The pain from plantar fasciitis is often felt on the bottom of the foot with the first few steps in the morning. It affects approximately 2 million Americans each year. In this article, I will briefly describe what plantar fasciitis is, common symptoms of plantar fasciitis, and how to identify five factors that may be contributing to your reoccurring plantar fasciitis.
Hopefully, this article will provide you with a new perspective about plantar fasciitis you haven't learned yet and hope for long-lasting recovery.
What is plantar fasciitis?
The plantar fascia is a band of connective tissue on the bottom of the foot that connects the heel to the toes.
It provides support and structure to the foot while walking or running. The function of the foot is very important for balance, strength, and keeping joints healthy.
Unfortunately, the plantar fascia can be over-strained resulting in pain at the insertion of the plantar fascia on the bottom of the heel. It’s one of the most common foot injuries that can stop you from hanging out with your friends, playing sports, or dancing with your loved one.
Plantar fasciitis affects nearly 2 million Americans per year. The estimated medical costs are approximately $192-$376 million per year in the United States.
What are the symptoms of plantar fasciitis?
- Pain on the bottom of the heel
- Pain with the first few steps in the morning
- Pain with walking, running, jumping or placing weight on the foot
- Pain after prolonged inactivity
What factors contribute to plantar fasciitis?
Plantar fasciitis may resurface after a day of strenuous activities. It may appear for no apparent reason when you wake up in the morning.
The pain has a tendency to return at the most inconvenient times and linger for months. What is causing your pain? And why are you getting this pain?
The research does not clearly identify the “cause” of plantar fasciitis. There is a multitude of factors that may contribute to plantar fasciitis; however, you can learn how to control these factors with proper education.
The actual mechanisms of pain are extremely complex, but I will try to simplify it down to what I believe is the most important factor: Your foot is not prepared to meet the demands placed on it.
In my opinion, the best solution to avoid reoccurring plantar fasciitis is an exercise-based prehab program.
What is prehab?
Prehab is the process of preparing your foot and body (it's all connected) to tolerate all the activities of your life. Your foot needs to support you while walking, running, hiking, playing soccer, dancing, and during most physical activities.
If your foot is not prepared for these activities then an injury can occur or pain can return. Prehab is not one or two exercises.
Prehab is a comprehensive process that teaches you how to:
1) Understand the factors that may increase your pain.
2) Increase or decrease the difficulty of exercises based on your response to the exercises.
3) Implement self-care strategies to give you the confidence to avoid plantar fasciitis in the future and act quickly if you feel the pain returning.
4) Improve the resiliency and capacity of your foot to meet and exceed the ability to perform all your favorite activities without pain.
5) Overcome stress, frustration, setbacks, and delays in your recovery process.
How can you avoid plantar fasciitis?
Unfortunately, the research does not provide a straight-forward answer to this question; however, we have research to guide our best attempt to avoid plantar fasciitis.
If you want to get back to your favorite activities without foot pain, then we should do our best to manage plantar fasciitis better based on the current research using a modern understanding of pain.
In the past decade, we have discovered revolutionary information about pain; however, this information has not been adopted by most of the medical community.
The medical community is lagging behind on the research and the slow adoption of this information is negatively affecting the lives of thousands of people struggling with recurring plantar fasciitis.
I would imagine one of your main goals right now is to reduce the pain in your foot and prevent the pain from coming back. These are reasonable goals, but I also want you to have realistic expectations.
Here are a few insights into the reality of plantar fasciitis recovery that you may have experienced:
1) Reducing your pain may be taking longer than you expected.
2) There have been unwanted setbacks.
3) It has been emotionally draining.
4) The amount of information on the internet about plantar fasciitis is enough to make your head spin.
5) Visiting a doctor, physical therapist, or chiropractor may not have helped you.
As a physical therapist, the last point makes me sad, but it's a reality. Some people have not benefited from traditional physical therapy.
It is important to realize that "physical therapy" is not a single solution. If "physical therapy" didn't help, then try not to throw the baby out with the bath water.
The skillset and experience of a physical therapist are vastly different between therapists. Unfortunately, some physical therapists have not adopted the new understanding of pain and plantar fasciitis.
I don't know your specific situation, but it is possible you could benefit by working with another physical therapist.
Now, we should discuss several of the contributing factors of plantar fasciitis. These factors are not all-inclusive of every possible factor that may be contributing to your pain, but it should provide a good starting point to understanding plantar fasciitis better.
Plantar fasciitis is a complex experience with many contributing factors.
Contributing Factor #1: Too Much Load
You may have heard about the concept of "doing too much, too soon." The concept is self-explanatory, but it involves doing too much activity in a short period of time.
Perhaps, you were walking on the beach all day or starting a high-intensity workout program. The next day you wake up with pain on the bottom of your foot and realize you overexerted yourself.
