Plantar Fasciitis – Breakdown of Causes, Prevention & Treatment

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For many runners, there’s nothing worse than feeling the first twinge of pain that signals an oncoming injury.  One of the most common injuries that runners deal with is Plantar Fasciitis, a debilitating ailment that affects the lower leg. For some, it may begin as a nagging pain in their heel, whereas for others, it’s a dull ache that affects the entire bottom of their foot. Others still may experience numbness or face more serious complications, such as a partial or complete rupture or tear, which will stop them in their tracks. The pain experienced can become unbearable when running, requiring extended periods of rest and recovery and hampering your training schedule.

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In most cases, it can be prevented, which makes it imperative that people –  athletic or not – know the risk factors and causes. That said, there is also a small subset of people who, even when doing everything right, it still may not be preventable. However, should it happen, they will be able to treat it properly and prevent it from getting worse, if they are properly educated. The result of ignoring or improperly treating bouts are dire: it can lead to more severe injury, possibly crippling you for life! The information in this review serves as a guide in opening a discussion with your health care provider. For quality this article was co-written by Eddy Mihai and curated by Diana Rangaves, PharmD, RPh. Please consult a physician if you feel anything mentioned in this article is significant to your individual and specific situation.

What Is Plantar Fasciitis?

Plantar Fasciitis is the inflammation or irritation. This is a band of ligament that runs from your heel to your toes, supporting the arch of your foot. Although the exact cause of Plantar Fasciitis is not known, it is commonly thought to be an overuse or misuse injury. In a healthy individual, the tissue stretches as their foot strikes the ground while running or walking.  In individuals with this condition; however, the ligament is unusually tight and causes tiny tears and strains in the ligament. After a period of time, these small injuries can be exacerbated and lead to swelling and pain in the ligament, typically felt in the heel.

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There is some research that shows that it may not be an inflammation disease and may actually be a degenerative disease. This means that the tissue is beginning to wear away after repeated irritation, rather than getting inflamed. At the onset of the condition, there may be inflammation resulting from overuse or misuse. As the condition persists, it is thought that the tissue begins to degrade. This is what causes the pain, rather than the tissue remaining inflamed as long as symptoms are present. This theory would lead to a chronic condition, as opposed to a condition that can be treated and will completely heal. After all, if the ligament is degenerating, there isn’t a way – without surgery – to get that tissue back and restore health to the tissue.

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Symptoms

The most common symptom is a sharp pain in the heel first thing in the morning or during increased activity. The pain may improve as the day wears on and the ligaments, tendons, and muscles of the foot are stretched, but it will return after periods of inactivity. This pain from inactivity can be caused by being forced into an uncomfortable position, or from soreness due to excessive strain. For many patients, the pain seems to lessen during workouts as the muscles and ligaments warm up and stretch.

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Some patients may feel pain throughout their entire foot (especially along the arch) regardless of heel pain. In cases where the pain is very sharp in the arch and does not seem to improve as the day progresses, there may be a more serious injury, such as a rupture or tear. These can sometimes come about as a result of improper treatment, since the underlying issues that cause it could also be causing additional health concerns.

If it is left untreated for an extended period of time, you may experience numbness rather than pain. This is because the nerves have become quite compressed as the swelling and inflammation has intensified. Alternatively, if it turns out this condition is a degenerative disease, then the numbness would be caused by the degeneration of the nerves, as opposed to compressed nerves.

Breakdown of Symptoms:
  • Pain in the heel – especially if it is worse in the morning and seems to lessen with activity
  • Swelling along the arch of the foot, in the heel, or on the ball of the foot
  • Pain along the arch of the foot
  • Weakness in the ankle or arch of the foot
  • Tightness in the calf or achilles tendon that doesn’t respond to moderate stretching

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Causes

Plantar Fasciitis thought to be an overuse or misuse injury, resulting from being too tight to support the pressure of walking. For some individuals, tight ligaments may be due to improper stretching or increasing activity too quickly, whereas for others it may be more of a mechanical/anatomical issue. This can be prevented by stretching properly before beginning intensive workouts, or by incrementally increasing the intensity of your workout over time.

