Plantar Fasciitis – Causes, Symptoms, Diagnosis, Treatment

Plantar fasciitis is a very common cause of inferior heel pain that can be triggered and aggravated by prolonged standing, walking, running, and obesity, among other factors. It is the result of degenerative irritation of the plantar fascia origin at the medial calcaneal tuberosity of the heel as well as the surrounding perifascial structures.[rx][rx][rx] Treatments are largely noninvasive and efficacious. Supportive treatments, including the plantar fascia-specific stretch, calf stretching, appropriate orthotics, and night dorsiflexion splinting, can alleviate plantar fascia pain. While local injections of corticosteroids can help with pain relief, the effects are short-lived and must be weighed against the risk of fat pad atrophy and plantar fascia rupture.

Plantar fasciitis is a disorder that results in pain in the heel and bottom of the foot. The pain is usually most severe with the first steps of the day or following a period of rest. Pain is also frequently brought on by bending the foot and toes up towards the shin and may be worsened by a tight Achilles tendon. The condition typically comes on slowly. In about a third of people, both legs are affected.

A fascia is a band or sheet of connective tissue, primarily collagen, beneath the skin that attaches, stabilizes, encloses, and separates muscles and other internal organs.^[rx] Fascia is classified by layer, as superficial fascia, deep fascia, and visceral or parietal fascia, or by its function and anatomical location. Like ligaments, aponeuroses, and tendons, fascia is made up of fibrous connective tissue containing closely packed bundles of collagen fibers oriented in a wavy pattern parallel to the direction of pull. Fascia

Types of Plantar Fasciitis

1. Acute overload fasciitis – Heel pain of less than six weeks that follows a sudden spike in running mileage, a new aerobic class, or a long day on hard concrete.

2. Chronic degenerative fasciopathy – Symptoms persisting beyond three months marked by thickened, hypoechoic fascia on ultrasound, indicating collagen degeneration rather than pure inflammation.

3. Bilateral fasciitis – Pain in both feet simultaneously, often linked to systemic conditions such as rheumatoid arthritis or a seronegative spondyloarthropathy.

4. Traction-spur–associated fasciitis – Characterized by a prominent bony outgrowth at the heel that perpetuates micro-tearing of the fascial attachment.

5. Pediatric calcaneal apophysitis (Sever’s disease) – Growth-plate irritation in active adolescents that mimics true plantar fasciitis but involves the posterior heel pad rather than the fascia itself. ncbi.nlm.nih.gov

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Common Causes

1. Sudden mileage jump in runners – A rapid increase in steps outpaces the fascia’s ability to remodel, leading to micro-tears. jospt.org

2. Prolonged standing on hard floors – Factory, retail, or kitchen workers absorb repetitive heel shock all day long.

3. Obesity – Every extra kilogram multiplies the load that the arch must dampen, stretching the fascia just a bit farther each step.

4. Flat feet (pes planus) – Excessive pronation flattens the arch, keeping the fascia under constant tension.

5. High arches (pes cavus) – Ironically, an overly stiff arch can transmit force more directly to the heel anchor point.

6. Tight calf muscles – Limited ankle dorsiflexion forces the foot to roll inward, amplifying strain on the fascia.

7. Tight Achilles tendon – Similar to calf tightness, a short tendon pulls the heel upward and overstretches the plantar band.

8. High-impact court sports – Repeated jumping and sudden stops jack up the peak load at toe-off.

9. Running on hard or cambered surfaces – Concrete and slanted roads concentrate shock on the medial heel.

10. Worn-out or unsupportive shoes – Compressed midsoles fail to cushion landing forces.

11. Barefoot walking on tiles or hardwood – The arch receives no structural help, especially first thing in the morning.

12. Rapid weight gain (e.g., pregnancy) – Hormonal laxity plus extra mass stretch the fascia.

13. Systemic inflammatory arthritis – Cytokines weaken collagen and lower the tissue’s load tolerance.

14. Diabetes mellitus – Glycation stiffens collagen, making it brittle and prone to tearing.

15. Vitamin D deficiency – Poor bone turnover and soft tissue healing slow recovery after micro-trauma.

16. Heel pad atrophy with aging – Thinner fat pads offer less shock absorption, so force is transmitted to the fascia.

17. Poor foot biomechanics (excess pronation) – The heel tilts inward, twisting the fascia during gait.

18. Chronic corticosteroid use or injections – Long-term steroids weaken connective tissue and raise rupture risk.

19. Footwear with elevated heels – High heels shorten the Achilles, then stretch the fascia abruptly once the shoe is removed.

