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Save Yourself from Plantar Fasciitis!

Plantar fasciitis explained in great detail, including every possible treatment option, and all supported by recent scientific research

updated
by Paul Ingraham, Vancouver, Canadabio
I am a science writer and a former Registered Massage Therapist with a decade of experience treating tough pain cases. I was the Assistant Editor of ScienceBasedMedicine.org for several years. I’ve written hundreds of articles and several books, and I’m known for readable but heavily referenced analysis, with a touch of sass. I am a runner and ultimate player. • more about memore about PainScience.com

illustrations by Paul Ingraham, Lindsay McGee
Picture of a foot about to step on a pile of colourful tacks, representing the pain of plantar fasciitis.

Tried everything? Maybe not yet. Plantar fasciitis can be stubborn, but many people have never even heard of the best treatment options.

What works for plantar fasciitis? What doesn’t? And why? Soon you will be able to answer these questions as well as they can be answered. This is a detailed tutorial for both patients and professionals about stubborn cases of chronic plantar fasciitis (PF) — it is thorough and scientifically current (but still readable).

I explain all the theories, myths, and controversies and review all treatment options (except the very silliest). Unlike many other conditions I write about, there are some PF treatments that are known to be at least a little effective…even with difficult cases sometimes. There’s hope.

The plantar fasciitis basics

Plantar fasciitis is a common and often persistent kind of repetitive strain injury afflicting runners, walkers and hikers, and nearly anyone who stands for a living — cashiers, for instance — especially on hard surfaces. Working on concrete and running on pavement are probably risk factors.

  • It causes mainly foot arch pain and/or heel pain.
  • Morning foot pain is a signature symptom.
  • Plantar fasciitis is not the same thing as heel spurs and flat feet, but they are related and often confused.

Most people recover from plantar fasciitis with a little rest, arch support (regular shoe inserts or just comfy shoes), and stretching, but not everyone. Severe cases can stop you in your tracks, undermine your fitness and general health, and drag on for years. This tutorial is mostly for you: the patient with nasty chronic plantar fasciitis that just won’t go away. (And for the professionals trying to help.) I can’t promise a cure for your foot pain — no one ethical can. But I can guarantee a deep understanding of the subject and your options.

I am a science writer & amateur athlete in Vancouver, Canada. I started writing about it because I have my own mild but incurable chronic case, due to a weird foot bone. ~ Paul Ingraham

The plantar fasciitis misinformation explosion

In the years since I started treating and writing about plantar fasciitis treatment, there has been an explosion of free information about it on the internet. Unfortunately, no one seems to be better informed!

Unsurprisingly, a lot of the information out there is simply repetition of the same tired conventional wisdom, much of which is just wrong. Misconceptions about foot pain have been spread far and wide, thanks to the miracle of the internet!1 (That’s the first of 174 footnotes. Click it!) While the quality of online information is gradually improving, it’s still mostly quite just the basics or people pushing crank theories and miracle cures.

Plantar fasciitis can be more stubborn than a cat that wants out. I have an incurable case of my own — I can’t recover fully because it’s caused by a minor foot deformity, a slight twist in my foot bones. But this also gives me a great opportunity to perpetually test treatments: every time it flares up again, I get to try again! So I’ve tried most of them personally, and I do quite well controlling it. I’ve also helped many patients and readers with their persistent cases.

So I know from both personal and professional experience that the prognosis isn’t always good. When the going gets tough, patients need to know their options inside and out.

About footnotes. There are 174 footnotes in this document. Click to make them pop up without losing your place. There are two types: more interesting extra content,1Footnotes with more interesting and/or fun extra content are bold and blue, while dry footnotes (citations and such) are lightweight and gray. Type ESC to close footnotes, or re-click the number.
and boring reference stuff.2“Boring” footnotes usually contain scientific citations from my giant bibliography of pain science. Many of them actually have pretty interesting notes.

Example citation:
Berman BM, Langevin HH, Witt CM, Dubner R. Acupuncture for Chronic Low Back Pain. N Engl J Med. 2010 Jul 29;(363):454–461. PubMed #20818865. PainSci #54942. ← That symbol means a link will open in a new window.
Try one!

Patients with severe plantar fasciitis face a challenge in finding good help

Most musculoskeletal problems are less “mechanical” and more mysterious than they seem at first. Plantar fasciitis is still a medical puzzle, and most health care professionals don’t know what the latest research says, and can’t offer patients advanced troubleshooting. In fact, many are not even aware of the basic evidence-based prescription for plantar fasciitis rehab, never mind the options for the severe and weird cases. (And weird cases are really what stubborn plantar fasciitis is all about.)

Photograph of a foot being massaged, as a possible treatment for plantar fasciitis.

Would a rub help?

If only! A foot rub is nice & in fact it can help a little, but massage therapy is actually one of the least effective of the common therapies for plantar fasciitis.

Family doctors in particular are not prepared to treat plantar fasciitis, or any musculoskeletal condition, really.2

Podiatrists (foot doctors) — especially in North America, where podiatrists are mostly focused on surgical procedures — often give poor quality advice about chronic repetitive strain injuries like plantar fasciitis, iliotibial band syndrome, or shin splints. A few take a special interest in these conditions, but most do not, and the occasional tough case of plantar fasciitis is not on their radar — understandable but unfortunate.