In many cases, plantar fasciitis is an overexertion injury from doing too much too soon. At a certain threshold, the plantar fascia can no longer withstand the demands placed on it.
In more scientific terms, we can identify these demands as the "load" placed on the plantar fascia. Over-straining the plantar fascia beyond the capacity of the plantar fascia to tolerate those loads can result in pain or injury.
The concept of balancing load with tissue capacity is relevant to most injuries and mastering this balancing act can help you avoid reoccurring plantar fasciitis.
Load > tissue capacity = Injury
Once the load exceeds the tissue’s capacity to tolerate that load, an injury is more likely to occur. Loading the plantar fasciitis with a strength training program is essential to staying pain-free and reducing your risk of injury.
It may still seem a little confusing to understand the concept of balance load on the plantar fascia. Here are two examples of two scenarios that could place too much load on the plantar fascia:
Examples of Too Much Load
Scenario #1- Running a 5K
You decide to run a 5K race without training for it. During and after the race, you feel a sharp pain at the bottom of your heel.
Unfortunately, you did not train the foot to tolerate the loads of running a 5K.
As a result, the plantar fascia can be over-strained and you may feel pain.
Scenario #2 – Starting a new job
You start a new job as a coffee shop barista. The new job requires many hours of prolonged standing or walking.
A rapid increase in the hours you spend standing or walking places a sudden increased load on the plantar fascia.
If you did not gradually adapt your foot to standing or walking for hours at a time, then you may develop plantar fasciitis.
The factors below also contribute to the amount of load placed on the plantar fascia. It is important to stay within the limits of what the plantar fascia can tolerate to avoid injury.
Contributing Factor #2: Increased Body Mass Index (BMI) - except for athletic populations
Studies show that body mass index (BMI) in non-athletic populations is correlated with plantar fasciitis. Those who had a BMI >30 were 5 times more likely to get plantar fasciitis compared to those with a BMI < 25.
An increased BMI can lead to more load and strain on the plantar fascia. The results of this study make a case that reducing BMI can have a beneficial effect to reduce the risk of getting plantar fasciitis.
A BMI calculator will help you determine your BMI. Test yourself and see if you have a high BMI.
Traditionally, BMI has been used as a measurement of obesity; however, muscle is heavy in weight, so those who are muscular may inaccurately be categorized as obese.
I think it is safe to say that you should not be worried about being too muscular. You will benefit from losing excess body fat and increasing your strength to avoid getting plantar fasciitis again.
Those who had a BMI >30 were 5 times more likely to get plantar fasciitis compared to those with a BMI < 25.
Contributing Factor #3:
Decreased lower leg and foot strength
Weakness in the lower leg and foot can place unwanted strain on the plantar fascia. To reduce excessive strain on the plantar fascia, you can strengthen the muscles in your legs such as the glutes, hamstrings, calves, and foot muscles.
Each foot is made up of 28 bones, 30 joints, and more than 100 muscles, tendons, and ligaments. (arthritis.org)
Imagine the complexity of movement occurring at the foot! Strong muscles will protect the plantar fascia by controlling these micro-movements at the foot and ankle.
The strength of your glutes, hamstrings, calves, and foot can be assessed by a physical therapist to determine your level of fitness.
After the strength assessment, you and your physical therapist will know what exercises initially appear to be most appropriate for your current fitness level and stage of injury. The type of exercises and difficulty of exercises should be carefully selected to avoid aggravating your foot.
Have you tried to get back to running or working out, but unexpectedly aggravated the pain in your foot which delayed your recovery by another few weeks or months? You had the right intentions to get back in shape, but the foot did not react appropriately.
It's okay. You can apologize to your foot, your foot will forgive you, and you can move on. These unexpected setbacks are common when you try to rehab from plantar fasciitis on your own.
In reality, these setbacks may occur when working with your physical therapist too until you both understand what is best for your foot. In general, these setbacks and frustrations will be significantly minimized when you have the guidance of a physical therapist.
Example of a strength test for the lower leg:
Calf Strength Test
The image on the left shows the heel raise test. The heel raise test is used to determine if you have adequate strength in the calf muscles. Weakness or poor tolerance of this movement may play a role in your pain.
As a reference, a 40-49-year-old male should be able to complete 32 heel raises without pain.
A 40-49-year-old female should be able to complete 24 heel raises without pain.
After looking at the calf strength test above, you may be thinking to yourself, "There is no way I can do one single leg heel raise right now - let alone 20!"
Don't worry. Your physical therapist will not have you perform strength tests beyond your ability level. Their goal is to alleviate your pain rather than increase it. After all, the Hippocratic oath states, "First, do no harm."
On that note, hurt does not equal harm. An exercise that leaves you hurting may not be causing harm. Pain is a complex process involving your mind and body.
