Plantar Fasciitis: The Scientific Signs, Symptoms and Causes as well as Research-Backed Treatment Options for Runners

Plantar fasciitis, an irritation to the tough, fibrous tissue at the base of the heel, is one of the most bothersome running injuries due to its infamous stubborn nature. Runners with plantar fasciitis can sometimes have heel pain for months or even years before the fascia finally heals.

Because of this, it is very important to catch and treat plantar fasciitis quickly. Fortunately, with proper treatment, most cases do come around in a matter of weeks.

Signs and symptoms of plantar fasciitis

The plantar fascia is a thick band of fibers that runs from the base of the heel to the metatarsal heads. It has several branches, any of which may become injured, but by far the most common area of the plantar fascia that’s hurt is the very base of the innermost bundle of fibers, right at the base of the heel.

Plantar fasciitis will hurt the worst at the beginning of a run, but will gradually go away once you get warmed up. It may return again at the end of the run, and will be more severe in less-supportive shoes or when barefoot. Your arch or heel may also hurt after a long day on your feet, especially in hard or uncomfortable shoes. The most tell-tale symptom is “first step pain”: a sharp, stabbing pain at the base of the heel immediately after you get out of bed in the morning.

Plantar fasciitis accounts for around eight percent of all running injuries,1 and is common among runners of all ability levels, and is even a problem for sedentary people, where obesity and working long hours while standing are probably the driving causes. Runners, of course, face additional issues due to the forces associated with running, but you shouldn’t overlook your footwear or habits in the rest of your life if you come down with a case of plantar fasciitis. Women’s footwear is especially bad with respect to strain on the arch, but unsupportive hard-soled men’s shoes are problematic too.

Causes and what irritates plantar fasciitis

Unfortunately, the root causes of plantar fasciitis are still not fully understood. There are, however, some clues.

Some studies have found a connection between poor ankle range of motion, especially in dorsiflexion,2, 3 which implies that calf tightness plays a role in the development of plantar fasciitis. Indeed, the plantar fascia itself is in many ways simply a continuation of the Achilles tendon, which anchors the calf muscles to the heel bone. Like a cable that angles around a corner, tight calves could put excessive tension on the plantar fascia, increasing the risk of injury. As mentioned earlier, obesity and time spent on your feet are risk factors as well,2 though these are not as often a problem for runners. However, they do indicate that putting high strains on the foot is problematic, and new research out of the University of Delaware has connected high impact loading rates with plantar fasciitis.4

The plantar fascia is also forced to absorb significantly more strain when you wear hard, flat shoes or walk around barefoot. While the dynamics of “arch support” are not fully understood from a biomechanical perspective, it’s fairly obvious to most sufferers of arch pain that a cushioned, supportive surface feels better on the foot than a hard, flat one.

Research backed treatment options for plantar fasciitis

To that end, the first goal of treatment should be to protect the plantar fascia from additional strain while it is injured. While the “-itis” suffix implies that inflammation is the cause of plantar heel pain, new evidence indicates that the real problem is damage and degeneration of the fascial fibers5—icing is always a good idea, but it’s not an excuse to continue to strain the plantar fascia with long runs, hard workouts, or unsupportive shoes. Aggressive rehabilitation, combined with avoiding activities that hurt, are your best chance for a speedy recovery.

Several conservative treatment methods are supported by scientific research. These treatments are all designed either to protect the arch or stretch the plantar fascia/calf muscle complex.

Several studies support arch taping, called “low-Dye taping” in medical circles after Ralph W. Dye, the inventor.6 While there are several ways to do a low-Dye taping, even its most basic form is effective. The magnitude of the effect, however, is small, so arch taping is only one part of a rehabilitation plan.

low dye taping plantar fascia

Instructions for a low-Dye taping. The lateral straps (lower left, lower right) should be pulled reasonably firmly and should always come FROM the outside of the foot TO the inside.