Posture plays a big role in overall body health. A properly aligned spine, neck and shoulders when standing and running is paramount to good running form. Having improper posture can result in extra pressure being distributed throughout the body: from the pelvis, to the knee, all the way down to the lower foot. This extra pressure flows down through the body, and can cause your feet to react negatively as a result. This is why posture is a common culprit.

Women who frequently wear high heels may find that they are prone to the condition. This is because their calf muscles get tighter and shorter when wearing them, making it difficult to stretch when they are wearing flat shoes or sneakers. While this is an injury that can afflict men and women equally, women experience it more often if they wear shoes that lack proper arch support.

Another common cause is excessive pronation. This is where your body weight is disproportionately distributed to your feet. Signs of excessive pronation include excessive bending of the ankle and flatter arches. Overpronation has been cited as the culprit for many different running injuries, and studies have shown that the damage caused by it is exaggerated. However, it’s still a possible cause, and should be considered before any other causes.

Causes:
  • Uncomfortably high level of activity
  • Tightness of calves and Achilles tendons
  • Excessive foot pronation
  • Wearing shoes with poor support
  • Weak leg muscles
  • Degrading tissue

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Risk Factors

While Plantar Fasciitis is typically an overuse injury, there are some factors to be aware of that will help you recognize if you are at risk of developing it:

As you can see, there are a number of risk factors, although experts debate as to which ones are the true culprits. It may be that individuals who have a combination of these traits develop Plantar Fasciitis. An example would be someone who frequently wears high heels, is overweight, and has tight calves. On the other hand, it may simply be dumb luck; some who overpronate will get it, while others won’t. Regardless, it’s important to know the signs and symptoms. This way, if you suspect it as the cause of your heel or foot pain, you can begin home treatment and see a medical professional right away.

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Diagnostic Practices

Typically, medical imaging (x-ray, CT scan, etc.) is not needed as a diagnostic tool; a simple physical examination will suffice. However, a doctor may decide to order imaging tests if there is a possibility of a fracture or break. This is especially common if the pain is very sharp or presenting in an atypical manner. In the absence of any issues with the bones, it will be diagnosed based on the presentation of physical symptoms.

In order to achieve an accurate diagnosis, doctors will review current symptoms experienced by their patient. This is done by pressing along the bottom of the foot and heel looking for tender spots, swelling, or any portion of the leg that feels unusual. The doctor may also ask the patient to walk or run a bit, so that they can examine the patient’s stride and see if there are any mechanical issues which may have contributed to their injury. They may ask questions related to the patient’s exercise habits: whether they are stretching properly before working out, whether they’re wearing the appropriate sneakers, and what type and length of workouts they’re putting in every week.

You may think that these diagnostic procedures are invasive and excessive, but it’s very important to rule out any false positives. According to this practicing podiatrist, heel pain can be caused by a number of ailments, including cysts, tears, gout, or a full-on stress fracture. Even if you experience very mild heel pain, it is highly recommended to seek a thorough diagnosis, as these injuries can worsen over time.

Breakdown of Diagnostic Practices:
  1. Ask patient about levels of activity and location of pain
  2. Test for pain in specific areas by pressing the heel and foot
  3. Observe patient walking and running to analyze gait
  4. Conduct X-rays or CT scans to study bone and tissue structure

False Positives:

Not all cases of foot pain are related to plantar fasciitis. While it is a common running injury, there are other potential causes for foot pain. A big reason why it’s important to receive a proper diagnosis is that it requires different treatment methods than other foot injuries. Be sure to rule out these other ailments before beginning treatment to avoid wasting your time and money:

  • Achilles Tendonitis: This is the injury most frequently confused with Plantar Fasciitis, causing pain and swelling around the back of the ankle.
  • Heel Spurs: Often found in patients with this condition, this is not the cause of that injury nor a symptom of it. It is a buildup of calcium that causes a protrusion in the heel.
  • Heel Bursitis: A swelling of the bursa, or cushion found near the ankle. Often associated with Achilles Tendonitis.
  • Heel Stress Fracture: One or more small cracks in the bones near the heel. Has similar causes and pain, but is a different condition entirely.
  • Bone Cysts: Also known as intraosseous lipoma. While scary sounding, these are non-cancerous and easily treated fluid pockets in the bones.
  • Arthritis: Commonly afflicting older people, this autoimmune disease causes joint pain in several locations on the body.