Physical therapists are the overall best bet for good plantar fasciitis care in my opinion, but often still lack the experience they need for tough cases.

Part 2

Nature of the Beast

What is plantar fasciitis?

Plantar fasciitis is an overuse injury, like carpal tunnel syndrome or tennis elbow in your foot, a kinda sorta tendinitis, an inflammatory thickening3 and/or degeneration of the plantar fascia. It’s especially common in runners, and in menopausal women. “Many people are afraid of running because between 30 to 70 percent (depending on how you measure it) of runners get injured every year.”4 And roughly 10% of those are PF cases.5

I’ve just used the familiar terms “tendinitis” and “inflammation” to introduce plantar fasciitis in the most familiar and conventional way. But these are misleading terms and the truth is trickier.

The plantar fascia is not really a tendon: it’s a sheet of connective tissue (“fascia”), more like a ligament than a tendon. It stretches from the heel to toes, spanning the arch of the foot, from bones at the back to bones at the front (whereas tendons connect muscles to bones).

The “itis” suffixes in tendinitis and fasciitis mean “inflammation,” but the tissue is rarely inflamed the way we usually understand it (maybe at first, not for long). Instead, the plantar fascia shows signs of collagen degeneration and disorganization. In 2003, Lemont et al looked at 50 cases and found so little inflammation that they declared that plantar fasciitis “is a degenerative fasciosis without inflammation, not a fasciitis.”6 So it would be better to use a more generic suffix — like opathy (diseased) or osis (condition).

In fact, this is true of all so-called “tendinitis” — inflamed tendons are not so very inflamed. “Recent basic science research suggests little or no inflammation is present in these conditions.”7 And Khan et al wrote that “numerous investigators worldwide have shown that the pathology underlying these conditions is tendonosis or collagen degeneration.”8

In the plantar fascia, the degeneration is “similar to the chronic necrosis of tendonosis.”9 Necrosis is Latin for “tissue death,” so that’s bad news. In plantar “fasciitis,” the plantar fascia is hurting because it’s dying — eroding like a rotten plank.10 And this isn’t just to make you squeamish: inflammation and “necrosis” are not the same medical situation, and understanding the difference is crucial for effective treatment.

Ink drawing of the bones of the foot, with a bow underneath the arch, and the string of the bow highlighted. The string of the bow is an analogy for the plantar fascia.

Foot arch-ery

The arch of the foot functions like a bow (as in a bow & arrow) & the plantar fascia is like the string of the bow. The tension in the “bow string” holds the shape of the arch. But every time you step, the “bow string” stretches… & when stretched too hard & too often, it gets irritated & then it’s like a bow shooting you in the foot!

So why does it happen? Plantar fasciitis is caused by tissue fatigue in the arch of the foot due to excessive strain, plus probably vulnerability due to biological factors. Not everyone who asks a lot of their feet gets plantar fasciitis!

If the arch of your foot is like a bow, think of the plantar fascia as the bow’s string. The plantar fascia, along with several muscles both in the foot and in the leg, supports the arch and makes it springy.11 Too springy, and the foot flattens out, overstretching the plantar fascia. Not springy enough, and the plantar fascia absorbs too much weight too suddenly.

Either way, it starts to burn with the strain.

Other than the fact that it’s on the bottom of your foot and you step on it a lot, why is the plantar fascia vulnerable to strain? Why exactly? What happens?

Getting to the root of plantar fasciitis: could it be bone spurs?

Clever-sounding biomechanical explanations for plantar fasciitis are as common as plantar fasciitis itself. Many therapists and articles on the internet will insist that you must treat the “root cause” of plantar fasciitis. It would certainly be a good idea — there’s no disputing that. Now, if only it were possible to identify the root cause!

There are three particularly common biomechanical “explanations” for plantar fasciitis, which I will cover over the next three sections. None of them is completely useless, but none even remotely qualifies for “root cause” status either:

  • bone spurs
  • flat feet and/or pronation
  • tight calves

Unfortunately, there are so many possible causes of plantar fasciitis — probably several of them happening at the same time — that it is effectively impossible (or just extremely impractical) for therapists to make any confident biomechanical diagnosis. It’s simply too complicated an equation, and the scientific literature is riddled with contradictions. Let’s start breaking this down with bone spurs…

Surely hard bony growths in the arch are painful?!

Bone spurs on the heel (aka heel spurs and calcaneal spurs) seem like they must be a smoking gun — a simple and obvious cause of plantar fasciitis. They are common — about 10–20% of the population12 has an extra bit of bone growing on the front of the heel. They often get the blame for plantar fasciitis because it seems so obvious that having a bony outcropping on your heel would indeed cause heel pain, for much the same reason that you wouldn’t want a rock in your shoe. Even more damning: they are indeed found more in people with plantar fasciitis than without.

X-ray of a heel spur or bone spur.

Not as bad as it looks. Having a bone spur is more like stepping on a cracker than a nail. A very thin cracker.

Seems straightforward, right?

Unfortunately for common sense, bone spurs aren’t very bone-y, and it’s not like having a rock in your shoe. Spurs are a slight calcification of the plantar fascia, brittle and thin. It’s as much like bone as tinfoil is like sheet metal. They make the plantar fascia a bit crispy and crunchy.13 So bone spurs aren’t nearly the serious mechanical problem they seem to be. Stepping on them is more like stepping on a cracker than a nail. A very thin cracker.