Supporting the arch with a custom or over-the-counter orthotic is another strategy that can protect the arch while it heals. It’s unclear whether there is a significant difference between custom orthotics or a rigid over-the-counter orthotic like SuperFeet Green or Powerstep insoles when it comes to treating plantar fasciitis.7 While they may not be tailored for your foot, over-the-counter insoles are not nearly as expensive and are available immediately—you’ll have to wait at least a few weeks for a pair of custom orthotics. Avoid soft gel arch supports, as they’ll likely do nothing to help your injury. In a similar vein, many runners find that wearing casual shoes with more arch support (including Birkenstocks and other brands of cork-soled shoes/sandals) relieves their symptoms.

Calf stretching, foot stretching, and using a night splint are the final three conservative treatments vetted by research. All three treatments are designed to stretch out the calf/Achilles/plantar fascia complex, reducing tension and strain on the arch.

For lack of any superior exercise, regular calf stretching is the mainstay of most plantar fasciitis treatment programs. Calf stretching should be done several times a day, including right away in the morning. A typical protocol would be three sets of 30 seconds, three times per day, stretching with the knee straight and bent each session.

Calf stretches, with both a straight knee (top) and a bent knee (bottom)

calf stretches

One study compared a calf stretching protocol to a plantar fascia-specific foot stretch, held for 10×10 seconds, three times per day, and pictured below.8

Plantar fascia-specific stretch. Note that all the toes are stretched, not just the big toe.

This study found better results from the plantar fascia specific stretch; the authors hypothesized that the advantage of the foot stretch is that it recreates the Windlass mechanism, the pulley-like connection between the plantar fascia, heel, Achilles tendon, and calf.

Night splinting is another treatment which aims to stretch out the plantar fascia. As its name suggests, a night splint is a device you wear while you sleep which keeps your ankle dorsiflexed. The theory is that the “first-step pain” that is the hallmark of plantar fasciitis is caused by the arch healing at night without any tension on it. In the morning, the healing is disrupted by the tension put on the arch when you get out of bed. Solid, cast-like night splints are available online and at a few specialty stores, but the Strassburg Sock is an easier and more practical solution.9. Personally, I have found the sleeping splints to be much more comfortable than “The Sock” and worth the extra cost. “The Sock” is a regular knee-high sock with a strap that runs from the toes to the kneecap. When this strap is (gently) tightened, the ankle is dorsiflexed like in a regular night splint, but so are the toes. A Strassburg sock can be ordered online or often picked up at your local running store. Be careful not to put excessive tension on the strap.

Other possible treatment options for plantar fasciitis

Manipulating the tissue of the plantar fascia is an approach that’s become more popular among runners recently. Using a golf ball or other hard, round object, you can “roll out” your arch much like you’d roll out your quads or calves with a foam roller. More aggressive soft-tissue manipulations like Active Release Technique (A.R.T.) or Graston Technique are also popular. All of these are unproven in the scientific literature, however, so while many runners do find them very helpful, there’s no evidence they’ll work for you. If you do decide to roll out your arch or get some soft tissue work done, icing your foot afterwards is not a bad idea.

Injections of corticosteroids are a common second-line treatment among podiatrists. While some research has showed that they may help,7 other scientists have urged caution, since their success rate is fairly low and there is a risk of complete rupture of the plantar fascia.10, 5 Application of a corticosteroid like dexamethasone through the skin via iontophoresis, an electric charge-driven process, may be more helpful and have a lower risk of complications than a direct injection.11 This is an issue you should talk with your orthopedist or podiatrist about.

Chronic, long-standing cases of plantar fasciitis can be particularly tricky to deal with. Two new treatments, extracorporeal shockwave therapy (ESWT)12, 13, 14and platelet-rich plasma therapy (PRP),15 show good promise in treating recalcitrant cases, especially in runners. Because of their relatively recent development, they may be difficult to get access to, however, and their efficacy is not yet solidly vetted.

Many proponents of minimalist and barefoot running have cured plantar fascia problems by transitioning to a more flexible training shoe that allows the arch to stretch out and strengthen itself. Unfortunately, there haven’t been any scientific studies that have monitored the effectiveness of barefoot running as a possible treatment for plantar fasciitis. Therefore, we list it under “other possible treatment options”. If you want to learn more, we recommend listening to our in-depth interview with minimalist running expert Dr. mark Cucuzzella.