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Running:

As a general rule, you should not run at all with Plantar Fasciitis. Your body will lash out at you with pain, and in many cases you will exacerbate the problems and make the condition worse. However, if you’re absolutely determined to continue running while suffering from this condition, there are a few methods you can try to decrease the agony and continue strengthening your legs.

Method 1: Slower Running

A good first option when suffering from foot pain is to cut out any speed drills or sprints. These can be great for promoting cardiovascular health, but are killer on your feet when suffering from this inflammation. Instead, switch to jogging or brisk walking, and take slower laps. This will allow you to continue strengthening your foot, which can help treat and prevent this condition in the long run.

Method 2: Anti-Inflammatory Medicine

If the pain is still unbearable when running, try taking some over the counter anti-inflammatory medicine before your workout. Something like Advil or Ibuprofen can decrease swelling from foot damage, and will numb some of the pain. There are stronger anti-inflammatory drugs and topical creams you can use for more serious cases, but you’ll need to get a prescription from a doctor to obtain them.

Method 3: Massage

With a bit of physical stimulation to the affected area, a lot of the swelling and pain can be reduced in milder cases. Something as simple as a foam roller or a towel can be effective, but what works even better is something cold, like an ice-cold bottle of water. This is best done in conjunction with other methods, such as anti-inflammatory medicine and KT tape.

Effective Massaging Tools:

  • Towel
  • Water Bottle
  • Foam Roller
  • Foot Massager
  • Tennis Ball
  • Ice pack

Method 4: Kinesio Tape

Kinesiology tape, or KT tape, is an elastic material that can provide additional support to the foot as well as reducing inflammation. By limiting the movement, properly applied KT tape will prevent the issues that cause and worsen the inflammation. However, this is only a temporary fix for the problem, and shouldn’t be used very frequently. The downside to this practice is over-reliance on it can cause the tissues in your foot to atrophy due to lack of activity. Regardless, taping can provide quick relief on especially painful days.

Applying Kinesio Tape Step by Step:

  1. With your toes stretching upward, attach one end of the tape to the underside of the foot.
  2. Stretching the tape slightly, place the rest of the tape down along the underside, stopping at the back of the ankle.
  3. With another strip of tape, attach one end to the upper ankle, on the inside of the lower leg.
  4. Adding minor tension with slight stretching, place the rest of the tape along the side of the foot, under the sole and ending on the other side.
  5. Place the tip of a third tape piece on the back of the foot, higher up than the first piece and at a 45-degree angle.
  6. Similar to the second strip, apply mild tension and place the rest of the piece along the lower foot and under the sole, ending on the other side.

Treatment

The first line of treatment for Plantar Fasciitis is rest, ice, and anti-inflammatory pills. Once the inflammation has gone down, your doctor may recommend gentle stretching or may refer you to a physical therapist. If you see a physical therapist, you may be treated with a combination of stretching, ice and heat therapy, and ultrasound therapy. Ultrasound therapy has been used effectively to treat plantar fasciitis in the past, but recent studies have found this to be due to a placebo effect.

As a simple and cost-effective first step for treating Plantar Fasciitis, you can try taking anti-inflammatory medicine. This ranges from pills to topical creams, and usually contains Ibuprofen, ketoprofen or piroxicam: common medicines with anti-inflammatory properties. Taking these medicines, whether over-the-counter or prescribed by a doctor, can reduce pain in mild cases of Plantar Fasciitis. In the event that it doesn’t help, you may have a more serious case, requiring more advanced treatment methods.

For patients that have a severe case or unusually tight muscles, you may be given a splint to wear at night. This will prevent your muscles from contracting in your sleep and aid in stretching. Additionally, some patients may be candidates for steroid injections, which will help to alleviate pain temporarily while promoting healing in the injury. Most patients recover within 2 months of beginning this style of treatment.