So it isn’t too surprising that lots of people have painless spurs. And there is good evidence that, when there is pain, it’s not the spur that hurts but the plantar fascia itself or other soft-tissue structures.1415 And surgically removing a bone spur does not necessarily relieve pain, which makes it a lot less likely that it was causing it in the first place.1617 Spurs also tend to just grow back. No wonder a 2007 study concluded, “Overall, the presence of a calcaneal spur [was] not correlated with patient satisfaction and recurrences.”18 And it’s why there is a broad consensus that they are not the culprit. In a 2014 review in the journal Foot & Ankle Specialist, Moroney et al wrote:

Though once synonymous with plantar fasciitis, calcaneal spurs have, for several decades, largely been regarded in the orthopaedic literature as incidental findings.

But they probably aren’t completely irrelevant. They also wrote:

However, it may be premature to completely dismiss the significance of plantar calcaneal spurs.

It’s clear that spurs are probably more painful and problematic when other tissue X factors are present, but those factors can and do also cause plantar fasciitis symptoms whether you have a heel spur or not — and heel spurs may be completely painless without those factors!

Of all the possible “root causes” of plantar fasciitis, bone spurs superficially seem like the simplest and most obvious — and yet it’s neither. As tempting as it is, it turns out that you just can’t count on a nice straightforward connection between heel spurs and plantar fasciitis.

Other alleged root causes are even less satisfying.

Maybe it’s my pronation? Or flat feet?

“My therapist said I’m a pronator.” I hear this a lot. It’s not clear that it matters.

Pronating is rolling the foot inward. It is almost synonymous with having flat feet, because the arch tends to collapse as you roll the foot inward. They don’t necessarily go together, but they often do, and they are both routinely claimed as root causes of plantar fasciitis. Personally, I think therapists just like to accuse their patients of “pronating” because it makes us sound like we know what we’re talking about. Sound a little harsh? Some experts believe the idea of pronation is so useless — and yet so common! — that they have called for it to be abolished:19

[Overpronation] contributes nothing to our understanding — it is not definable, not reliable or valid, not diagnostic, its relationship to injury is not fully understood, and it does not dictate what the most appropriate management plan may be. It should not be replaced, it should be removed.

Ian Griffiths, Overpronation: Accurate or Out of Date Terminology?

It’s just as likely that under-pronation and high arches are a problem. While flat feet are a more popular cause, one professional will blame high arches, but the next will say it’s flat feet … about the same patient. Surprisingly, professionals often seem to have trouble deciding whether a given foot has a flat arch or a high arch!2021

So why are experts contradicting each other? Probably because both flat and high arches are factors in plantar fasciitis.222324

For years, I incorrectly told plantar fasciitis clients with high arches that they were exceptional, because I knew only the conventional wisdom: plantar fasciitis afflicts the flat-footed. But obviously the plantar fascia can also be irritated by a too-tall arch.25 This is a Goldilocks case: the arches need to flex and give just the right amount — not too little, and not too much.

Pronation is one side of a Goldilocks equation too. The truth is that excessive supinating — rolling outwards — is probably just as much of a problem26 — but that gets almost completely ignored. You never hear about supinating.

If you walk in a shoe store and their sole basis for choosing a shoe for you is how much your pronate and what your arch looks like, turn around and walk out the door. The science simply does not support this protocol.

runblogger

As much as the body likes things to be just right, it’s also super adaptable. Many flat-footed pronators and high-arched supinators in fact do not have plantar fasciitis. And many people who do have plantar fasciitis have completely normal arches, and neither pronate nor supinate excessively. Arch height and pronation are almost certainly risk factors … but not root causes.

Probably my calves are too tight!

Could be. Tight calves are another classic plantar fasciitis scapegoat, and the gastrocnemius and soleus muscles (the big calf muscles) certainly can put a strain on the plantar fascia.27 This situation is typical for people with a leaning-forward “ski jumper” postural pattern. And of course it is the predictable side effect of wearing high-heeled shoes for many years.28

For interesting contrast, the Twa people of Africa grow up climbing trees, which earns them amazingly limber calves that allow their ankles to bend halfway (45˚) to the shin29two to four times greater than the average urban person! Look at them go:

But hold on to your muscle tone, because it turns out that it’s amazingly difficult to even define “tight calves,” let alone blame them for plantar fasciitis. Why?

END OF FREE INTRODUCTION

Purchase full access to this tutorial for USD$1995. Continue reading this page immediately after purchase. Most other content on PainScience.com is free.?Almost everything on this website is free: about 80% of the site by wordcount, or 95% of the bigger pages (>1000 words). This page is only one of 8 big ones that have a price tag. There are also hundreds of free articles (and several of them about plantar fasciitis). But this page goes into extreme detail, and selling access to it keeps the lights on and allows me to publish everything else (without ads).


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Part 2.4

Appendices

Reader feedback… good and bad

Testimonials on health care websites reek of quackery, so publishing them has always made me a bit queasy. But my testimonials are mostly about the quality of the information I’m selling, and I hope that makes all the difference. So here’s some highlights from the kind words I’ve received over the years… plus some of the criticisms I receive, and why people ask for refunds (which doesn’t happen very much).

