Plantar Fasciitis: A Guide to Effective Physical Therapy!

What is plantar fasciitis?

Plantar fasciitis is characterized by localized pain in the heel, often radiating to other parts of the foot, particularly the underside. It is the most common cause of heel pain, affecting approximately 4 to 7% of the population at least once in their lifetime (Luffy et al., 2018).

It mainly occurs in active adults between 25 and 65 years of age (Buchanan et al., 2020), especially between 45 and 64 years old (Nahin 2018).

ℹ️ Plantar fasciitis results from inflammation of the plantar fascia, also known as the plantar fascia. It is a band of fibers that connects the heel bone to the bones of the forefoot.

Imaging tests such as ultrasounds, MRIs, and CT scans provide a clear visualization of plantar fasciitis. However, as we will see, they are of no use in diagnosing and effectively managing this condition. A simple interview and clinical examination are sufficient for diagnosis.

Sometimes, individuals with plantar fasciitis also have what’s called a heel spur: a bony spike forms at the heel bone. Good news: this is not a sign of severity of plantar fasciitis. In fact, foot pain does not disappear any slower in people with a heel spur (Hansen et al., 2018).

What are the symptoms of plantar fasciitis?

The main sign is pain:

• at the level of the heel, more towards the bottom and the inside;
• which can radiate into the calf;
• that appears progressively;
• especially strong in the morning upon waking up;
• also strong when standing for long periods, sometimes even when sitting;
• aggravated by palpation of the base of the heel, where the fascia inserts; also aggravated when dorsiflexing the ankle (bringing the front of the foot toward the shin);
• sometimes present at night or at rest. (Buchanan et al., 2020)

ℹ️ There is no need for additional tests (X-rays, MRI, blood tests, CT scans, etc.). The examination and interview are sufficient.

In case of doubt about another possible condition if other signs are present, these tests are sometimes prescribed. But they do not help to diagnose or manage plantar fasciitis better. They also do not provide more precise information about the duration of recovery.

For example, even if an MRI can evaluate the thickness of the fascia where the inflammation is, it does not necessarily indicate whether plantar fasciitis will heal faster or slower. People with significant inflammation and a substantial thickness of fascia do not necessarily recover more slowly than those with mild inflammation and a thinner fascia (Ermutlu et al., 2018).

It is not necessary to have an X-ray, ultrasound, CT scan, or MRI to diagnose plantar fasciitis. The interview and examination are more than sufficient.

What is the cause of plantar fasciitis?

Here are the identified or suspected causes and risk factors:

• being obese or overweight;
• starting running, or suddenly increasing the frequency, intensity, or duration of running;
• standing for several hours a day, whereas you spent little time on your feet before;
• running itself. Up to 22% of runners are affected by it; having flat or high arches; being stressed (Harutaichun et al., 2019);
• having limited ankle dorsiflexion range of motion (the end of the foot doesn’t move much toward the shin) (Hasmtra-Wright et al., 2021). (Buchanan et al., 2020)

ℹ️ Some people wonder if Kalenji brand shoes (Decathlon) can cause plantar fasciitis. Indeed, some individuals who purchase Kalenji shoes may experience heel pain in the weeks that follow. However, this pain would likely have occurred with any brand of sneakers!

The pain is due to the fact that people are starting to run, changing their habits, or increasing their training frequency. This frequently happens to people wearing Kalenji shoes because it’s a very popular brand in France, especially among those who are new to running.

To prevent plantar fasciitis, you can: 1/ avoid being overweight; 2/ gradually increase the frequency and intensity of running or standing for extended periods; 3/ maintain ankle flexibility.

What are the treatments and management options for plantar fasciitis?

Numerous treatments are recommended and offered for plantar fasciitis:

• physical therapy / physiotherapy sessions,
• stretching,
• cryotherapy,
• shockwave therapy,
• wearing orthotics,
• night splints,
• injections of anti-inflammatories,
• platelet-rich plasma,
• botulinum toxin,
• corticosteroids,
• cessation of sports activities,
• acupuncture, etc.