20. Repetitive hill climbing – Uphill walking forces the toes to dorsiflex, lengthening the fascia under load.

The main cause of heel pain is overstretching of the plantar fascia ligament under the foot. So why is the ligament being overstretched? There are different factors

• Over-use – too many sports, running, walking or standing for long periods (e.g. because of your job)
• Weight gain –  our feet are designed to carry a ‘normal’ weight. Any excess weight places great pressure on the bones, nerves, muscles, and ligaments in the feet, which sooner or later will have consequences. Even pregnancy (in the last 10 weeks) can cause foot problems!
• Age – as we get older ligaments become tighter & shorter and muscles become weaker; the ideal circumstances for foot problems
• Unsupportive footwear –  ‘floppy’ shoes with no support as well as thongs affect our walking pattern
• Walking barefoot –  especially on hard surfaces like concrete or tiles
• Low arch/flat feet or over-pronation
• Standing on your feet for several hours each day.
• Medical conditions such as rheumatoid arthritis or lupus (systemic lupus erythematosus)
• Wearing high-heeled shoes, and switching abruptly to flat shoes.
• Wearing shoes that are worn out with weak arch supports and thin soles.
• Having flat feet or an unusually high arch.
• Having legs of uneven lengths or an abnormal walk or foot position.
• Having tight Achilles tendons, or ‘heel cords’.

An important contributing factor to Plantar Fasciitis is ‘excess pronation’ (or over-pronation). This is a condition whereby the feet roll over, the arches collapse and the foot elongates. This unnatural elongation puts excess strain on the ligaments, muscles, and nerves in the foot.

When the foot is not properly aligned, the bones unlock and cause the foot to roll inward. With every step taken your foot pronates and elongates, stretching the plantar fascia and causing inflammation and pain at the attachment of the plantar fascia into the heel bone. Re-alignment of the foot should, therefore, an important part of the treatment regime.

Risk factors of Plantar Fasciitis

Though plantar fasciitis can arise without an obvious cause, factors that can increase your risk of developing plantar fasciitis include:

• Age – Plantar fasciitis is most common between the ages of 40 and 60.
• Certain types of exercise – Activities that place a lot of stress on your heel and attached tissue — such as long-distance running, ballistic jumping activities, ballet dancing, and aerobic dance — can contribute to an earlier onset of plantar fasciitis.
• Foot mechanics – Being flat-footed, having a high arch or even having an abnormal pattern of walking can affect the way weight is distributed when you’re standing and put added stress on the plantar fascia.
• Obesity – Excess pounds put extra stress on your plantar fascia.
• Occupations that keep you on your feet – Factory workers, teachers and others who spend most of their work hours walking or standing on hard surfaces can damage their plantar fascia.

Symptoms of Plantar Fasciitis

Pain is usually felt on the underside of the heel and is often most intense with the first steps of the day or after rest.  It is commonly associated with long periods of weight-bearing or sudden changes in weight-bearing or activity.

You may experience

• Sharp pain in the inside part of the bottom of the heel, which may feel like a knife sticking into the bottom of the foot.
• Heel pain tends to be worse with the first few steps after awakening, when climbing stairs or when standing on tiptoe.
• Heel pain after long periods of standing or after getting up from a seated position.
• Heel pain after, but not usually during, exercise.
• Mild swelling in the heel.

• First-step heel pain – A knife-like jolt under the heel when getting out of bed.

• Pain after prolonged sitting – The “theater sign” of aching heel when standing after a movie.

• Dull ache turning sharp with activity – Gentle throbbing morphs into stabbing pain during a run.

• Medial heel tenderness – A sore spot the size of a fingertip at the inside bottom of the heel.

• Early-morning stiffness – The foot feels stiff until the fascia warms and loosens.

• Worse pain in thin-soled shoes – Minimal cushioning intensifies every ground strike.

• Improvement after light walking – Mild movement loosens the stiff band, briefly reducing discomfort.

• Flare-ups after climbing stairs – Toe-off on steps magnifies tension.

• Pain radiating into the arch – Aching or burning spreads forward along the medial longitudinal arch.

• Heel swelling – A subtle puffiness where the fascia inserts.

• Warmth over the heel – Mild localized heat signals active inflammation.

• “Pebble in the shoe” sensation – Some patients feel as if a stone hides under the heel pad.

• Thickened fascia to touch – A cord-like band along the arch indicates chronic change.

