The majority of foot pain is caused by a sprain or by wearing the wrong shoes. However, there are other times when foot pain stems from a deeper issue, and the most prevalent of these is plantar fasciitis.
Plantar fasciitis is the most frequent cause of heel pain in adults. Approximately 1 million U.S. patients visit health care for plantar fasciitis annually. It impacts both athletes and non-athletes. It is observed in those who stand for long periods of time and in those who sit for most of the time.
If not treated properly, it can last between 6 and 18 months. Most cases can be treated and resolved within 6 to 12 months. The difference between these two results is usually depend of whether the mechanical root causes are treated or not.
What is Plantar Fasciitis?
The plantar fascia is a thick band of fibrous tissue that stretches from the bottom of the heel, across the arch, and to the toes. It serves as a shock absorber and as a foot support during walking, running, and standing. Plantar fasciitis happens when this tissue gets irritated, develops micro-tears, and is in a state of chronic low-grade injury.
There are actually two phases to Plantar Fasciitis. Acute inflammation is the first stage. This is the first intense pain that you experience. It is a rapid immune reaction in response to a micro-tear.
The second stage is known as tendinosis. This is the chronic, degenerative phase. At this stage, the tissue’s normal blood supply is lost. When the blood flow is compromised, the tissue doesn’t have the exact nutrients and oxygen supply it needs to repair. The micro-tears do not heal because the tissue doesn’t have what it needs.
Until recently, the condition was thought to be inflammatory, although the term was not correct. Over the last 20 years, studies have proven that there is little to no active inflammation in the plantar fascia in most chronic situations.
Instead, there is evidence of failed tissue healing, collagen degradation, and disorganized tissue repair. Pathologists now use the term fasciosis instead of fasciitis.
This makes sense why anti-inflammatory treatments like anti-inflammatory medications, cortisone injections, or ice provide only temporary relief. These plantar fasciitis treatments are ineffective for long-term cure. Plantar fasciitis is actually a tissue healing problem, and not merely an inflammation.
Causes of Plantar Fasciitis
Plantar fasciitis occurs when the plantar fascia is continually subjected to a load that it cannot handle and recover from. Your body is designed to handle specific mechanical loads. When the mechanics of your foot are compromised, the tissue receives a lot of concentrated, repetitive stress.
- Flat Feet (Pes Planus): When you have flat feet, the fascia is overstretched. It is like a stretched-out rubber band. It loses its structural integrity and tears easily.
- High Arches (Pes Cavus): If you have high arches, the fascia is too tight. It pulls on the heel bone, which results in biomechanical pressure points.
- Unsupportive Shoes: When you wear flat, unsupportive shoes, you take away the external structure, forcing your foot to collapse and the fascia to overwork.
- Leg length discrepancy: Any difference in the length of your legs can affect the mechanics of your gait and can overload one side of your plantar fascia more than the other side.
- Rapid mechanical load: Sudden increase in activity, such as starting a new exercise program, can be very stressful for the tissue and lead to rapid micro-tears.
- Obesity: Extra weight on your body puts more mechanical strain on the sole of your feet. BMI > 30 has been repeatedly reported as a risk factor for plantar fasciitis in non-athletic populations.
- Age: As you age, all connective tissue becomes less elastic and slower to recover from microtrauma with age. This can incidence between between 40 and 60 years old.
- Hidden conditions: In some cases, diabetes, rheumatoid arthritis, seronegative spondyloarthropathies (including ankylosing spondylitis and psoriatic arthritis), and hypothyroidism are all associated with plantar fasciitis
Plantar fasciitis cases
Most plantar fasciitis cases are not due to one specific cause. They can be caused by a variety of factors, including tight posterior chain muscles, load being applied to tissue that it has not adapted to, and changes to footwear or surfaces. These often happen simultaneously. Addressing only one of these factors is a common reason for treatment not working.
Plantar Fasciitis Symptoms
The symptom of plantar fasciitis is easily recognizable, which makes a clinical diagnosis easy in most cases; you should be looking for these specific plantar fasciitis symptoms to determine whether or not this is your problem:
- Sharp, stabbing pain at the bottom of the feet
- Pain after sitting for extended periods of time
- The first step in pain
- Pain after activity
- Pain when toes are bent upward
- Pain in the bottom of the arch
- Soreness at the sole of the foot
- Absence of pain at rest
What plantar fasciitis does not typically cause: Swelling visible to the naked eye, skin changes, warmth or redness over the heel, numbness or pins and needles, or pain that radiates up the leg. If you have any of these features, another diagnosis (such as tarsal tunnel syndrome, a stress fracture, nerve entrapment, or a systemic inflammatory condition) should be considered. Each of these needs a different investigation and management.
Why is Plantar Fasciitis so Slow to Heal?
Without specific treatment, the recovery period would be around 6 to 18 months. Most cases can be successfully treated in 6 to 12 months. This timeframe is confusing to those who thought that only a few weeks of rest and anti-inflammatories would be enough for a painful foot to get better.