How to navigate through all of this?

This section discusses each of these treatments and their benefits. The goal is to identify the treatment to implement that is:

• the most effective;
• the least time, energy, and cost-intensive;
• the simplest to carry out;
• with the fewest possible side effects.

This conservative treatment relies on three very simple things to implement, as you will see when reading this section:

1. resting the foot;
2. wearing comfortable shoes with a thick heel;
3. potentially performing a few stretches every day, either supervised or unsupervised by a physiotherapist.

And that’s it. Let’s delve into this a bit more.

What Shoes to Wear for Plantar Fasciitis?

In the case of plantar fasciitis, doctors sometimes prescribe custom-made insoles from a podiatrist. However, off-the-shelf insoles, which can be purchased in supermarkets or online, can be sufficient to alleviate pain. Even the latter are optional.

When experiencing heel and foot pain, what matters most is finding comfortable shoes. Their original sole and heel should be thick enough. Typically, Dick’s Sporting Goods’s running shoes do the job very well.

Here are an example of sneakers (on Amazon) that are comfortable and provide relief from plantar fasciitis-related pain.

Regardless of the brand and model, what matters is that they have a thick enough heel without being rigid. You can find this type of footwear in all sports stores or major general shoe retailers.

Plantar Fasciitis: Are Insoles Useful?

Custom or off-the-shelf heel inserts should be avoided: individuals suffering from plantar fasciitis find better relief with full-length standard insoles than with custom or non-custom heel inserts (Schuitema et al., 2019).

Purchasing standard insoles with sufficient thickness in the heel area can be beneficial if:

• The insoles of your everyday shoes are too worn out.
• Your shoes lack insoles or have uncomfortable ones in the heel area.

Here are on Amazon some budget-friendly insoles that work well. You can find similar insoles in sports stores like Dick’s Sporting Good or even in department stores. What matters most is that they are full-length insoles (not just heel inserts), sufficiently thick, and comfortable in the heel area.

Night Splints/Orthotics for plantar Fasciitis ?

It appears that some individuals find more relief when they combine wearing thick-heeled sneakers during the day with using night splints at night (Schuitema et al., 2019).

These splints maintain the ankle in a certain position to stretch the plantar fascia. This can be uncomfortable and somewhat restrictive because you need to remember to wear them every night, not to mention the non-reimbursed cost of about 20 euros.

ℹ️ Therefore, I simply recommend to my patients to:

• Wear thick-heeled sneakers as often as possible.
• Avoid high heels and very thin flip-flops, even when staying at home.
• Limit the time spent barefoot, at least during the first few weeks, until the pain decreases significantly or disappears.

Here are an example on Amazon of night splints that you can use in case of plantar fasciitis. You can find these models or similar ones for purchase at any pharmacy, drugstore, or medical equipment retailer.

Wearing standard shoes with thick insoles and heels is recommended for plantar fasciitis (sneakers++). Specific insoles or custom-made insoles from a podiatrist are not necessary. Heel lifts should be avoided.

Is hard massage good for plantar fasciitis?

When we have pain in a certain area, we often think that a massage can relieve us, relax us, and make us feel good. And that is indeed often the case; in the short term.

Massage can be a pretty good ally against pain, but only for a very short duration: for a few minutes or a few hours most of the time, sometimes a few days or weeks if done regularly.

ℹ️ (Hard) massage has no curative effect on plantar fasciitis; at best, it provides temporary relief.

Some people wonder if applying Tiger Balm can be more effective? Tiger Balm contains essential oils, camphor, and menthol, in varying proportions depending on the preparations.

These substances are present in small quantities in the product. A very small amount of the product is applied to the skin (Tiger Balm jars are only 68 grams!), and an even smaller amount has a chance to penetrate into the fascia or into the bloodstream. Moreover, none of these substances have an established anti-inflammatory effect when applied to the skin.