• Antalgic gait (limping) – Walking on the forefoot to avoid heel strike.

• Reduced ankle dorsiflexion – Tight calf muscles restrict upward ankle bend.

• Tight hamstrings – Protective muscle guarding that accompanies chronic foot pain.

• Secondary knee ache – Limp-induced altered biomechanics strain the knee.

• Hip or low-back discomfort – Compensation higher up the kinetic chain.

• Sleep disturbance – Persistent ache can interrupt rest.

• Decreased exercise tolerance – Patients gradually abandon walks or runs, leading to de-conditioning. orthoinfo.aaos.org

Diagnosis of Plantar Fasciitis

A. Physical-Examination Tests

The health care provider will perform a physical exam. This may show:

• Pain on the bottom of your foot.
• Pain along the sole of the foot.
• Flat feet or high arches.
• Mild foot swelling or redness.
• Stiffness or tightness of the arch in the bottom of your foot.

1. Visual inspection of stance and arch height – Reveals flat or high arches and asymmetry while the patient stands. orthopt.org

2. Palpation of the medial calcaneal tubercle – Direct fingertip pressure reproduces the patient’s focal pain.

3. Point-tenderness mapping – Helps distinguish fascia pain from tarsal-tunnel or fat-pad pain.

4. Morning first-step provocation – Clinician asks the patient to simulate first steps to gauge severity.

5. Gait analysis – Observes heel strike, mid-stance pronation, and toe-off mechanics.

6. Passive ankle dorsiflexion range measurement – A goniometer quantifies tightness below 10°.

7. Single-leg balance test – Challenges proprioception; poor control hints at intrinsic foot-muscle weakness.

8. Heel-rise endurance test – Measures calf strength and endurance; premature fatigue often co-exists with fasciitis.

B. Manual (Provocation) Tests

9. Windlass test – The big toe is passively extended, tightening the plantar fascia; pain is a positive sign. physio-pedia.com

10. Tinel’s sign at the tarsal tunnel – Percussion over the posterior tibial nerve checks for confounding neuropathy.

11. Silfverskiöld test – Compares ankle dorsiflexion with knee bent versus straight, identifying gastrocnemius tightness.

12. Calcaneal squeeze (compression) test – Differentiates stress fracture (diffuse pain) from fascial insertion pain (focal).

13. Toe-extension stress test – Actively dorsiflexing toes under resistance strains the fascia.

14. Plantar fascia compression test – Direct thumb pressure along the arch searches for fibromas or fascial nodules.

15. Thompson calf-squeeze test – Rules out Achilles rupture, which can mimic plantar heel pain.

16. Metatarsal head pressure test – Identifies transfer metatarsalgia often present when patients off-load the heel.

C. Laboratory & Pathological Tests

17. Complete blood count (CBC) – Screens for infection or anemia in recalcitrant cases.

18. Erythrocyte sedimentation rate (ESR) – Elevated values suggest systemic inflammation.

19. C-reactive protein (CRP) – Another inflammation marker that helps rule out infection.

20. Rheumatoid factor (RF) – Detects rheumatoid arthritis underlying bilateral heel pain.

21. Anti-CCP antibodies – More specific test for early rheumatoid disease.

22. Serum uric acid – Hyperuricemia can deposit crystals that mimic plantar fasciitis flares.

23. HLA-B27 antigen test – Screens for spondyloarthropathies like ankylosing spondylitis, which often start at the heel.

24. Thyroid-stimulating hormone (TSH) – Hypothyroidism slows tissue repair and can intensify heel pain.

25. Vitamin D level – Low vitamin D impairs bone and fascial healing.

26. Fasting glucose or HbA1c – Diabetes is linked to slower collagen turnover and worse outcomes.

Imaging Studies

Imaging studies are typically not necessary for the diagnosis of PF.[rx,rx] In the clinical management of chronic heel pain, diagnostic imaging can provide objective information. This information can be particularly useful in cases that do not respond to first-line interventions, or when considering more invasive treatments (e.g. corticosteroid injection).