In more severe cases, where the patient has an abnormally high amount of pain, or does not show signs of improvement after over six months of non-surgical treatment, their doctor may recommend surgery. This rare treatment is performed to release some of the tension in the plantar fascia and/or remove heel spurs that may have formed. However, in cases where surgery is necessary depending on the exact procedure that is undertaken, the arch of the foot may be weakened and running may no longer be possible.

On average, pain from Plantar Fasciitis tends to subside after 12 months. This could be due to the muscles and tissues in your feet adjusting to your activity and gait. On the other hand, this can also be caused by a loss of feeling from the plantar nerves due to degradation, so it’s still important to undergo proper treatment. Just know, no matter how bad the pain gets, it is only temporary.

Physical Therapy for Treating Plantar Fasciitis:

Usually, physical therapy is handled by a doctor or other medical professional. They will advise you on specific practices and tools to use when treating your injury. As a general rule, you should always consult a professional before engaging in physical therapy to achieve the best results. However, these are some general tools and exercises you can try, that doctors may end up recommending to you.

  • Stretching: Some examples of stretches you can do to prevent and treat Plantar Fasciitis can be read below.
  • Massage: This can be done by hand or with the use of a tool, such as a water bottle or ball.
  • Ice: Applying ice to the affected area can be used in physical therapy, and can be combined with other methods like massage.
  • Orthotics: Whether it’s a brace worn at night or gel inserts worn in your shoe, physical therapists will usually implement some form of orthotic technology.
  • Taping: The affected area is taped with either medical tape or KT tape in order to reduce tension and/or align the parts of your leg properly.
  • Steroids: In some extreme cases, doctors will treat the affected area with steroid injections as a short-term recovery method.
  • Shockwaves: Extracorporeal Shock Wave Theory, or ESWT, is a method of relieving pain from Plantar Fasciitis by generating vibrations from sound waves.
  • Acupuncture: As scientific studies have shown, the selective use of acupuncture can greatly decrease foot pain in a majority of cases.
Breakdown of Steps for Treating Plantar Fasciitis:

These are ordered from least to most severe.

  1. Resting affected foot while applying ice
  2. Stretching and physical therapy
  3. Ultrasound therapy
  4. Wearing a splint
  5. Steroid injections
  6. Surgery

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Prevention

Plantar Fasciitis can be treated when it comes up, but it’s equally important to take measures in order to prevent it from ever occuring. This is especially the case if you’ve just recovered from a bout of it, since your likelihood of repeat injury is high. Keep these techniques in mind and you should be able to prevent any future occurrences of Plantar Fasciitis.

Method 1: Proper Stretching

The first line of defense in preventing Plantar Fasciitis is to make sure you’ve thoroughly stretched your calves and ankles before every workout. If you wear high heels often, you may also want to stretch during the day and at night before bed.  This will prevent your calf muscles from tightening or shortening, which can cause problems down the line. The most commonly held belief is that Plantar Fasciitis is caused by excessive tightness in your calf muscles, achilles tendons, or toe muscles. If these are too tight, they pull at your plantar fascia in an effort to maintain normal range of motion. Therefore, stretching these groups of muscles will help lengthen them and eliminate the strain on the plantar fascia.

Stretches to Prevent Plantar Fasciitis

These are some simple stretches you can do to help reduce tightness in trouble spots, such as the calf and Achilles tendon. Some of these stretches may require additional materials, such as a step, towel or resistance band.

