stair with a towel inserted under the toes to elevate the toes or a special tool to help with toe position.

    The towel should be thick enough that your toes are bent up as far as they will go at the top of the heel raise. Rather than a towel you can also use the Fasciitis Fighter dev

    (The unaffected leg should hang free, bent slightly at the knee.)

      Perform the exercises every other day for three months.

      Every heel-rise consists of a three second concentric phase (going up) and a three second eccentric phase (coming down) with a 2 second isometric phase (pause at the top of the exercise).

      Start at twelve repetition maximum for three sets.

      After two weeks, increased the load by using a backpack with books in it and reduce the number of repetitions to 10 and at the same time increase the number of sets to four.

      After four weeks, perform eight reps and perform five sets. Keep adding books to the backpack as you become stronger.

    To maximize the benefit of this exercise it is important that the toes by bent up to the end of their range of motion.

    high load stretching

    A 2014 study by Ratcliff demonstrated that doing high load strength training has potential to improve plantar fasciitis symptoms faster than just stretching.

    Clinical data indicates that this stretching program alone can help in improving the symptoms of Plantar Fasciitis in about 72% of the cases.

    Clinical Paper
  4. Ice and deep ice massage

    Ice is very effective at reducing swelling and pain. Keeping socks on to avoid an ice burn.

    heel ice pack

    1. Place the heel on an ice pack for fifteen minutes three times a day.

    2. Deep ice massage. Use a small plastic soft drink bottle.

      Fill nearly to top with water.
      Do not put lid on.
      Place in freezer.
      Once frozen replace lid.
      Place a towel on the ground in front of armchair and put bottle on towel.
      Roll foot over bottle from heel to toes pressing well up into the arch area. Ideally for 10 minutes three times a day.
Injection therapy image

Injection therapy is used to supplement rehabilitation programs or orthotic therapy when conservative care is failing to make sufficient progress.

We often use diagnostic ultrasound to guide injections to the site that is causing pain. Injections can be given to reduce inflammation (corticosteroid) or to reduce friction and provide nutrient for the joint (hyaluronic acid).

  • An advantage of steroid injections is that when they work they tend to give very rapid relief.
  • What is a steroid injection? A steroid injection contains medicine made from a group of drugs called corticosteroids. The steroid acts like the natural hormones that your body makes to stop inflammation.
  • The pros of steroid injections are that they can provide very rapid relief. If you have a holiday coming up and need to be pain free for the trip or are having trouble walking because of the pain we can use steroid injections to help give you almost immediate relief.
  • The downside of steroid injections is that they do not help heal the tissue (as shockwave does). Also, there are some potential complications of the injections including thinning of the fat pad under the heel, degeneration of the plantar fascia and an increased chance of a rupture of the plantar fascia.
Further Reading
Extra corporal Shockwave therapy

Extracorporal shockwave therapy is a non-invasive, non-surgical treatment option for treatment of ligament and tendon injuries.

“Extracorporeal” means “outside the body”. “Pulse Activation” is a type of shockwave, also known as pressure or sound waves.

These shockwaves are generated from the unit and are focused onto the painful heel tissue. The shockwaves trigger the body’s repair mechanisms.

The concept behind shockwave therapy is that the shockwave stimulates and reactivates healing to encourage new blood vessel formation and other elements necessary to advance normal tissue healing.

Additionally, shockwaves help to over-stimulate pain transmission nerves, which can lead to a reduction in sensitivity and pain.

  • Treatments take approximately 15 minutes. Generally 3 treatments are necessary at weekly intervals. Patients are evaluated for success at 12 weeks after the first treatment.
  • In general it takes 10 – 16 weeks to see initial improvement.
  • Maximum improvement is usually seen at about 12 weeks after the final session.
ECST gun

Keep in mind that this isn’t like a steroid injection where rapid results can be seen. What shockwave does is stimulate the bodies healing process, so it takes a number of weeks to see results.

Most of the best studies show about 70% of patients with chronic heel pain due to plantar fasciitis will find relief with ECSW therapy.

How is the Shockwave Treatment Performed?

Coupling gel is applied to your foot in the area requiring treatment. ECSWT pressure waves are then released via the applicator while moving it over the treatment area.

Is it Safe?

Yes. There are a tremendous number of clinical studies and tests that have confirmed its effectiveness and safety. In fact, for most patients ECSWT has virtually no side effects, risks or complications.

Extra corporal Shockwave therapy machine
  • ECSWT has been shown to be one of the most effective treatments for plantar fasciitis with the highest level of medical evidence for treating this condition.
  • ECSWT is about 70% effective in relieving plantar fasciitis pain and has no side effects or complications.
  • ECSWT is done in combination with treatments to decrease load on the plantar fascia which might include orthotics, walking boots, activity modification and weight loss.
Further Reading
plantar fasciitis surgery

Very rarely if the pain has been present for a very long period and causing distress then surgery may be undertaken to relieve the tension off the plantar fascia and heel bone.