• A lateral radiograph – of the ankle should be the first imaging study. It is a good modality for the assessment of heel spur, the thickness of plantar fascia, and the quality of the fat pad. Stress fractures, unicameral bone cysts, and giant cell tumors are usually identified with plain radiography.[rx,rx,rx]
• Ultrasound – examination is operator-dependent, but it proves to be significant when the diagnosis is unclear.[rx,rx] In the literature, the normal thickness of the plantar fascia when measured in ultrasound varies in range (mean 2–3 mm). People with chronic heel pain are likely to have a thickened plantar fascia with the associated fluid collection, and that thickness values >4.0 mm are diagnostic of plantar fasciitis.[rx]
• Plantar fascia thickness values  – have also been used to measure the effectiveness of treatments and there is a significant correlation between decreased plantar fascia thickness and improvement in symptoms.[rx,rx,rx]
• MRI – can be used in questionable cases, which fail conservative management, or are suspected of other causes of heel pain, such as tarsal tunnel syndrome, soft tissue and bone tumors, osteomyelitis, subtalar arthritis, and stress fracture.[rx,rx]

D. Electrodiagnostic Tests

27. Tibial-nerve motor conduction study – Confirms or excludes tarsal-tunnel neuropathy.

28. Electromyography (EMG) of intrinsic foot muscles – Detects denervation in chronic nerve entrapment.

29. F-wave latency measurement – Sensitive to subtle proximal or distal nerve delays.

30. Tarsal tunnel post-exercise nerve conduction – Provocation test that reproduces dynamic compression.

31. Somatosensory evoked potentials – Maps sensory pathway integrity from foot to cortex.

32. Quantitative sensory testing (QST) – Objectively measures thermal and vibratory thresholds, helpful in diabetic patients with heel pain.

33. Weight-bearing foot X-ray – Identifies heel spurs and rules out stress fracture or arthritis. ncbi.nlm.nih.gov

34. Diagnostic ultrasound of plantar fascia thickness – Thickness > 4 mm and hypoechoic areas confirm pathology. pmc.ncbi.nlm.nih.govmdpi.com

35. MRI of the foot – Gold standard for complex cases; shows edema, partial tears, and occult fractures.

36. CT scan for bone spur morphology – Offers 3-D detail when planning surgery.

37. Bone scintigraphy (triple-phase bone scan) – Highlights metabolic activity in chronic stress injuries.

38. Dynamic ultrasound during toe-off – Observes real-time fascial elongation and detects micro-tears.

39. Ultrasound elastography – Evaluates fascial stiffness to track degeneration over time.

40. Weight-bearing cone-beam CT (WB-CT) – Provides precise 3-D alignment data for surgical planning in refractory fasciitis.

Treatment of Plantar Fasciitis

Nonsurgical Treatment

More than 90% of patients with plantar fasciitis will improve within 10 months of starting simple treatment methods.

A. Physiotherapy & Electro-Therapy Modalities

1. Plantar-fascia-specific stretching – pulling toes toward the shin for 30 s, 3× per session, five times daily. Purpose: lengthens the fascia to cut morning pain. Mechanism: reduces tensile load peaks.

2. Gastrocnemius–soleus calf stretch on a wall – loosens the ankle, decreasing fascial strain.

3. Eccentric heel drops on a step – controlled lowering strengthens the Achilles–plantar chain and stimulates collagen remodeling.

4. Intrinsic foot-muscle strengthening with towel scrunches – builds arch “core” to off-load the fascia.

5. Low-Dye supportive taping – gives an immediate pain dip by limiting arch flattening.

6. Prefabricated orthotic inserts – redistribute pressure; best when worn >7 h/day for 6 weeks.

7. Night splints – keep the ankle at 90° during sleep so the fascia doesn’t tighten overnight.

8. Iontophoresis with dexamethasone – delivers steroid ions through skin via mild current; useful for acute flares.

9. Therapeutic ultrasound (1 MHz, 1.5 W/cm², pulsed) – micro-massage and warmth speed tissue metabolism.

10. Low-Level Laser Therapy (LLLT) – 830 nm beam boosts mitochondrial activity and collagen synthesis.

11. Extracorporeal Shock-Wave Therapy (ESWT) – acoustic pulses trigger new blood‐vessel growth and disrupt pain-nerve endings; mid-term pain relief often beats steroid injection. pubmed.ncbi.nlm.nih.govpubmed.ncbi.nlm.nih.gov