All these factors suggest that applying Tiger Balm has no healing effect. It can simply make the moment pleasant for people who enjoy this product.

Massage serves no purpose other than providing temporary relief for some people at the time it is applied. It does not cure plantar fasciitis.

Are essential oils effective against plantar fasciitis?

Many people wonder about the effectiveness of essential oils (aromatherapy) in healing or relieving plantar fasciitis. To date, no studies have investigated the effectiveness of essential oils for plantar fasciitis.

Can we still hypothesize the possible effectiveness of essential oils? To lend weight to this hypothesis, it would be necessary to ensure that the oil can penetrate the body up to the fascia.

Moreover, it would need to penetrate in sufficient quantity to have an effect. Finally, the active substance contained in the oil would need to be effective in reducing inflammation or simply relieving pain.

It is unlikely that any one of these hypotheses is correct, and therefore, essential oils are unlikely to have any efficacy.

If you are interested in a similar context, like therapeutic cannabis, here are one article that might interest you: CBD and joint pain/osteoarthritis.

Essential oils do not speed up the healing of plantar fasciitis.

What physical therapy is recommended for plantar fasciitis?

First and foremost, your physical therapist should conduct an assessment by asking you certain questions:

• How long have you been experiencing pain?
• Have you changed your lifestyle, leisure activities, or sports practices a few weeks or months before the onset of pain?
• When do the pains occur the most? At what intensity? Ideally, your physical therapist will ask you to rate the intensity of your pain over a few days to establish a starting point for better evaluating the effectiveness of physical therapy sessions. Various tools are available for this and can be provided by your physical therapist, particularly rulers with a Visual Analog Scale (VAS).
• What are the consequences of your pain? How do they hinder you (e.g., sleeping, working, exercising, walking, etc.)?

Once the discomfort is well understood, a physical therapy treatment plan can be put in place.

It is crucial to have a good understanding of, identify, and if possible, quantify the pain BEFORE physical therapy sessions. This way, it will be easier to assess their effectiveness.

ℹ️ Physical therapy management primarily involves:

• Learning stretches to perform independently.
• Supervising the gradual resumption of activities that cause pain, especially sports activities (🔗 see this article on the healing time of plantar fasciitis, which provides more details on how to implement this).

Physical therapists sometimes also use ultrasound therapy, shockwave therapies, dry needling, electrotherapy (Compex), or specific manual therapies (Maitland, trigger points, myofascial techniques, etc.) for plantar fasciitis.

However, these techniques and devices have not shown superior efficacy compared to rest and stretching. Furthermore, they are more costly to implement and cannot be performed independently by the patient.

Therefore, they are not necessary for treating plantar fasciitis (if we are on the same page with my initial principles that guide the choice of treatments).

ℹ️ Also, for physical therapists, see this article published in BMJ 2019: Management of plantar heel pain: a best practice guide informed by a systematic review, expert clinical reasoning, and patient values.

What stretches & exercises should you perform?

These stretches include:

• The plantar fascia stretch
• Calf stretches (soleus and gastrocnemius).

How often should you do them? Although there isn’t a precise guideline, you can start with the idea of stretching for 5 minutes twice a day, every day. For those who find this too frequent, you can aim for 5 minutes three times a week, which is still better than not stretching at all.

Varying the stretching positions doesn’t offer significant benefits, aside from addressing potential boredom and motivation.

What matters more is gradually increasing the stretch’s intensity by going further into the stretch as your tissues adapt to the regular stretching.

Here’s an example of a possible progression: 9 plantar fasciitis exercise fot treatment of foot pain.

Does physical therapy really help plantar fasciitis?

It is true that there are many websites, some of which are run by physical therapists, that claim that physical therapy can clearly help heal plantar fasciitis. However, I would be more cautious in my assessment.

Firstly, it will depend on what you mean by “physical therapy.” Are you referring to exercises done under the guidance of a physical therapist? A one-time consultation to provide guidance and reassurance on what you can do? Sessions involving massage or shockwave therapy?