I’ve been practicing in podiatry for 16 years and I have successfully treated thousands of cases of plantar fasciitis. The condition is often misunderstood, and there are a myriad of theories out there, but this tutorial is one of the best things I’ve read on the subject. It provides an excellent overview of the latest treatment and self-treatment options, and makes sure that patients know when to see a medical professional. The crucial point Paul makes that I would like to back up is that plantar fasciitis can be successfully treated, but often requires multiple therapies and persistence.

— Mark Heard, Podiatrist D.App.Sci, M.A.Pod.A., Australia


Plantar fasciitis successfully treated with your advice. Now pain free for almost a year.

— Nicole Villen, cashier who was having trouble working


Really interesting reading. I quickly found information I haven’t seen anywhere else, and it was referenced. No one has ever even suggested that the lower leg muscles might be involved. I have often wondered about that.

— Steven Coombs, plantar fasciitis sufferer


Thank you! There is more and better information here than anything else I could find. What a relief to find a truly comprehensive resource. I was so sick of reading all the same old advice that I’d already tried.

— Jan A., triathlete, Oregon


It was (almost literally) killing me that I couldn’t walk. I’d gained weight, morale was very low. Thanks a million for this article, it’s so much more informative than anything else I could find it’s just crazy. Why isn’t this information more available?

— Janice Campbell, mother of five, enthusiastic recreational walker, Oregon


I have been waking up to pain for almost ten years, and I’d been through every popular remedy, and there are a lot of them. Not once in all that time did I know science. Not once did any doctor or therapist inform me what the latest research says about this condition. Thanks for finally correcting that! (And, yes, I’m finally feeling better, probably because of the night splints, which I actually hadn’t tried before.)

— Andrew Hall, IT guy, Ithaca, NY


I came across your article about plantar fasciitis and you have managed to diagnose what my doctor could not. Impressive! Many thanks for publishing your clear and concise explanation.

— anonymous reader


One more noteworthy endorsement, with regards to this whole website and all of my books, submitted by a London physician specializing in chronic pain, medical education, and patient-advocacy (that’s a link to his excellent blog):

I’m writing to congratulate and thank you for your impressive ongoing review of musculoskeletal research. I teach a course, Medicine in Society, at St. Leonards Hospital in Hoxton. I originally stumbled across your website whilst looking for information about pain for my medical students, and have recommended your tutorials to them. Your work deserves special mention for its transparency, evidence base, clear presentation, educational content, regular documented updates, and lack of any commercial promotional material.

— Dr. Jonathon Tomlinson, MBBS, DRCOG, MRCGP, MA, The Lawson Practice, London

High praise indeed! Thank you, Dr. Tomlinson — testimonials just don’t get much better than that.

What about criticism and complaints?

Oh, I get those too! I do not host public comments on PainScience.com for many reasons, but emailed constructive criticism, factual corrections, requests, and suggestions are all very welcome. I have made many important changes to this tutorial inspired directly by critical, informed reader feedback.

But you can’t make everyone happy! Some people demand their money back (and get it). I have about a 1% refund rate (far better than average in retail/e-commerce). The complaints of my most disatisfied customers have strong themes:

  • Too negative in general. Some people just can’t stomach all the debunking. Such customers often think that I dismiss “everything” … which I disagree with.
  • Too negative specifically. Some are offended by about a treatment option that they personally use and like. Or sell.
  • Too advanced. Although I work hard to “dumb” the material down, quite a few people still just find it too dense and dorky.
  • Too simple. Some people think they already know everything about the topic. Maybe they do, and maybe they don’t. I always wish I could give these readers a pop quiz. 😉 In my experience, all truly knowledegable people get that way by embracing every new persective and source of information.

Acknowledgements

This document and all of PainScience.com was, for many years, created in my so-called “spare time” and with a lot of assistance from family and friends. Undying thanks to my wife, Kimberly, for countless indulgences large and small, and for being my “editor girlfriend”; to my parents for (possibly blind) faith in me, and much copyediting; and to Mike Gobbi, buddy and digital mentor, for many of the nifty features of this document (hidden and obvious). And thanks to all of the above, and many others, for many (many) answers to “what do you think of this?” emails.

Thanks finally to every reader, client, customer, and big tipper for your curiosity, your faith, and your feedback and suggestions and stories. Without you, all of this would be pointless.

And a few thanks to some health professionals who have been particularly inspiring to me: Dr. Rob Tarzwell, Dr. Steven Novella, Dr. David Gorski, Sam Homola, DC, Dr. Harriet Hall, Simon Singh, and Dr. Stephen Barrett.

What’s new in this tutorial?

Regular updates are a key feature of PainScience.com tutorials. As new science and information becomes available, I upgrade them, and the most recent version is always automatically available to customers. Unlike regular books, and even e-books (which can be obsolete by the time they are published, and can go years between editions) this document is updated at least once every three months and often much more. I also log updates, making it easy for readers to see what’s changed. This tutorial has gotten 71 major and minor updates since I started logging carefully in late 2009 (plus countless minor tweaks and touch-ups).