  • Step Stretch: While standing on the edge of a step with your heels hanging off, slowly lower and then raise your heels. Do three sets of 10 or two sets of 15.
  • Domes: Stand flat on a floor and press your toes down into the ground, forming a dome with your entire foot. Hold and release for three sets of 10 or two sets of 15.
  • Calf Raises: While standing flat on a floor or on the edge of a step, raise and then slowly lower your heels. This movement is essentially the opposite of the step stretch. Do three sets of 10 or two sets of 15.
  • Marble Pickups: Place a cup on the floor next to a pile of small marbles. Use your toes to pick up the marbles and place them in the cup. Do this with both feet.
  • Toe Stretches: While seated, grab your big toe with your hand and pull it back, toward your ankle. Hold for 20 to 30 seconds and release. Do this with both feet, 3 or 4 times a day.
  • Achilles Tendon Stretch: With one leg behind the other, extend your front knee while keeping the bag leg straight. Hold this lunge position for 10 seconds and then release. Do this ten times for each foot, up to three times a day.
  • Rolling Foot MassageUsing a foam roller, roll the sole of your foot back and forth across while seated for one minute. Repeat with your other foot. This can also be performed with a cold water bottle or metal can.
  • Arch Stretch: Loop a resistance band under the arch of your foot while seated. Full the band toward your body, stretching your toes. Hold for 15 to 30 seconds. Do this for both feet, three times a day. You can also use a rolled up towel for this exercise.

Method 2: Appropriate Footwear

Wearing supportive footwear will help to decrease pressure on the plantar fascia, thus preventing inflammation. The main cause is a swollen or degenerated tissue.  Therefore, shoes that support the arch of your foot will distribute the pressure caused by your body weight, helping to alleviate pain and prevent further injury. In addition, using orthotics such as gel inserts can also decrease stress on your lower foot, even in shoes without adequate arch support.

Plantar-Fasciitis-Footwear
Top Shoe Models for PF: Asics Gel Kayano | Brooks Adrenaline GTS | Asics GT 2000

While these aren’t to be worn during the day, night splints are also a very effective form of footwear that can prevent Plantar Fasciitis. If you have abnormal sleep habits and feel sore in the morning, you may want to consider wearing a night splint when you go to sleep. These will gently stretch your plantar fascia and Achilles tendon, preventing stress while sleeping. They are generally meant to be worn temporarily, but you may want to wear it from time to time if you find your heel acting up.

Types of Appropriate Footwear

Method 3: Incremental Training

One of the most common cause is overexertion. This can occur when runners increase their level of activity to a level too high for their body to adjust to. If you’ve started running several miles a day after a long period of inactivity, this is the most likely cause of any heel pain that may occur. This common culprit for Plantar Fasciitis is confirmed by medical professionals, and slowly acclimating the body to working out is the proposed solution. A good rule of thumb to adhere to is that you should increase the length of your workout by 10% every week.

When first starting to run seriously, it’s a good idea to run on softer surfaces. If you have access to an Olympic-style track with rubbery material, that is the most ideal training surface for running. If that isn’t available, try running on grass or soft dirt. Some surfaces to avoid (at first) are cement sidewalks and asphalt, as these are harder and can cause more shock to lesser developed knees and feet. While studies have shown that the effects of surfaces on running injury are mostly circumstantial, it’s still a good idea to start with softer surfaces, as it can help develop muscles and proper running form.

Running Surfaces, Soft to Hard:

These are some of the different running surfaces you may encounter when training, ordered from softest to hardest. It’s a good idea to train on all types of surfaces eventually, but in order to avoid injury you should start with the softer surfaces first.

  1. Olympic-style running track
  2. Carpet
  3. Grass
  4. Soft dirt
  5. Gravel
  6. Asphalt
  7. Hard dirt
  8. Hardwood floor
  9. Cement

Method 4: Correcting Anomalies

For some people with Plantar Fasciitis – especially those who have it as a result of an anatomical abnormality – the best preventative measure is to correct those abnormalities. This ensures that your running form is correct, and is more effective than simply using orthotics. Orthotics can help in the short term, but correcting the underlying problem with your gait or posture is an effective long-term solution. After all, wearing orthotics doesn’t solve the underlying problems; it simply relieves pain associated with these problems.

There are slight physical deformities that can cause Plantar Fasciitis: for example, having a twisted bone structure or one leg being slightly shorter than the other. In these cases, you should consult with a medical professional in order to identify the most effective solution. For example, those that have pronated feet may find that a specific orthotic is helpful, while those with a slightly shorter leg may use padded cushions in their shoe to accommodate the height difference.