I believe it’s important to consider these elements individually rather than bundling them all under the term “physical therapy.” Even within a single country like mine, France, physical therapists can have widely varying practices.

Therefore, it is reasonable to think that:

• Consulting with a physical therapist whose approach you appreciate can provide reassurance and assistance.
• There is no one-size-fits-all technique practiced by physical therapists that guarantees your recovery.

Furthermore, there are no high-quality studies that directly compare the progress of people with plantar fasciitis who received physical therapy to those who did not, mainly because “physical therapy” is a very broad category. Studies typically evaluate specific techniques or types of interventions.

Plantar Fasciitis: Are there possible complications?

Complications are very rare. There is a much higher chance that you will not experience any complications; keep that in mind!

In rare cases, complications may include:

1. Tendon rupture (especially if corticosteroid injections have been administered).
2. Necrosis of the fat pad.

Complications of plantar fasciitis are extremely rare.

Can you recover from plantar fasciitis?

Certainly! If you ask a physical therapist or a general practitioner who has seen dozens of people with this condition during their career, there is a strong chance they will tell you that plantar fasciitis has disappeared in these patients.

However, can we be sure that these individuals have truly recovered? Perhaps they simply stopped mentioning their heel pain to their healthcare professional? In this case, it likely means that the pain:

1. Has disappeared.
2. Is not significant enough to be a real hindrance in everyday life, provided some easy adaptations are made.

ℹ️ Doctors and researchers have tried to learn more about the 10-year evolution of people with plantar fasciitis (Hansen et al., 2018). They interviewed and examined around 173 people about 9 years after being diagnosed with plantar fasciitis.

One year after the onset of the first pain, 80% of the individuals still had pain. Then, only 50% did after 5 years, and 45% after 10 years.

Do you find these figures discouraging? Rest assured: they likely pertain to individuals with “severe” plantar fasciitis.

Those in whom the pain disappears quickly consult for a shorter period and are probably lost to follow-up. Moreover, without necessarily sourcing their claims, other studies are much more optimistic and report that after 1 year, 75% of people are cured (Buchanan 2020).

The majority of people recover from plantar fasciitis. The longer the time passes, the greater the chances of recovery.

What is the recovery time for plantar fasciitis?

It depends on what you mean by recovery. Recovering from plantar fasciitis can mean:

1. Having no more pain at all.
2. Having much less pain.
3. Having mild pain that doesn’t interfere with daily life, work, sports, and other daily activities.

In general, it takes at least 2 to 3 weeks after the onset of symptoms to start seeing improvement. This requires some lifestyle adjustments: reducing time spent standing, adjusting footwear, and modifying sports activities.

Some people report that they got rid of the most troublesome pain within 1.5 to 2 months. For others, it takes longer, or the pain fluctuates over several months: sometimes it is much less severe and bothersome, and other times it is more intense, and it is difficult to identify what is responsible for these fluctuations.

Let’s not forget that one year after the onset of the first symptoms, 75% of people have no more pain (Buchanan 2020).

👉 Read this more comprehensive article on the healing time of plantar fasciitis.

Expect a few weeks for pain to decrease. Sometimes, it fluctuates over a few months, and for most people, it disappears completely within a year.

Is walking good for plantar fasciitis?

Yes, walking can be good for plantar fasciitis, but it’s important to adapt the load gradually by increasing the duration, intensity, and frequency of your walks.

This helps recondition your plantar fascia to handle stress. It’s all about finding the right balance!

What not to do with plantar fasciitis?

Here are the two main things not to do with plantar fasciitis:

1. Avoid continuing activities like walking or driving that significantly increase heel and foot pain during or after. Overloading the plantar fascia can exacerbate the condition, so it’s crucial to reduce or modify activities that worsen the pain.
2. Refrain from walking barefoot or wearing completely flat and unsupportive shoes with minimal heel cushioning, as they can increase discomfort and strain on the plantar fascia. Opt for shoes with proper arch support and cushioning to reduce the pressure on your heels.