12. Transcutaneous Electrical Nerve Stimulation (TENS) – gates pain messages at the spinal cord.

13. Pulsed radio-frequency therapy – delivers non-destructive energy that modulates nerve hypersensitivity.

14. Cryotherapy (ice bottle roll 10 min, 3×/day) – numbs pain and tones down inflammatory enzymes.

15. Heat packs before stretching – increase pliability, lowering risk of re-micro-tear.

B. Exercise-Based Therapies

16. Progressive brisk walking program – graded loading re-educates fascia to tolerate stress.

17. Pool running or aqua-aerobics – maintains fitness minus impact.

18. Cycling with correct shoe cleat – cardio without heel pounding.

19. Yoga sun-salutations focusing on calf/hamstring flexibility – holistic kinetic-chain lengthening.

20. Foam-roller myofascial release of calves and plantar surface – eases trigger bands and improves ankle range.

C. Mind-Body Approache

21. Mindfulness-based stress reduction (MBSR) – tames pain catastrophizing, proven to lower chronic foot-pain scores.

22. Breathing-guided progressive muscle relaxation – reduces sympathetic overdrive that heightens pain perception.

23. Cognitive-behavioural therapy (CBT) – reframes fear of movement and boosts adherence to rehab.

24. Biofeedback-assisted gait retraining – teaches softer landing patterns.

25. Guided imagery of relaxed, healthy feet – surprisingly effective adjunct for pain modulation pathways.

Key Medicines

Reminder: Always consult a qualified health-care professional before starting drugs. Below doses are adult averages; adjust for age, kidney function, and other illnesses.

1. Ibuprofen 400–600 mg orally every 6–8 h with food (NSAID). Limits prostaglandins; may upset stomach / raise blood-pressure. pubmed.ncbi.nlm.nih.govjournals.sagepub.com

2. Naproxen 500 mg b.i.d. (NSAID). Long half-life helps overnight pain; watch for reflux.

3. Diclofenac sodium 50 mg t.i.d. (NSAID) or topical 1 % gel q.i.d. Fewer systemic effects topically.

4. Celecoxib 200 mg once daily (COX-2 selective). Lower gastric-ulcer risk but still take with food.

5. Meloxicam 7.5–15 mg daily (NSAID). Convenient once-daily dosing.

6. Prednisone oral taper, e.g., 30 mg for 5 days then taper 5 mg every 2 days (systemic corticosteroid). Rapid anti-inflammatory punch; may raise blood sugar and mood swings.

7. Methylprednisolone dose-pack (6-day blister) – handy for acute flare.

8. Triamcinolone acetonide 10–40 mg (40 mg / mL) mixed with 1 % lidocaine, injected into fascia; provides 1–3 months relief but risk of fat-pad atrophy.

9. Botulinum toxin A 50 U injected into fascia; blocks acetylcholine, relaxing tension for ~3 months.

10. Glyceryl trinitrate 5 mg transdermal patch nightly on heel for 12 weeks; elevates nitric oxide to drive collagen repair; may cause headache.

11. Capsaicin 0.075 % cream t.i.d. depletes substance P; expect burning for first week.

12. Diclofenac-epolamine patch 1.3 % q12 h for localized topical relief.

13. Amitriptyline 10–25 mg nightly (tricyclic). Modulates central pain pathways; causes drowsiness & dry mouth.

14. Duloxetine 30–60 mg daily; helpful for neuropathic overlay.

15. Gabapentin 300 mg at night, titrate to 900 mg t.i.d.; sedating.

16. Pregabalin 75–150 mg b.i.d.; reduces overactive pain nerves.

17. Ketorolac tromethamine 10 mg q6 h (max 5 days); potent NSAID for flare crisis.

18. Triamcinolone iontophoresis 0.4 % two sessions per week for 4 weeks; avoids needle.

19. Etodolac 300 mg b.i.d.; balanced COX-2/COX-1 NSAID.

20. Topical 5 % lidocaine patch 12 h on/off; numbs superficial nerve endings.

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Dietary Molecular Supplements

(Discuss with your clinician if you have kidney, liver, or bleeding issues.)

1. Omega-3 fish-oil (EPA/DHA 1 500 mg/day) – anti-inflammatory eicosanoid shift; may thin blood.

2. Hydrolysed collagen peptides (10 g powder daily) – supply glycine & proline for fascia repair.

3. Curcumin (Turmeric extract 500 mg b.i.d.) – blocks NF-κB; improves pain and oxidative stress.

4. Bromelain (Ananas extract 250 mg t.i.d.) – proteolytic enzyme that clears inflammatory debris.

5. Boswellia serrata (AKBA 65 % 300 mg b.i.d.) – 5-LOX inhibitor; joint-pain relief.

6. Vitamin D₃ (2 000 IU daily) – supports musculoskeletal health; correct deficiency common in indoor workers.

7. Vitamin C (500 mg b.i.d.) – co-factor for collagen cross-linking.

8. Magnesium glycinate (200–400 mg nightly) – relaxes calf muscle spasm and improves sleep.

9. Zinc picolinate (25 mg daily) – key for tissue healing enzymes.

10. Glucosamine-chondroitin (1 500 mg/1 200 mg daily) – supplies GAG building blocks; evidence mixed but low risk.

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Advanced (Bisphosphonate / Regenerative / Viscosupplement / Stem-Cell) Interventions

1. Alendronate 70 mg orally weekly – bisphosphonate that suppresses bone resorption, potentially helpful when heel-spur stress reaction co-exists; may cause heartburn.