AugustNew section: A review of other kinds of problems with the plantar fascia and how some might be related to and confused with plantar fasciitis. [Section: Other plantar fascia lesions, especially plantar fibromatosis.]

AugustMajor science update: The section now takes a much more detailed look at the only relevant science. [Section: Does arch stretching work? The most over-rated stretching method.]

AugustScience update: Night splints now have their own section, along with some more detail and science updates. [Section: Does a lot of calf stretching work? Night splints.]

AugustRewrite: Complete citation reboot and much more thorough critical analysis of calf stretching science. [Section: Does calf stretching work? The state of the science of calf stretching.]

AugustRewrite: Complete revision of the introduction to stretching. [Section: Stretching.]

AprilRewrite: Like-new section with many new concepts, citations, and recommendations related to impact. [Section: Hitting the road: shoes, surfaces, impact, and the spring in your step.]

AprilRewritten: Thorough revision with many updated citations, focusing mainly on orthotics efficacy. [Section: Orthotics, arch support, and heel cups.]

MarchMinor update: Added an analogy, an example, a useful link, and generally modernized the section. [Section: Hitting the road: shoes, surfaces, impact, and the spring in your step.]

JanuaryNew section: An important tip I should have written about long ago, finally added. [Section: These cast boots are made for walking (without stressing your plantar fascia).]

2016Science update: More recent test and reviews of steroid injection now cited. No significant change in recommendations, but the evidence is more settled now. [Section: Steroid injections are promising for short term relief only, and problematic.]

2016Science update: Significant revision in light of (finally!) good new evidence about natural running and injury prevention. [Section: Should you run naked? On faddish running styles and running shoes (or the lack thereof).]

2016Good news update: Another good news update: ESWT is starting to look more promising. The section has been revised to be much more positive. [Section: Fancy ultrasound: Extracorporeal Shockwave Therapy (ESWT).]

2016New advice: Not only a new section but new good news! First version added Feb 2, substantial edit and expansion Feb 26. [Section: Strengthening is a strong option.]

2016Update: Careful and thorough editing/update of NSAID recommendations, especially with regards to safety. [Section: Ibuprofen and friends: non-steroidal anti-inflammatory drugs (NSAIDs), especially Voltaren® Gel.]

2015Science update: Some good news changed to bad news: a discouraging follow-up study on arch-specific stretching. [Section: Stretching.]

2015Upgraded: Many editorial and referencing improvements. [Section: Ultrasound and plantar fascia thickness.]

2014New section: A short new section, finally, on PRP injections. It’s brief, but links to a main, free article covering the topic in some detail. [Section: Regenerative medicine? Platelet-rich plasma injections.]

2014Major edit: Modernized. I continue to hone my understanding of pain weirdness science and its implications. [Section: Pain is weird: the surprisingly fallible role of the brain in all this.]

2014Minor addition: Brief review of calf-stretching gadgets [Section: Does calf stretching work? The state of the science of calf stretching.]

2014Upgraded: Much more information about the (minor) significance of bone spurs. They may not matter a lot, but it’s good, useful, evidence-based context. [Section: Using other diagnostic technologies.]

2014Major update: The first complete professional editing of this book has now been completed. Although the difference will not be obvious to most readers, several hundred improvements and corrections were made, and it is definitely a smoother read.

2013Minor update: Added a fun science item about the amazing ankle mobility of the Twa people of Africa. [Section: Probably my calves are too tight!]

2013New recommendation: Now recommending a specific type of MRI to scan for bone swelling. Thanks to reader R Russell for the suggestion. [Section: Using other diagnostic technologies.]

2013Minor update: Added a terrific quote from a famous podiatrist about inconsistency in orthotics prescriptions. [Section: Orthotics, arch support, and heel cups.]

2013Minor update: Upgraded risk and safety information about Voltaren Gel. [Section: Ibuprofen and friends: non-steroidal anti-inflammatory drugs (NSAIDs), especially Voltaren® Gel.]

2013Product upgrade: Audiobook version now available.

2013Improved: Expanded and edited. Reflexology and acupuncture added. [Section: Don’t bother with ….]

2013improved: A little more and better advice. [Section: Some tips on beating the morning pain.]

2012Minor update: More detail in my personal story of truly structural foot problem. [Section: So what if you are a flat-footed, tight-calved pronator?]

2012Expanded: Added much more detailed self-help information for trigger points. [Section: Trigger point massage for your feet, shins & calves.]

2012Major upgrade: Rewritten, modernized, expanded. [Section: Trigger point massage for your feet, shins & calves.]

2012Minor update: Some customizing of “brain wrangling” for plantar fasciitis. [Section: Brain wrangling: what to do about sensitization.]

2012Science update: Weak but interesting new evidence on natural running and injury prevention. [Section: Should you run naked? On faddish running styles and running shoes (or the lack thereof).]

2012Rewritten: Bigger, better, more positive discussion of this option. [Section: Friction massage the plantar fascia.]

2012Major update: A “minor” science item really changed the tone of this section. The point is still the same — avoid heels — but now it’s a more interesting point. [Section: Beware of high heels.]

2012Science update: Unimportant but interesting science update about the forces required for arch muscles to activate for support. [Section: Nature of the Beast: What is plantar fasciitis?]