During your strength training program, there may be times when your foot hurts and this is a normal part of your recovery. I'll discuss more about pain later in this article.
Contributing Factor #4:
Decreased motion in your lower body may place added strain on the plantar fascia. Reducing strain on the plantar fascia while increasing your activity tolerance is one of the primary goals to avoid reoccurring pain on the bottom of your foot.
There are three key areas to focus on:
1) Calf tightness
2) Decreased ankle range of motion
3) Big toe stiffness
According to the research, the most important of these three areas is big toe motion. Before starting exercises to improve these areas, go through an assessment with a physical therapist to identify what areas you should prioritize.
For example, if you don't have restrictions in your big toe, then it's not a good use of your time to focus your attention on stretches for the big toe. The areas to focus on may be different for each person.
I'll provide a brief description of each of there three areas to improve your familiarity with them when working with your physical therapist.
1) Calf Tightness
The calf muscle is comprised of two main muscles: the gastrocnemius and soleus. Technically, there are additional muscles in the calf, but these are the ones usually involved with "tight calves."
The length of the gastrocnemius and soleus muscle may be restricted resulting in limited motion at the ankle joint. Adequate ankle motion is needed for walking, running, climbing stairs, and many other activities.
A lack of ankle motion due to calf tightness can potentially increase strain on the plantar fascia.
I want to emphasize that calf tightness plays a smaller role in plantar fasciitis. The research does not conclusively identify "tight calves" as a risk factor for plantar fasciitis.
Does that mean that tight calves don't matter?
I'm sure they play a role, but it's not as significant as previously believed by the medical community. In spite of limited research, it's not going to hurt you to stretch your calves.
However, people frequently make mistakes when stretching their calves which may lead to more stress on the plantar fasciitis. So maybe, calf stretching can do more harm if you are not performing the stretches properly.
Examples of exercises to stretch the calf muscles:
Calf stretch with the knee straight
Stand with one foot in front of the other. The front knee should be bent and the back knee should be straight. Make sure the arch of the foot does not collapse. The stretch should be felt in the calf muscles of the back leg.
Calf stretch with the knee bent
Stand with one foot in front of the other. The stance is more narrow compared to the stretch on the left. The front and back knee should be bent. The stretch should be felt in the lower part of the calf muscles on the back leg.
2) Decreased ankle motion
Limited motion of the ankle joint can potentially lead to more strain on the plantar fascia. Adequate ankle mobility will help you perform tasks with less difficulty and minimize strain to the plantar fascia.
As mentioned above, tightness in calves can be one factor contributing to decreased ankle motion. Another contributing factor to limited ankle motion may be restrictions at the ankle joint.
Restrictions in the ankle joint are different than restrictions in the calf muscle. The bones that form the ankle joint may not move smoothly resulting in decreased motion at the ankle joint.
You can do exercises to selectively target the ankle joint to improve motion in the ankle. A physical therapist can assess your ankle motion using several different tests. One test is the ankle mobility wall test.
The ankle mobility wall test is a great way to check an important motion called dorsiflexion in the ankle joint. Your physical therapist can help you perform and interpret this test properly.
The ankle mobility wall test:
Start with the toes of the front foot 5 inches from the wall.
Lunge forward and try to touch the front knee to the wall. Do not let the arch of the foot collapse or the knee move inward.
The inability to touch the knee to the wall shows a decrease in ankle dorsiflexion motion. According to the research, a lack of dorsiflexion is a risk factor for plantar fasciitis.
If you have limited ankle dorsiflexion and want to avoid reoccurring plantar fasciitis, then you will likely benefit from exercises to increase your ankle motion.
3) Big toe mobility
The research shows the limited motion in the big toe is another risk factor plantar fasciitis.
The big toe should be able to extend backward approximately 45-70 degrees. Similar to ankle motion, the amount of motion required from the big toe depends on the types of activities you are doing.
A lack of motion in the big toe can also strain the joint of the big toe while walking, running, and most activities. Years of repetitive strain to the big toe place a cumulative effect on the big toe potentially contributing to bunions or structural changes in the foot.
People with plantar fasciitis often have bunions or a big toe that drifts inward. You may have noticed that your big toe is started to turn inward or deviate inward toward the second toe.
The importance of big toe motion is often overlooked during the management of plantar fasciitis. If you live an active life, then you will benefit from improving motion in the big toe.
As a reminder, all these factors can potentially play a role in plantar fasciitis. It's not just one thing.
Check your big toe mobility:
Take off your socks and shoes. Cross your leg and pull back on the big toe.
The big toe should extend back approximately 45-70 degrees.
A lack of big toe extension can lead to problems in the foot including plantar fasciitis. Ideally, there should be no pain in the big toe or on the bottom of the foot as the toe is pulled back.