2. Zoledronic acid 5 mg IV once yearly – potent anti-resorptive; reserved for MRI-confirmed stress-reaction cases.

3. Autologous Platelet-Rich Plasma (PRP) 3–5 mL injected into fascia – releases growth factors (PDGF, VEGF) to jump-start repair and rivals stretching in pain reduction. pubmed.ncbi.nlm.nih.govpubmed.ncbi.nlm.nih.gov

4. Autologous whole-blood injection (2 mL) – simpler regenerative alternative to PRP.

5. Hypertonic dextrose prolotherapy (15 % dextrose 3 mL, three sessions) – osmotic shock induces fibroblast growth.

6. Viscosupplementation with hyaluronic acid 1 % (1 mL x 3 weekly) – adds lubrication and anti-inflammatory effect.

7. Mesenchymal stem-cell concentrate (bone-marrow aspirate, 2–4 mL) – supplies pluripotent cells; still experimental.

8. Amniotic membrane-derived allograft 1 mL injectable – rich in cytokine modulators.

9. Recombinant platelet-derived growth factor (becaplermin gel 0.01 %) – topical off-label use for chronic fascial ulcerations.

10. Autologous fat-pad grafting – adds cushioning and stem cells under chronic atrophic heel fat.

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Surgical Procedures (Last-Resort Options)

Surgery is reserved for <5 % of sufferers who fail ≥9–12 months of structured conservative care.

1. Endoscopic plantar fascia release (EPFR) – 0.5–1 cm cut is made endoscopically to divide medial one-third of fascia; >85 % good-excellent results, <9 % complications. pubmed.ncbi.nlm.nih.govpmc.ncbi.nlm.nih.gov

2. Open plantar fasciotomy – small incision on medial heel; easier for surgeons without endoscopic kit.

3. Percutaneous ultrasound-guided micro-fasciotomy (TOPAZ®) – radio-frequency coblation pokes stimulate healing.

4. Gastrocnemius recession – lengthens tight calf muscle, reducing fascial tension.

5. Heel-spur resection – removes bony prominence irritating fascia.

6. Calcaneal osteotomy realignment – corrects hindfoot varus mal-alignment that overloads fascia.

7. Plantar fascial strip excision with Baxter’s nerve decompression – addresses entrapment neuropathy overlap.

8. Cryoablation of calcaneal nerve branches – freezes pain fibers for chronic refractory pain.

9. Stem-cell augmented fascial reconstruction – experimental; adds scaffold and cells during open release.

10. Combined EPFR plus PRP injection – pairs mechanical release with biologics to speed recovery.

D. Educational & Self-Management Strategies

1. Footwear education – choose stiff-soled, cushioned, heel-drop 10 mm shoes; dump worn-out runners after 500 miles.

2. Activity pacing diary – avoid the boom-and-bust cycle; increase walking or running mileage by <10 % per week.

3. Weight-management coaching – every extra kilogram multiplies heel load ~1.6×.

4. Work-station modifications – anti-fatigue mats and sit-stand desks protect standing workers.

5. Symptom-tracking app reminders – reinforce home exercises and detect early flare signs.

6. Activity Modification – Modification of activities should be advised, while those that involve repetitive impact, such as running (even on a treadmill), should be avoided during the treatment phase. Patients can continue performing non-weight-bearing activities such as cycling, swimming, and rowing to maintain their cardiovascular fitness while minimizing cyclic loading. A gradual return to activity may be allowed after the patient is asymptomatic for 4–6 weeks and no longer has localized tenderness over the plantar fascia.

Exercise

Plantar fasciitis is aggravated by tight muscles in your feet and calves. Stretching your calves and plantar fascia is the most effective way to relieve the pain that comes with this condition. Exercise must be done by the following system.