Outline of treatment options

Because of plantar fasciitis’ reputation for hanging around for months at a time if not properly addressed, even a mild case of arch pain should be attacked aggressively with several treatments. Protection, ice, and stretching should be the mainstays of your early treatment. While you don’t have to completely cease physical activity, you should avoid anything that makes your arch worse, and protect it while you run and while you go about your daily life.

Conservative treatments

These are methods that are fairly simple, inexpensive, and can be done on your own at home.

  • Wear comfortable shoes with some cushioning and arch support, and avoid hard shoes or anything barefoot.
  • Ice your foot several times a day, either with ice cups or a round, frozen object like a plastic water bottle. If you run, ice immediately afterwards.
  •  Stretch your calves at least three times per day. Each session should consist of 3×30 second holds, first with your knee straight, then with it bent.
  •  Stretch your plantar fascia three times per day. Each session should consist of 10×10 second holds. Make sure you stretch right after getting up in the morning.
  • Use a low-Dye taping to protect your arch when you walk around or exercise.
  • Consider using an over-the-counter orthotic like SuperFeet Green or Powerstep in your everyday shoes and running shoes.
  •  Roll out your plantar fascia with a golf ball, taking care not to press too hard on the injured area.

Aggressive treatments

These are treatments with more cost and less certainty about outcomes, but may prove useful in recalcitrant cases.

  • Consider seeing a podiatrist and getting custom orthotics made. They have a large up-front cost and may take a few weeks to arrive, but many runners credit their recovery to orthotics.
  • Talk with your doctor or podiatrist about the risks and benefits of a corticosteroid injection or, preferably (to reduce the risk of plantar fascia rupture), iontophoresis.
  • Seeing an A.R.T. or Graston Technique practitioner may speed your recovery, though there’s no research to back these treatments
  • Look into extracorporeal shockwave therapy or platelet rich plasma injections for particularly stubborn cases

Return to running

How quickly you can return to running will depend on the severity of your injury and how fast you heal. Some runners find that they can work their way back into running even while some residual arch stiffness persists, but if running is making your arch pain worse, you need more time off and more time for your rehab program to do its job. As you return to running, consider increasing your stride frequency by 10% or so to reduce your impact loading rate,16 a factor connected with the development of plantar fasciitis in runners. Keep stretching your calves even after you’ve recovered to stave off any future bouts with plantar fasciitis.