The primary reason your condition is lasting months is the transition from acute inflammation to chronic tendinosis. There may also be other reasons like:
- The plantar fascia does not have its own blood supply
- The tissue is continuously loaded onto the machine
- The underlying mechanical factors are usually not addressed
- Partial rest can actually worsen deconditioning, but not heal it
One study has shown that about 80% of plantar fasciitis will heal within 12 months of conservative therapy. But, the same review pointed out, there was little difference in the rate of resolution in patients who had no treatment at all in many studies. This implies that doing something is not enough. You need to do the right things to address the underlying mechanical drivers and stimulate proper tissue remodeling.
Plantar Fasciitis Treatment
There is a solid body of evidence supporting the treatment of plantar fasciitis, and the most effective treatments are usually the easiest.
1. Stretching
Targeted stretching of the plantar fascia and calf muscles is the most supported plantar fasciitis treatment.
Stretching the plantar fascia specifically is done by sitting down, crossing your affected foot over your knee, and moving your foot towards your shin until there is a stretch felt along the arch and bottom of your foot.
Repeat 10 times and do at least 3 times daily. Do this before you start walking in the morning and after a long sitting period.
2. Eccentric and Isometric Loading
As opposed to muscles, the rest is not enough to stimulate connective tissue. It requires mechanical loading to stimulate collagen remodeling and strengthen tissue, which is controlled.
Eccentric heel drops are performed by stepping on the balls of the feet, raising onto both feet and slowly lowering onto the affected foot.
Isometric calf holds involve standing on the balls of both feet and holding the raised position for 30–45 seconds. These can be very beneficial in the initial stages when eccentric loading is too painful.
3. Night Splints
Night splints keep the foot in a mild dorsiflexed position, e.g., toes pointing slightly upward. Apply a gentle stretch to the plantar fascia and calf while sleeping throughout the night. This directly addresses the mechanism behind morning pain. They work best in patients with predominant first-step morning pain.
Clinical trials consistently show that the treatment of plantar fasciitis with night splints is effective, with several randomized controlled trials demonstrating that pain in the morning can be significantly reduced in 1–3 months.
4. Orthotics and Footwear Modification
While custom orthotics are commonly used, the evidence is not strong enough to recommend them for the majority of patients over a good-quality prefabricated orthotic. You should look for these footwear features:
- A rigid heel counter
- Adequate midsole cushioning
- Slight heel-to-toe drop (8- 12 mm) to minimize the tensile forces on the plantar fascia
5. Physical Therapy
A physical therapist can use hands-on techniques to break up scar tissue and teach you how to physically load the tissue to stimulate repair.
A trained physiotherapist will examine your ankle dorsiflexion range, calf flexibility, and the strength of the intrinsic foot muscles, as well as your gait mechanics, to create a program to suit your individual pattern. If your physical therapy is not working, your provider can recommend specific targeted therapies.
6. Extracorporeal Shockwave Therapy (ESWT)
Extracorporeal Shockwave Therapy (ESWT) is an excellent plantar fasciitis treatment. It stimulates the growth of new blood vessels by uisng high energy acoustic waves and activates the natural repair process in your body.
This is usually done right in the clinic by your primary care provider, and it is a service that is almost covered by your health insurance.
7.Corticosteroid Injections
Corticosteroid injection is one of the most common treatments in primary care for plantar fasciitis. These injections can offer some short-term pain relief. But the evidence of their long-term relief and the risks should be discussed with your provider.
Multiple studies have shown that cortisone injections reduce pain significantly at 4–8 weeks, but the use of multiple cortisone injections is linked to a high risk of plantar fascia rupture. It is a serious complication that can result in sudden, severe worsening of the condition and a much longer recovery.
Currently, there is a clinical consensus that a single shot of cortisone may be suitable for short-term pain in severe cases, but should not be used as long-term treatment.
When to Seek Help
The majority of plantar fasciitis can be treated with the above methods and does not require immediate medical care. You should seek immediate medical attention if you cannot put weight on your foot without severe pain. Any case of redness, severe swelling, heat, or numbness in your heel should also prompt you to seek immediate medical attention.
Numbness is a red flag for a nerve issue, and severe heat and swelling are a red flag for a severe infection. This is a serious medical issue that requires a completely different medical approach than standard plantar fasciitis and getting back on your feet.
Bottom Line
Plant fasciitis is a tissue healing issue that is caused by mechanical load, inadequate tissue adaptation, and biomechanical factors that keep stressing the fascia more than it can withstand.
Its treatment is not as simple as just resting. It cannot be fixed with ice. It can’t be fixed with one cortisone injection. The problem can be corrected with targeted stretches, controlled loading of tissue to promote remodeling, footwear, and orthotic support when done correctly and regularly.
A Kairos Integrative Care, Lola, one of our integrative primary care nurse practitioners, provides evidence-based chronic disease management, screenings, and personalized treatment plans to help patients improve long-term health outcomes.
We see patients in Houston, Sugar Land, Richmond, and nearby areas (77046 & 77478) and accept major insurance plans, including Blue Cross, Aetna, Ambetter, Cigna, and more.
New patients are always welcome, and if coming into the clinic isn’t possible, telemedicine appointments are available across Texas.