2012New section: New standard section I’m introducing to most of the tutorials to “manage expectations.” Too many readers assume there’s going to be a specific miracle treatment plan. [Section: So what’s the plan?]

2012Rewritten: Completely revised to reflect new science and new understanding of the interaction of ice with “inflammation.” [Section: Icing: more is better?]

2012New science: Same content, more science support. [Section: Ultrasound and plantar fascia thickness.]

2012New section: No notes. Just a new section. [Section: Now what?: An action-oriented round-up of my recommendations.]

2012Science update: References pretty much completely renovated and upgraded — and generally good news for once. [Section: Stretching.]

2012New section: No notes. Just a new section. [Section: Ibuprofen and friends: non-steroidal anti-inflammatory drugs (NSAIDs), especially Voltaren® Gel.]

2012Like new: Major upgrade, with a much more detailed introduction to this part of the book, and long and useful list of summarized treatment options. [Section: Treatment: What can you do about plantar fasciitis?]

2012Minor update: Slightly expanded and clarified. Added a note about feeling a thickened plantar fasciitis with your fingers. [Section: Ultrasound and plantar fascia thickness.]

2012Minor update: Several minor clarifications and improvements. [Section: Several conditions that might get confused with plantar fasciitis.]

2012New section: No notes. Just a new section. [Section: Brain wrangling: what to do about sensitization.]

2012New section: No notes. Just a new section. [Section: Pain is weird: the surprisingly fallible role of the brain in all this.]

2012New section: No notes. Just a new section. [Section: Where’s the fire? The inflammation myth.]

2012Edited: Revision in preparation for audiobook production, with a focus on modernizing information about trigger points. [Section: How trigger points can hurt like plantar fasciitis.]

2012Edited: Revision in preparation for audiobook production, with a focus on modernizing information about trigger points. [Section: The general importance of muscle in plantar fasciitis.]

2012Rewritten: Merged information on arches and pronation, rewrote for clarity, and added a couple nice new supporting quotes. [Section: Maybe it’s my pronation? Or flat feet?]

2012Edited: Longer and clearer than before. In particular, I came up with a much better way of explaining the fragility of “bony” spurs. [Section: Getting to the root of plantar fasciitis: could it be bone spurs?]

2012Science update: Added good new evidence that customization of orthotics isn’t very accurate. [Section: Orthotics, arch support, and heel cups.]

2012New section: Inspired by something surprising that I learned writing the new surgery section, this is a brief description of another major possible explanation for persistent symptoms. [Section: Plantar fasciitis in the bone?]

2012New section: Substantive new section of about 1400 words, with several footnotes and new references. [Section: Surgical options for plantar fasciitis: so many!]

2012More expert opinion: Added a particularly strong anti-steroids opinion to the section. [Section: Steroid injections are promising for short term relief only, and problematic.]

2011Minor update: Added some more detail to exercise description, and a whimsical ankle coordination challenge. [Section: Mobilize your lower leg musculature.]

2011Minor update: Addressed some common fears about the threat of getting out of shape while resting. [Section: The art of rest: the challenge and the opportunity for patients who have supposedly “tried everything”.]

2011Minor update: Added reference to Kong et al, about the effect of shoe wear. [Section: Hitting the road: shoes, surfaces, impact, and the spring in your step.]

2011New section.: Now cautiously endorsing Oesh shoes. [Section: Hitting the road: shoes, surfaces, impact, and the spring in your step.]

2011Minor update: Added a reference about high heels and knee pain. [Section: Beware of high heels.]

2011Minor update: Added a reference about the poor overall quality of online information about common injuries. See Starman et al. [Section: The plantar fasciitis misinformation explosion.]

2011Major update: Major improvements to the table of contents, and the display of information about updates like this one. Sections now have numbers for easier reference and bookmarking. The structure of the document has really been cleaned up in general, making it significantly easier for me to update the tutorial — which will translate into more good content for readers.

2011New section: Finally, long overdue, a new section on this topic (for all the running injury tutorials, in fact). [Section: Should you run naked? On faddish running styles and running shoes (or the lack thereof).]

2011Minor update: Added a reference to a large, interesting study that showed that custom orthotics failed to reduce injury rates in marines. [Section: Orthotics, arch support, and heel cups.]

2010Improved: Beefed up with better explanations and science about how plantar fasciitis involves more “degeneration” of your foot than inflammation. [Section: Nature of the Beast: What is plantar fasciitis?]

2010New cover: At last! E-book finally has a “cover.”

2010Expanded: Added a substantial chunk of content about a promising experimental treatment protocol. Unproven but interesting. [Section: Steroid injections are promising for short term relief only, and problematic.]

2009Minor Update: Some new comments on Graston Technique in response to a reader’s questions. [Section: Don’t bother with ….]

2009Minor update: Added an answer to a reader question, “Are soft night splints good enough?” [Section: Stretching.]

2009New section: No notes. Just a new section. [Section: Steroid injections are promising for short term relief only, and problematic.]

Older updatesListed in a separate document, for anyone who cares to take a look.