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References

1. Taunton, J.; Ryan, M.; Clement, D.; McKenzie, D.; Lloyd-Smith, D.; Zumbo, B., A retrospective case-control analysis of 2002 running injuries. British Journal of Sports Medicine 2002, 36, 95-101.
2. Riddle, D. L.; Pulisic, M.; Pidcoe, P.; Johnson, R. E., Risk factors for plantar fasciits: a matched case-control study. Journal of bone and Joint Surgery 2003, 85 (5), 872-877.
3. Kibler, B. W.; Goldberg, C.; Chandler, T. J., Functional biomechanical deficits in running athletes with plantar fasciitis. American Journal of Sports Medicine 1991, 19 (1), 66-71.
4. Davis, I. S.; Pohl, M. B.; Hamill, J., Biomechanical and Anatomic Factors Associated with a History of Plantar Fasciitis in Female Runners. Clinical Journal of Sports Medicine 2009, (19), 372-376.
5. Lemont, H.; Ammirati, K.; Usen, N., Plantar fasciitis: a degenerative process (fasciosis) without inflammation. Journal of the American Podiatric Medical Association 2003, 93 (3), 234-7.
6. Dye, R. W., A Strapping. 1939. Journal of the American Podiatric Medical Association 2007, 97 (4), 282-284.
7. Cole, C.; Seto, C.; Gazewood, J., Plantar Fasciitis: Evidence-Based Review of Diagnosis and Therapy. American Family Physician 2005, 72 (11), 2237-2242.
8. DiGiovanni, B. F.; Nawoczenski, D. A.; Malay, D. P.; Graci, P. A.; Williams, T. T.; Wilding, G. E.; Baumhauer, J. F., Tissue-Specific Plantar Fascia-Stretching Exercise Enhances Outcomes in Patients with Chronic Heel Pain - A Prospective, Randomized Study. Journal of Bone and Joint Surgery 2006, 88-A (8), 1775-1781.
9. Barry, L. D.; Barry, A. N.; Chen, Y., A Retrospective Study of Standing Gastrocnemius-Soleus Stretching versus Night Splinting in the Treatment of Plantar Fasciitis. The Journal of Foot and Ankle Surgery 2002, 41 (4), 221-227.
10. Ziya Tatli, Y.; Kapasi, S., The real risks of steroid injection for plantar fasciitis, with a review of conservative therapies. Current Reviews in Musculoskeletal Medicine 2009, 2 (1), 3-9.
11. Gudeman, S. D.; Eisele, S. A.; Heidt, R. S. J.; Colosimo, A. J.; Stroupe, A. L., Treatment of Plantar Fasciitis by iontophoresis of 0.4 percent dexamethasone-a randomized double blind placebo-controlled study. American Journal of Sports Medicine 1997, 25 (3), 312-317.
12. Rompe, J. D.; Decking, J.; Schoellner, C.; Nafe, B., Shock Wave Application for Chronic Plantar Fasciitis in Running Athletes: A prospective, randomized, placebo-controlled trial. American Journal of Sports Medicine 2003, 31 (2), 268-275.
13. Ogden, J. A.; Alvarez, R.; Levitt, R.; Cross, G. L.; Marlow, M., Shock wave therapy for chronic proximal plantar fasciitis. Clinical Orthopaedics and Related Research 2001, (387), 47-59.
14. Moen, M. H.; Rayer, S.; Schipper, M.; Schmikli, S.; Weir, A.; Tol, J. L.; Backx, F. J. G., Shockwave treatment for medial tibial stress syndrome in athletes; a prospective controlled study. British Journal of Sports Medicine 2011, 46 (4), 253-257.
15. Barrett, S. L.; Erredge, S. E., Growth Factors for Chronic Plantar Fasciitis? Podiatry Today 2004, 17 (11), 36-42.
16. Hamill, J.; Derrick, T. R.; Holt, K. G., Shock attenuation and stride frequency during running. Human Movement Science 1995, 14 (1), 45-60.

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16 Responses on “Plantar Fasciitis: The Scientific Signs, Symptoms and Causes as well as Research-Backed Treatment Options for Runners

  1. In my personal experience, plantar pain is always connected with tightness and knots higher up in the calf, either the gastrox/soleus or the peroneals (which run down the outer part of the calf). Trigger point massage on those muscles, often coupled with use of the foam roller or massage stick and a day or two off, can usually eliminate plantar pain quickly if I catch it right away.

      • My wife has the worst case scenario – back in college in the late 80s, she started having foot pain, and over the next 25 years she went through nearly every imaginable treatment for PF. Everything seemed to help a little at first, but was ultimately unsuccessful. In the last year or so, she has managed to beat it largely by focusing on better running mechanics and getting into more minimal shoes, and she’s run her first races since college this fall (which makes going to cross-country meets even more fun!). I suspect that a number of the treatments actually did help, but because her form was bad and she was wearing problematic (in retrospect) shoes, it just came back quickly each time.

    • I find with plantar fasciitis there is a specific intensely painful point about 6 inches above the lateral ankle between the tibia and the fibula with a coresponding point behind that point toward the back of the calf. (It is not a trigger point.) Releasing it only requires firm (but not hard contact). Over a period of time, it releases and the pain reduces. I find the peroneals are actually more important than the gastroc and soleus for relieving PF pain.