Contributing Factor #5
The position of the foot is much different wearing high heels compared to wearing sandals. Imagine being able to wear high heels again!
Forget about high heels. At this point, you may be happy to walk 10 minutes with athletic shoes without foot pain. We'll take this recovery process one step at a time. But I hope you will be able to wear high heels again if that is your goal.
Should you be wearing cushioned shoes or minimalist shoes?
In recent years, there has been increased awareness about the benefits of wearing minimalistic shoes. A book called, Born to Run was released which sparked debate about the most ideal types of shoes to wear.
The book's central message is that humans were born barefoot and we were not meant to wear shoes; therefore, the invention of the modern, cushioned shoe has caused our feet to become weak and deconditioned.
Proponents of minimalist shoes believe that our feet should have the least amount of support possible to allow our feet to interact naturally with the ground.
However, the mere thought of flat shoes with no arch support may cause your feet to ache. The best way to start wearing these minimalistic shoes is through a slow and gradual transition with guidance.
Prior to a transition to minimalistic shoes, it will be beneficial to strengthen the foot and increase the activity tolerance of your foot with more supportive shoes.
From my experience in the clinic and coaching clients online, I realize that most people with plantar fasciitis benefit from wearing cushioned and supportive shoes until their pain subsides.
Once their pain is more controlled, we can start to transition away from supportive athletic shoes into less supportive shoes, flats, or even high heels.
The selection of footwear is a similar process to the selection of exercises for plantar fasciitis. Initially, footwear and exercises serve to protect sensitive feet. As someone reduces pain increases activity tolerance, then we can move into more demanding types of footwear and exercise.
Contributing Factor #6
Pain is a complex experience that has emotional, physical, and psychological components. Think of a time when you experienced more pain due to stress or lack of sleep.
Up to this point, I have discussed five contributing factors of plantar fasciitis. These five factors primarily focused on the biological aspects of plantar fasciitis such as exercise, body weight, muscle length, joint motion, and strength.
However, we have not discussed additional contributing factors like stress, sleep, nutrition, and other lifestyle factors like smoking and drinking alcohol. These factors are categorized as the psychosocial aspect of plantar fasciitis.
The approach that focuses on all these factors is known as the biopsychosocial model (BPS). Each of these components must be addressed in your recovery program.
One problem with our current medical model is that many healthcare providers are providing their patients with outdated advice that does not implement the biopsychosocial model (BPS).
For example, stretching your calves every day and strengthening your hips sound like a good idea. If these are appropriate for you, then these are only two parts of your recovery.
Poor eating habits and lack of sleep may be the main barrier holding you back rather than tight calves and hip weakness.
Overall, the causes of plantar fasciitis are not clearly defined in the research because there are many contributing factors. It appears mostly related to the inability of your body to tolerate the demands placed on the foot.
The contributing factors above may or may not apply to your specific situation. An assessment by a physical therapist will help you find the most relevant factors to help you recover.
If you are participating in activities that are beyond your level of fitness and ability to control movement then you can aggravate the plantar fascia. The imbalance between the difficulty of your activities and the capacity of the plantar fascia to support you during those activities can push you past the threshold of pain.
If you want to increase the support to the plantar fascia, then your top priority should be following a progressive strength training program from a physical therapist designed to increase your activity tolerance.
Thankfully, you can build resiliency in the foot by strength training and modifying your activity levels. Over time, you will recover from plantar fasciitis through a progressive strength training program.
If we could identify the triggers of your pain, then it may be possible to stop plantar fasciitis from coming back and to recover faster.
If you are worried about feeling permanently limited, then I want you to know most people recover plantar fasciitis over time.
There is no reason to fear plantar fasciitis because the human body has an incredible capacity to heal and recover from injuries naturally without surgery, injections or pain medications.
How can you maximize your function with plantar fasciitis?
Right now, you may feel frustrated about your reoccurring foot pain. You may have negative feelings about doctors, physical therapists, or chiropractors. You may be jaded about another person talking about plantar fasciitis.
I am not proclaiming to be a miracle-worker, but I know that you need to focus on a comprehensive program if you have not done so already.
Your medical doctor, physical therapist, or chiropractor may have missed a key part of the system to recover from plantar fasciitis. I view recovery from injuries as a systematic process. If one part of the system is missing, then the process may not work.
For example, if a car is missing a spark plug then the car will not operate properly. The spark plug is very small, but it plays a key role in the proper operation of a car.
If you still have persistent pain in your foot and have not participated in a program that addresses all these factors, then you should be excited because you have found a new opportunity for full recovery.
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6. Rathleff MS, Mølgaard CM, Fredberg U, et al. High-load strength training improves outcome in patients with plantar fasciitis: A randomized controlled trial with 12-month follow-up. Scand J Med Sci Sports 2015; 25:e292.