Phase 1 exercises

• No running – walking or any other activity which causes pain either during, after or the following day.
• Night splint – wear a plantar fasciitis night splint for as long as is comfortable, overnight if possible but if you can manage 1 hour then gradually increase over time. If it is painful then remove it. Do not give up!
• Maintain fitness – by swimming or cycling and use the opportunity to work on upper body strength.
• Gentle stretching – if pain allows. Stretching the plantar fascia is essential but in addition, all the muscles of the lower leg should be stretched – including the calf muscles and the tibialis anterior at the front of the leg. Continue stretching daily throughout the rehabilitation phase and long after the injury has healed.

You are ready to move onto phase two when you can walk pain-free in the mornings.

Phase 2 treatment

The second phase of plantar fasciitis treatment aims to get the athlete back to full fitness once initial pain and inflammation has gone.

• Ice – Continue with ice after activity such as walking.
• Massage – massage techniques can be applied to further stretch and improve the elasticity of the plantar fascia. Initially, massage may be light on a daily basis but deeper techniques can be used as the condition improves. Deeper techniques may require a days recovery in between sessions.
• Ball rolling – If you are unable to see a massage therapist regularly then roll the foot over a ball or rolling pin or similar to help stretch and apply myofascial release. Do this exercise for 10 minutes per day.

Continue with this until foot fitness has been regained. If the pain becomes worse then drop back to phase 1.

Plantar Fascia Stretch

• This stretch is performed in the seated position. Cross your affected foot over the knee of your other leg. Grasp the toes of your painful foot and slowly pull them toward you in a controlled fashion. If it is difficult to reach your foot, wrap a towel around your big toe to help pull your toes toward you. Place your other hand along the plantar fascia. The fascia should feel like a tight band along the bottom of your foot when stretched. Hold the stretch for 10 seconds. Repeat it 20 times for each foot. This exercise is best done in the morning before standing or walking.

Ice and Anti-Inflammatories

• Two or three times a day, apply an ice pack directly onto the heel and hold it for 5 to 10 minutes. This will help cool down the inflammation and provide temporary pain relief. Anti-inflammatory medications like Ibuprofen (found in Nurofen™ and Advil™) will help decrease the inflammation of the plantar fascia. Rapid™ is another nicely potent anti-inflammatory drug and can be helpful for temporary pain relief.

Night Splints

• Most people sleep with their feet pointed down. This relaxes the plantar fascia and is one of the reasons for morning heel pain. A night splint stretches the plantar fascia while you sleep. Although it can be difficult to sleep with, a night splint is very effective and does not have to be used once the pain is gone.
• The use of night dorsiflexion splints can also help with plantar fasciitis, especially pain that is worse during the first few steps in the morning. Night splints have produced highly positive outcomes such as the resolution of symptoms within 12 weeks of use. The patient may see improvement as early as after four weeks of use. (rx)

• Orthotics are corrective foot devices. They are not the same as soft, spongy, rubber footbeds, gel heel cups etc. Gel and rubber footbeds may cushion the heels and feet, but they do not provide any biomechanical correction. In fact, the gel can do the opposite and make an incorrect walking pattern even more unstable!
• Orthotic insoles work by supporting the arches while re-aligning the ankles and lower legs. Most people’s arches look quite normal when sitting or even standing. However, when putting weight on the foot the arches lower, placing added tension on the plantar fascia, leading to inflammation at the heel bone. Orthotics support the arches, which reduces the tension and overwork of the plantar fascia, allowing the inflamed tissue to heal.
• Orthotics needn’t be expensive, custom-made devices. A comprehensive Heel Pain study by the American Orthopaedic Foot and Ankle Society found that by wearing standard orthotics and doing a number of daily exercises, 95% of patients experienced substantial, lasting relief from their heel pain symptoms.

Plantar Fasciitis Medical Treatments

Cortisone-Steroid Injections

• Cortisone is a powerful anti-inflammatory and when injected directly into the heel it will work almost immediately. Bear in mind, however, that the treatment does not address the root cause of the inflammation, and needs to be repeated every few months. Also note, these injections are quite painful, and most doctors today will consider other, less invasive treatment options first.

Acupuncture

• Electroacupuncture and standard acupuncture are used in the treatment of plantar fasciitis and other foot problems such as neuromas and nerve impingement, numbness in the toes, etc. In some cases, there is nerve entrapment within the foot combined with referred pain from other areas of the body.  Some research suggests that acupuncture can be effective in the treatment of heel pain.

