Plantar fasciitis is one of the most common musculoskeletal conditions, in fact it is estimated that 1 in 10 people will develop plantar fasciitis at some point in their life. The root cause of plantar fasciitis is inflammation of the plantar fascia, which is a thick band of connective tissue that runs along the bottom of your foot, from your heel to the base of your toes. The function of the plantar fascia is to provide shock absorption as we move and because of this it endures small tears which can lead to inflammation and pain. Plantar fasciitis is typically characterized by sharp or stabbing pain located in your heel. This pain is generally worse during the first few steps after a prolonged period of rest and lessens as you move. 

Although plantar fasciitis can occur in any demographic, there are some predisposing factors. It is most common among individuals aged 40-60, as well as obese individuals. It is also common in runners or those who engage in repetitive high intensity activity. In fact, it accounts for 10% of running-related injuries. Occupations, such as medical staff or factory workers, are also at an increased risk of developing plantar fasciitis due to prolonged periods of time on their feet. 

Plantar fasciitis can significantly impair an individual’s mobility and overall quality of life. An individual suffering from plantar fasciitis might find it challenging to walk, exercise, or perform work related tasks. This can lead to a sedentary lifestyle which lends itself to the development of other harmful conditions as well as the development of chronic pain, compensatory movements or development of knee or hip pain. 

Causes of Plantar Fasciitis

Plantar fasciitis is typically caused by excessive stress that leads to pain within the foot. Common contributing factors include: 

• Repetitive strain: Activities such as running, dancing, or other high intensity sports, place repeated stress on the foot which can lead to plantar fascia pathology and pain felt along the arch of the foot.
• Sudden Increases in activity level: Sudden increase in exercise intensity, duration, or frequency can overload the fascia as it does not have time to adapt to this new level of activity. 
• Poor foot maintenance: Failing to engage in a proper stretching or warm up routine prior to exercising can lead to excessive strain on the plantar fascia. It is also important to wear proper footwear to provide adequate support to the foot during activity. 
• Prolonged standing on hard surfaces: Daily routines or jobs that require prolonged time on your feet can lead to overuse of the foot and thus strain to the plantar fascia, especially on concrete or solid surfaces. 

There are several risk factors  that contribute to an individual’s likelihood of developing plantar fasciitis. Some of which include: 

• Age: Most common in those aged 40-60 due to reduced tissue elasticity. 
• Musculoskeletal factors: A high arch, flat feet, tight calf muscles, or tight achilles tendon may put an individual at increased risk of developing plantar fasciitis as these factors alter the weight distribution and thus the force applied to the foot. 
• Obesity: Excess body weight increases the load on the foot and can lead to inflammation in the plantar fascia. Rapid weight gain can also increase an individual’s likelihood of developing plantar fasciitis as the fascia does not have time to adapt to the new load. 
• Overuse: Common in athletes or those whose jobs require prolonged periods of time on their feet. 

In addition to the risk factors stated above, there are numerous underlying conditions that predispose an individual to developing plantar fasciitis. These include but are not limited to:

• Flat Feet: A lack of natural arch in the foot decreases the body’s ability to absorb shock and therefore, causes excessive strain to the plantar fascia. 
• High Arches: An excessive arch in the foot may be correlated with plantar fasciitis.
• Tight Achilles Tendon or Calf Muscle: Tightness in either of these structures can lead to decreased dorsiflexion of the ankle and thus increase strain applied to the plantar fascia when walking.

Symptoms of Plantar Fasciitis 

Individuals with plantar fasciitis typically experience a distinct set of symptoms that aid in diagnosis. Although symptoms can vary in intensity, plantar fasciitis often follows a recognizable pattern. One of the most common characteristics of plantar fasciitis is heel pain that is worse upon taking your first few steps in the morning, after prolonged periods of non-weight bearing activity, or at the onset of a workout. It is often described as a sharp, stabbing, or aching pain that is located at the anterior medial heel and often improves with mild activity. Pain is noticeably worse when barefoot or walking/standing on a hard surface as well as when climbing stairs. Limited dorsiflexion, which is caused by a tight achilles tendon or calf muscle, is also a common symptom of plantar fasciitis and can cause an individual to feel tightness or stiffness in the calf muscles. 

Diagnosing Plantar Fasciitis 

Although diagnosis of plantar fasciitis can often be made based upon clinical presentation alone, ultrasound is the most commonly used modality  in identifying plantar fasciitis as it can reveal thickening or inflammation of the plantar fascia. X-rays are also often used to rule out the possibility of bone spurs or fractures. MRIs are less commonly used but might be used in complex or chronic cases to thoroughly evaluate the soft tissue and structures of the foot. 

A physical therapist (PT) can aid in the diagnosis of plantar fasciitis by completing a clinical evaluation that is based upon symptom presentation and physical examination. A thorough PT evaluation includes obtaining a detailed history of symptoms, including  onset, duration, activity level, as well as aggravating and alleviating factors. The PT will also conduct a physical exam which includes palpation of the foot, gait analysis, strength and range of motion (ROM) assessment of the lower extremity as well as an evaluation of foot alignment and arch height. Additionally, a PT will conduct functional tests such as heel or toe walking to determine how particular movement patterns affect pain. The most common differential diagnosis test a PT conducts during an evaluation is the Windlass test. The Windlass test is conducted by passively extending the great toe while the patient is seated or standing. A positive test elicits heel pain or reveals limited toe extension, indicating tension in the plantar fascia. 