    • Completely agree, with my history of plantar fasciitis including my SO’s recent battle with it, tightness of the calves is definitely a huge factor. I find that proper stretching of the legs/calves including using a foam roller would help immensely with prevention- good shoes and a proper running form will also help you make great strides. Issue is people assume one they get plantar fasciitis that stretching it or wearing orthotics will help- big nono. Firstly, the plantar is a thin tissue comprising of 3 bands (tough fibrous tissue) which like any other of your muscles, will further tighten and get agitated when stressed. Would you jab at an open wound? Stretching and using hard orthotic inserts will essentially be the same thing. My secret just literally consists of icing, rest, massaging, Dr. Scholl’s athletic gel soles/inserts (super soft supports that wont cause further harm) and BFST Plantar Wrap (stimulates blood flow in my plantar using EMR to bring nutrients and oxygen back into my feet to promote healing). http://www.kingbrand.com/Plantar_Fasciitis_Treatment.php?REF=33PV1

  2. Excellent article. All of the stretches and strengthening exercises demonstrated can prove incredibly useful, however, the overwhelming stress of a person’s bodyweight upon an arch in a gravity environment cannot be overcome without a helping hand. Let’s not forget the average person takes over 10,000 steps per day. This is largely exaggerated by running.

    So, the true question is…”How does this inflammatory process begin?” Common contributors to this condition include: progressive flattening of the arches over time (primary reason); lack of flexibility in the calf muscles; changes in activity levels; overuse; and weight gain. When your arch drops, the plantar fascia begins to tear away from its insertion at the heel. When this happens over a long period of time, it can overcome the body’s ability to repair itself.

    So, a potential solution is a custom foot orthotic created from an accurate 3D impression of a clients corrected foot posture and calibrated to their weight, foot flexibility and activity level. Unfortunately, most “custom” foot orthotics fail to support the clients arch in a full contact position which clearly fails to meet the definition of custom. Therefore, a truly custom foot orthotic created from an accurate 3-D impression of their feet, calibrated to match their weight, foot flexibility, and activity level could provide the relief and solution you need! Additionally, an orthotic made completely from scratch, with no generic starter plates, add-on pads or arch filler could make a huge difference of force passage through your foot.

  3. I like to call Plantar fasciitis the “nuisance injury” because it’s pretty hard to fully rest your feet…ever! Tight calves, lack of arch or foot support, or a tight Achilles are often causes of PF. Stretching the interconnective chain of the lower leg (Calves, Achilles, and bottom of foot) is key to getting rid of PF for good. THe ProStretch is a great tool that stretches all three areas at the same time. Check it out: http://www.medi-dyne.com. Medi-Dyne offers a discount to Facebook fans http://www.facebook.com/medidyne if they order online.

  4. Very well researched, but also balancing out the peroneals and the tibialis anterior strength in relation to the calf will really help with the relief of plantar fascitis

  5. A very informative article. I don’t do all of the stretching/preventive techniques discussed, but I definitely do some of them and I notice a difference (usually cramping) if I don’t do those. I think it is important to take this kind of preventive action even if PF is not a problem for future prevention.

  6. Fantastic advice, for which many thanks. Can anyone give me any idea about the recovery takes place? Will it suddenly feel better? Is the improvement gradual? Are there improvement/deterioration plateaux? I have now had this injury for 9 months – is there any likelihood that it will recover in the next few months? I have done no running or other impact sports in this time. Should I keep off them, or is it a good idea to re-introduce activity before complete recovery?

  7. my only good lasting results for dealing with plantar fasciitis and achilles tendonitis, have been with the ancient practice of castor oil hot packs daily for several days. i use a clean thick white cotton sock, and soak only the heel area with castor oil, heat it a bit in micro when i take it out of freezer storage, put it on, and wrap in 2 plastic bags, another larger sock. Then wrap and secure a heat pad around the heel. low heat for 45 minutes or more. i dont wash any oil off but rather, rub it in. use castor oil hot pack for 3 days or more, then only as needed. it’s been a life-changing tool for me. many videos on YT about castor oil packs, but i’ve never seen one for tendonitis, fasciitis pain.

  8. I have had cronic plantar fascitis for over 2 years. I’ve done physical therapy, injections, surgery, more PT, more injections all with no positive results. I’ve worn several types of boots during the day and at night. I’ve used various orthopedic inserts in my sneakers. I’ve been to 2 orthopedic surgeons, and 6 podiatrists. I don’t know what to do next. Is there any research going on that I could participate in? Do you have any other suggestions?