Trigger-Point Massage

• A trigger point is an irritable knot in the muscle tissue. When pressed trigger points are very tender and can cause pain in that specific spot or elsewhere in the body (referred pain). The response to pushing into the knot is a muscle twitch.
• The foot contains 126 muscles, tendons, and ligaments, so there are plenty of ‘hiding places’ for trigger points. Trigger points in the calf muscles often refer pain directly to the bottom of the foot. Trigger point therapy of the lower leg and foot can, therefore, be successful in the treatment of plantar fasciitis.

Strassburg Sock and Night Splint

• The Strassburg Sock consists of a tubular fabric with two adjustable straps which extends from the toes to the lower leg. The aim is to keep tension on the plantar fascia ligament all night long, so no tightness occurs overnight and little or no pain is experienced in the morning. In combination with orthotic insoles and exercises, this device can be very effective indeed. In an independent study published in the Journal of Foot and Ankle Surgery found some significant improvement in 55% of the participants.
• A night splint is very similar to the Strassburg sock, serving the same purpose. However, this boot-type device is very uncomfortable to wear at night and very cumbersome, this is why most people prefer wearing a sock.
• If the patient continues to have moderate to severe symptoms that do not respond to nonoperative treatment for more than 6–12 months, referral to an orthopedic surgeon for operative treatment may be required.
• Albert dropped by your clinic two weeks later to thank you for treating his pain with only the calf and plantar fascia-specific stretch you taught him. He had since revised his health pledge to include a regular exercise program that combines stationary cycling and a slow jog. He will gradually work toward 150  minutes of moderate exercise a week and will postpone his half marathon pledge for another year. Surgery is considered only after 12 months of aggressive nonsurgical treatment.

Gastrocnemius Recession

• This is a surgical lengthening of the calf (gastrocnemius) muscles. Because tight calf muscles place increased stress on the plantar fascia, this procedure is useful for patients who still have difficulty flexing their feet, despite a year of calf stretches.
• In the gastrocnemius recession, one of the two muscles that make up the calf is lengthened to increase the motion of the ankle. The procedure can be performed with a traditional, open incision or with a smaller incision and an endoscope, an instrument that contains a small camera. Your doctor will discuss the procedure that best meets your needs. Complication rates for gastrocnemius recession are low but can include nerve damage.

Plantar Fascia Release

• If you have a normal range of ankle motion and continued heel pain, your doctor may recommend a partial release procedure. During surgery, the plantar fascia ligament is partially cut to relieve tension in the tissue. If you have a large bone spur, it will be removed, as well. Although the surgery can be performed endoscopically, it is more difficult than with an open incision. In addition, endoscopy has a higher risk of nerve damage.

Endoscopic Plantar Fasciotomy (EPF)

• It is a form of surgery whereby two incisions are made around the heel and the ligament is being detached from the heel bone allowing the new ligament to develop in the same place. In some cases, the surgeon may decide to remove the heel spur itself, if present.
• Just like any type of surgery, Plantar Fascia surgery comes with certain risks and side effects.  For example, the arch of the foot may drop and become weak. Wearing an arch support after surgery is therefore recommended.
• Heel spur surgeries may also do some damage to the veins and arteries of your foot that allow blood supply in the area. This will increase the time of recovery.

Prevention

There are certain things that you can do to try to prevent plantar fasciitis, especially if you have had it before. These include:

1. Regularly changing training shoes used for running or walking.
2. Wearing shoes with good cushioning in the heels and good arch support.
3. Losing weight if you are overweight.
4. Regularly stretching the plantar fascia and Achilles tendon, especially before exercise.
5. Avoiding exercising on hard surfaces
6. Maintain healthy body-weight; each kilogram lost cuts heel load.

7. Invest in good shoes with arch support and replace them before mid-sole collapse.

8. Rotate sports—mix running with cycling or swimming.

9. Warm-up calves and fascia before activity; cool-down stretches after.

10. Increase walking/running mileage by no more than 10 % weekly.

11. Avoid prolonged barefoot standing on hard tiles or concrete.

12. Use silicone heel cups when floors cannot be changed.

13. Strengthen foot-arch muscles twice weekly.

14. Log early twinges and back off intensity for 48 h.

15. Address tight hamstrings and hip weakness that alter foot mechanics.

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When Should You See a Doctor?

• Pain lasts >2 weeks despite rest, ice, and stretching.

• Shooting, burning, or night pain wakes you—could signal nerve or fracture.

• Swelling, redness, or tingling in the heel.

• Inability to bear weight on waking.

• Diabetes, inflammatory arthritis, or previous foot surgery complicates the picture.
  Prompt medical imaging (ultrasound, X-ray, MRI) rules out stress fracture or systemic causes.

Reference

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