Treatment Options 

The prime focus of plantar fasciitis treatment is pain and load management, promoting healing of the plantar fascia, and addressing the underlying causes such as tight muscles. Most cases of plantar fasciitis respond well to conservative treatments however, in chronic more persistent cases, advanced interventions such as surgery are required. The following sections outline both non-surgical and surgical treatments options. 

Non-surgical Treatment Options:

Physical therapists play a key role in the treatment of plantar fasciitis. One of the most important components of plantar fasciitis management is patient education. Unfortunately, plantar fasciitis is not a condition that will go away overnight and timely initiation of conservative management is important. This includes, rest, icing, and stretching of the calf and plantar muscles. Other non-surgical treatment options that are initiated by PTs include: 

• Manual therapy: This might include soft tissue massage and joint mobilization. 
• Stretching: With emphasis on the calf and plantar muscles of the foot as well as the achilles tendon. 
• Taping:  Taping may be used to discourage pronation (when your foot rolls slightly inward) 
• Night Splints: Posterior-night splints help maintain ankle dorsiflexion and toe extension at night, providing a constant stretch to the plantar fascia. 
• Low Level Laser: Accelerates the repair of plantar fascia by acting as an anti-inflammatory agent. 
• Foot Orthoses: A proper foot orthosis should support the medial longitudinal arch of the foot. These can be bought over the counter or custom made by an orthopedist.  
• Dry needling: Dry needling of the calf muscles can aid in reducing tension leading to increased ankle mobility. 

Surgical Treatment Options: 

Surgical treatment for plantar fasciitis is considered in cases where conservative treatments fail to improve symptoms. These procedures aim to relieve tension in the plantar fascia and address any other structural issues that might be contributing to chronic pain. The two most common surgical procedures include a Plantar Fascia Release and Gastrocnemius Recession.

• Plantar Fascia Release: A surgical procedure that involves cutting the plantar fascia to relieve tension and reduce inflammation. This reduces stress on the tissue and thus reduces pain and allows the individual to improve foot mechanics. 
• Gastrocnemius Recession: A surgical procedure that involves lengthening the calf muscles to relieve tension and restore ankle mobility. 

Plantar Fasciitis Prevention 

Preventing plantar fasciitis involves a combination of maintaining a healthy body weight, avoiding overuse by being mindful of activity levels, utilizing proper footwear, and being aware of how much stress is applied to your feet throughout the day. Another key to reducing strain on the plantar fascia is load management. It is important to gradually increase activity intensity and avoid sudden spikes in physical demands. For example, if you are ramping up to run a marathon, it is best to follow a program that gradually increases distance to reduce risk of developing plantar fasciitis. Appropriate footwear also plays a crucial role in preventing plantar fasciitis however, there is no one-size-fits-all solution. If you are unsure which shoes are best suited for you it might be worth making an appointment with an orthopedist or podiatrist. 

In general, a shoe that provides good arch support, a cushioned heel, firm and flexible midsole, and a secure fit are optimal for someone suffering from plantar fasciitis. However, the best footwear is whatever feels most supportive and comfortable to the individual based upon their specific needs. 

Living with Plantar Fasciitis

Living with plantar fasciitis can be challenging and affect one’s daily life however, with the proper approach and compliance with the individualized treatment plan provided by a PT, most individuals can manage their symptoms and return to their prior level of function. Each individual’s condition, lifestyle, and response to treatment varies and this is why a personalized treatment plan is essential. Seeking assistance from a skilled PT can help ensure proper diagnosis and provide patient specific management of plantar fasciitis. Along with the guidance provided by a PT, individuals should take an active role in treatment by making thoughtful choices about their activity levels, footwear, and overall health in order to maintain long-term health and well-being. 

Physical Therapy for Plantar Fasciitis  

As mentioned previously, PTs play a vital role in the treatment of plantar fasciitis as they  provide patient centered and personalized treatment plans that address the individual’s unique symptoms and goals. This is done by addressing the root causes of pain, improving mobility, and promoting long-term healing all while considering the unique goals of the individual. The clinics under Confluent Health utilize a patient-centered and evidence-based approach to the treatment of plantar fasciitis. Their model emphasizes functional movement assessments and hands-on care, with a primary goal of long-term pain relief and injury prevention. 

A skilled PT will guide you through some of the following treatment strategies based upon your individualized goals and needs: 

• Manual Therapy: Soft tissue massage might be performed to the calf and foot muscles to alleviate tension. Joint mobilizations to the ankle might also be provided in order to improve mobility. 

• Plantar Fasciitis Stretches: Stretching exercises to the calf and plantar fascia itself improve mobility of the ankle and therefore, reduce the stress applied to the plantar fascia. An example is a standing calf stretch.  

• Strengthening Exercises: Exercises such as a standing heel raise, can improve plantar fasciitis by supporting the structures of the foot and ankle reducing stress applied to the plantar fascia. 

• Modalities: Specific modalities such as iontophoresis, dry needling, and instrument-assisted soft tissue massage (IASTM) are also used in treating plantar fasciitis.

The overall goal of physical therapy in the management of plantar fasciitis is pain management and restoration of normal movement and function in the foot. By empowering patients with the right tools such as an individualized treatment plan and knowledge surrounding the condition, PTs offer an effective and sustainable path to recovery.

If you’re living with heel pain or suspect you might have plantar fasciitis, don’t wait for it to get worse- early intervention for the treatment of plantar fasciitis is crucial. The PTs at our clinics  offer proven, personalized solutions to help you manage and treat plantar fasciitis. Take control of your foot health by connecting with a licensed PT who will take your needs and goals into consideration. To find a clinic near you and schedule an appointment. We look forward to treating you soon!