Notes

  1. In 2010, the Journal of Bone & Joint Surgery reported that “the quality and content of health information on the internet is highly variable for common sports medicine topics,” such as knee pain and low back pain — a bit of an understatement, really. Expert reviewers examined about 75 top-ranked commercial websites and another 30 academic sites. They gave each a quality score on a scale of 100. The average score? Barely over 50! For more detail, see Starman et al. BACK TO TEXT
  2. Doctors lack the skills and knowledge needed to care for most common aches, pains, and injury problems, especially the chronic cases, and even the best are poor substitutes for physical therapists. This has been proven in a number of studies, like Stockard et al, who found that 82% of medical graduates “failed to demonstrate basic competency in musculoskeletal medicine.” It’s just not their thing, and people with joint or meaty body pain should take their family doctor’s advice with a grain of salt. See The Medical Blind Spot for Aches, Pains & Injuries: Most physicians are unqualified to care for many common pain and injury problems, especially the more stubborn and tricky ones.
    Cartoon of a man sitting in a doctor’s office. The doctor is holding a clipboard with a checklist with just two items on it: stress related and age related. The caption reads: “An extremely general practitioner.”

    Cartoon by Loren Fishman, HumoresqueCartoons.com

    BACK TO TEXT
  3. Karabay N, Toros T, Hurel C. Ultrasonographic evaluation in plantar fasciitis. J Foot Ankle Surg. 2007;46(6):442–446.

    These researchers used ultrasonography to show that people with plantar fasciitis have thickened connective tissue on the bottom of their feet. The results were clear and unambiguous — a rare bit of clarity in a murky subject!

    See Plantar Fasciitis Patients Have Thick Soles for more information. BACK TO TEXT
  4. That’s from a fascinating talk about the athletic toughness of human beings, Brains Plus Brawn, by Dr. Dan Lieberman, evolutionary biologist of “Born to Run” fame. BACK TO TEXT
  5. Chandler TJ, Kibler WB. A biomechanical approach to the prevention, treatment and rehabilitation of plantar fasciitis. Sports Med. 1993;15. PubMed #8100639.

    Chandler and Kibler report a 10% occurrence rate of plantar fasciitis in runners.

    BACK TO TEXT
  6. Lemont H, Ammirati KM, Usen N. Plantar fasciitis: a degenerative process (fasciosis) without inflammation. J Am Podiatr Med Assoc. 2003;93(3):234–7. PubMed #12756315. BACK TO TEXT
  7. Andres BM, Murrell GA. Treatment of tendinopathy: what works, what does not, and what is on the horizon. Clin Orthop Relat Res. 2008;466(7):1539–1554. BACK TO TEXT
  8. Khan KM, Cook JL, Taunton JE, Bonar F. Overuse tendinosis, not tendinitis, part 1: a new paradigm for a difficult clinical problem (part 1). Phys Sportsmed. 2000;28(5):38–48. PubMed #20086639. BACK TO TEXT
  9. Young CS, Rutherford DS, Niedfeldt MW. Treatment of Plantar Fasciitis. Am Fam Physician. 2001 Feb 1;63:467–74. PainSci #56910. Such degeneration is “similar to the chronic necrosis of tendonosis, which features loss of collagen continuity, increases in ground substance (matrix of connective tissue) and vascularity, and the presence of fibroblasts rather than the inflamatory cells usually seen with the acute inflammation of tendinitis.” BACK TO TEXT
  10. The necrosis “features loss of collagen continuity, increases in ground substance (matrix of connective tissue) and vascularity, and the presence of fibroblasts rather than the inflammatory cells usually seen with the acute inflammation of tendinitis.” BACK TO TEXT
  11. The arch muscles do less than you might think: Basmajian et al showed in 1963 that muscles in the arch of the foot only kick in to under heavy loads: about 180 kilograms. Although that sounds like a lot, loading may spike that high in an average person with every step, so the strength and responsiveness of the arch muscles may still be routinely important. We don’t have muscles there for nothing, of course. Nevertheless, this study pretty clearly shows that “the first line of defense” against arch collapse is the shape of the bones, the elasticity of ligaments, and probably the “stirrup” tendons from leg muscles — but not so much the strength of the arch muscles. BACK TO TEXT
  12. In 1995, Barrett et al found that 21% of 200 randomly selected American corpses had heel bone spurs, and in 2014 Moroney et al found 12% in about 1100 foot x-rays (though they qualify that: “This is a lower rate than that cited in many published series.”) BACK TO TEXT
  13. Some bones spurs are undoubtedly thicker and harder than others, just like some people have much larger calluses than other people. (I have a callus on one foot that is always far thicker and sturdier than I seem to need.) But regardless, the spur tends to disintegrate the further it gets from the heel. BACK TO TEXT
  14. Osborne HR, Breidahl WH, Allison GT. Critical differences in lateral X-rays with and without a diagnosis of plantar fasciitis. J Sci Med Sport. 2006 Jun;9(3):231–7. PubMed #16697701.

    From the abstract: “ ... the key radiological features that differentiate the groups were not spurs but rather changes in the soft tissues.”

    BACK TO TEXT
  15. Tountas AA, Fornasier VL. Operative treatment of subcalcaneal pain. Clin Orthop Relat Res. 1996 Nov:170–8. PubMed #2663678.

    This paper reports on a study of twenty patients in the years after surgical removal of bone spurs. Although most of the patients had “excellent” or “good” results three years later, their spurs had reformed in many casees, and analysis of the soft tissues showed that “changes within the fascia, rather than the spur, are primarily responsible for the pathogenesis of the syndrome.”