Medical Treatment:
  1. Anti-Inflammatory Medicine: This involves using over-the-counter medicines such as Ibuprofen to reduce swelling in the affected area.
  2. Gait Analysis: In cases where this injury is caused by improper walking methods, being examined thoroughly by gait analysts can help pinpoint the problem.
  3. Physical Therapy: If the source of your problem is determined to be related to poor gait or weak muscles, doctors can have you undergo physical therapy. Training incrementally can help correct poor walking habits or strengthen weak muscles.
  4. Radiotherapy: Commonly used for cancer treatment, this procedure involves bombarding the affected part of the body with X-rays. Studies have shown this procedure to be remarkably effective at reducing pain.
  5. Plantar Fascia Release: In rare cases where surgery is required, a medical professional may recommend this surgery. It involves using a needle or direct incision to release tightness, sometimes by removing a portion of it.
  6. Heel Spur Removal: When the pain is caused by a heel spur, this medical procedure is conducted to relieve it. It is similar to plantar fascia release surgery, although it may also involve directly removing calcium deposits or other protrusions from the foot.
  7. Botulinum Toxin Treatment: A somewhat unconventional treatment, this involves the use of botulinum toxin, commonly used in Botox surgery, to the affected foot. There have been studies verifying its effectiveness, but the treatment has yet to gain popularity.

Conclusion

Injuries such as Plantar Fasciitis are inconvenient at best, and unbearably painful at worst. If improperly treated, it can cause setbacks in a runner’s workout, forcing you to lose weeks of effort due to downtime. In the worst cases, left untreated can lead to serious crippling injuries, permanently affecting your ability to run. Understanding how this injury happens and what areas of your body it affects is paramount to properly treating it. With the information presented in this article, you should be able to effectively treat any instances of Plantar Fasciitis, as well as prevent future bouts of heel pain from occuring.

Co-written by Eddy Mihai

Curated by Diana Rangaves, PharmD, Rph

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Some of the sources used while conducting our research

These are the sources cited in this article with additional information on Plantar Fasciitis. While these are reputable sources with information from medical professionals, you should not take the information in this article as professional medical advice. Consult a doctor before trying anything listed in this article.

Sources

  1. HeelthatPain.com, Plantar Fascia Ruptures and Tears, Medical Technology Database,
  2. Paul Ingraham, Save Yourself from Plantar Fasciitis!, Online Database for Advice for Aches, Pains & Injuries,
  3. Mayo Clinic Staff, Plantar fasciitis: Symptoms and causes, Online Clinic & Health Information Database,
  4. American Osteopathic Association, The Real Harm in High Heels, Online Database of osteopathic medicine Information,
  5. British Journal of Sports Medicine, Foot pronation isn't associated with increased injury risk in novice runners wearing a neutral shoe: a 1-year prospective cohort study., National Institutes of Health Online Library of Medicine,
  6. Bob Baravarian, DPM, A Guide To The Differential Diagnosis Of Heel Pain, Online Publication of Medicine and Health Information,
  7. FootCareMD, Plantar Fasciitis, Orthopedic Foot & Ankle Society & Online Information Database,
  8. Renata Graciele Zanon | Adriana Kundrat Brasil | Marta Imamura, Continuous Ultrasound for Chronic Plantar Fasciitis Treatment, Plantaar Fasciitis Treatment Article,
  9. WebMD, Plantar Fasciitis - Prevention, Online Database of Health and Medicine,
  10. SportsInjuryExcercises, Plantar Fasciitis Exercises, Online Clinic and Sports Injury Database,
  11. Foot & Ankle Center of Washington, The Best Orthotics for Plantar Fasciitis, Online Information Database of Foot and Ankle Care ,
  12. Badakhshi | Buadch, Low dose radiotherapy for plantar fasciitis. Treatment outcome of 171 patients., National Institutes of Health Online Library of Medicine,
  13. FootCareMD, Plantar Fascia Release, Orthopedic Foot & Ankle Society & Online Information Database,
  14. DoveMed | Douglas J. Jones, MD FACS, Heel Spur Removal, Health Topics and Medical Information Online Library,
  15. The Clinic Journal of Pain, Is botulinum toxin A effective for the treatment of plantar fasciitis?, National Institutes of Health Online Library of Medicine,
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