  9. A very good article Jeff, well researched. I’d like to pass along our Technical Paper on exercises & stretching for Plantar Fasciitis and get your comments as we are in the process of setting-up a clinic trial. In addition to some of the exercises and stretches you’ve outlined, we’ve had success with incorporating eccentric loading in to the strengthening program after about 4 weeks, essentially treating the plantar fascia as a thick tendon:
    http://www.afx-online.com/news_research/afx-technical-paper-plantar-fasciitis/
    Full Disclosure: I’m one of the people who invented the product that is seen in the exercises and the Paper is on our Company website, but it is *not* a marketing piece. I just want to reach out to people who have done solid research on PF and see if they have anything to add. You can send your comments to me directly at matt progressivehealth.ca. Thanks!

  10. I’ve had Plantar Fasciitis in both feet and I couldn’t seem to find any relief from the pain. I took 5 shockwave therapies till now and have been stretching exercising and putting night split, ice rolling, shoes. And I couldn’t even walk without pain. I’ve been using MEDICOVI Twin-heels orthopedic insoles. There’s extensive information for patients on their page – http://www.medicovi.com . It’s a new type of orthopedic from Scandinavia, Denmark. I’ve been using theese for months now and I’ve just bought my second pair. I’ve always suffered from pain in my feet, especially around the heels. Since owning these my life has literally changed. I can now run with a smile on face. Can’t recommend them highly enough.

  11. Plantar fasciitis is one of the most common explanations of heel pain. It is caused by inflammation to the thick band that connects the toes to the heel bone, called the plantar fascia, which runs across the bottom of your foot. The condition is most commonly seen in runners, pregnant women, overweight people, and individuals who wear inadequately supporting shoes. Plantar fasciitis typically affects people between the ages of 40 and 70.

    Symptoms
    Plantar fasciitis commonly causes a stabbing pain in the heel of the foot, which is worse during the first few steps of the day after awakening. As you continue to walk on the affected foot, the pain gradually lessens. Usually, only one foot is affected, but it can occur in both feet simultaneously.

    Diagnosis
    To diagnose plantar fasciitis, your doctor will physically examine your foot by testing your reflexes, balance, coordination, muscle strength, and muscle tone. Your doctor may also advise a magnetic resonance imaging (MRI) or X-ray to rule out other others sources of your pain, such as a pinched nerve, stress fracture, or bone spur.

    Treatment
    Treatment for plantar fasciitis includes medication, physical therapy, shock wave therapy, or surgery.

    Medications
    Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and naproxen are used to treat the inflammation and pain of plantar fasciitis, but they won’t cure the condition. Corticosteroids can also be used to ease pain and reduce inflammation. Corticosteroids are applied either as a topical solution in conjunction with a non-painful electric current or through injections to the affected area.

    Physical Therapy
    Stretching exercises for the Achilles tendon and plantar fascia are recommend to relieve pain and aid in the healing process. Sometimes application of athletic tape is recommended. In moderate or severe cases of plantar fasciitis, your doctor may recommend you wearing a night splint, which will stretch the arch of your foot and calf while you sleep. This helps to lengthen the Achilles tendon and plantar fascia for symptom relief. Depending on the severity of your plantar fasciitis, your physician may prescribe a store-bought orthotic (arch support) or custom-fitted orthotic to help distribute your foot pressure more evenly.

    Surgery and Other Procedures
    When more conservative methods have failed to reduce plantar fasciitis pain, your doctor may suggest extracorporeal shock wave therapy, which is used to treat chronic plantar fasciitis. Extracorporeal shock wave therapy uses sound waves to stimulate healing, but may cause bruises, numbness, tingling, swelling, and pain. When all else fails, surgery may be recommended to detach the plantar fascia from the heel bone. Few people need surgery to treat the condition.

    Home Remedies
    Stretching your plantar fasciitis is something you can do at home to relieve pain and speed healing. Ice massage performed three to four times per day in 15 to 20 minute intervals is also something you can do to reduce inflammation and pain. Placing arch supports in your shoes absorbs shock and takes pressure off the plantar fascia.

  12. Ive been training for a half marathon (which is Sunday) and I started feeling the arch pain two weeks ago. I’ve been able to do a few short runs since then without pain, maybe just some pulling. If I feel the pain during my race Sunday, will the pain subside at any point if I try to run through it to finish?

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