    BACK TO TEXT
  16. Onwuanyi ON. Calcaneal spurs and plantar heel pad pain. Foot. 2000;10.

    From the abstract: “Calcaneal spurs cause plantar heel pad pain, but the roles of other co-morbid factors are significant. The excision of these spurs does not necessarily abolish pain.”

    BACK TO TEXT
  17. Fishco WD, Goecker RM, Schwartz RI. The instep plantar fasciotomy for chronic plantar fasciitis. A retrospective review. J Am Podiatr Med Assoc. 2000 Feb;90(2):66–9. PubMed #10697969. In this study, surgical outcomes were similar — and generally good — with or without heel spur removal. BACK TO TEXT
  18. Beyzadeoglu T, Gokce A, Bekler H. The effectiveness of dorsiflexion night splint added to conservative treatment for plantar fasciitis. Acta Orthop Traumatol Turc. 2007;41(3):220–224. PubMed #17876122. BACK TO TEXT
  19. Kinetic-revolution.com [Internet]. Griffiths I. Overpronation: Accurate or Out of Date Terminology?; 2012 Sep 28 [cited 13 Dec 11]. BACK TO TEXT
  20. Sensiba PR, Coffey MJ, Williams NE, Mariscalco M, Laughlin RT. Inter- and intraobserver reliability in the radiographic evaluation of adult flatfoot deformity. Foot Ankle Int. 2010 Feb;31(2):141–5. PubMed #20132751. Although the reliability isn’t terrible, even x-rays of the same foot get judged differently (just fine with some measures, merely okay for others). However, that’s radioloists evaluated x-rays: you would hope it would be fairly reliable. The problem is with some kinds of clinicians (see next note). BACK TO TEXT
  21. This is a bit of a cheat: I don’t have a proper reliability study to back this up, just a professional story: when I worked as massage therapist, it was common for people to come into my office with so-called “flat” feet, convinced by a previous massage therapist (or chiropractor) that they “have no arch left” (or some other motivating hyperbole) … when in fact I could still easily get my finger under their arch up to the first knuckle. That’s something that you simply can’t do on someone who really has flat feet. Similarly, though not so common, I have often seen people accused by another professional of having high arches, when in fact they look nothing like it to me. So take such diagnoses with a grain of salt. BACK TO TEXT
  22. Huang YC, Wang LY, Wang HC, Chang KL, Leong CP. The relationship between the flexible flatfoot and plantar fasciitis: ultrasonographic evaluation. Chang Gung J Med. 2004 Jun;27(6):443–8. PubMed #15455545.

    From the abstract: “There was a higher incidence of plantar fasciitis in the flexible flatfoot group than the normal arch control group in this study.”

    BACK TO TEXT
  23. Kwong PK, Kay D, Voner RT, White MW. Plantar fasciitis: Mechanics and pathomechanics of treatment. Clin Sports Med. 1988;7(1):119–26. PubMed #3044618.

    This is an expert opinion paper — not original research — which simply states that excessive pronation in the foot (part and parcel of having flat feet) is “the most common mechanical cause of structural strain resulting in plantar fasciitis.” This is debatable. The relevance of the reference is simply to demonstrate the diversity of opinion on the subject. It may well be that pronation and/or flat feet is the most common cause of plantar fasciitis, but it is certainly not the only mechanical factor that does so.

    BACK TO TEXT
  24. Bolgla LA, Malone TR. Plantar fasciitis and the windlass mechanism: a biomechanical link to clinical practice. J Athl Train. 2004 Jan-Mar;39(1). PubMed #16558682. PainSci #56983.

    From the article: “A review of the literature reveals that a person displaying either a lower- or higher-arched foot can experience plantar fasciitis. Patients with lower arches have conditions resulting from too much motion, whereas patients with higher arches have conditions resulting from too little motion.”

    BACK TO TEXT
  25. If the arch is high, it means the arch-support system may be too rigid and not springy enough, so it absorbs too much force too quickly. BACK TO TEXT
  26. Hertling D, Kessler R. Management of common musculoskeletal disorders. 3rd ed. Lippincott; 1996. p434. “Functionally abnormal supination is a failure of the foot to pronate, resulting in a foot unable to compensate normally. There is prolonged supination during the stance phase and a delayed pronation during the gait cycle. Stress fractures, metatarsalgia, plantar fasciitis, and Achilles tendinitis are common in this type of foot.” BACK TO TEXT
  27. Cheung JT, Zhang M, An KN. Effect of Achilles tendon loading on plantar fascia tension in the standing foot. Clin Biomech (Bristol, Avon). 2006 Feb;21(2):194–203. PubMed #16288943. BACK TO TEXT
  28. Csapo R, Maganaris CN, Seynnes OR, Narici MV. On muscle, tendon and high heels. J Exp Biol. 2010 Aug;213(Pt 15):2582–8. PubMed #20639419. PainSci #55265.

    High heels are often vilified, but this carefully done 2010 study showed that the body adapts effectively and minimally, producing quite similar functional results. The most interesting implication of their results is simply that “muscle structure may adapt to a chronic change in functional demand” — which might seem obvious, but that little bit of science has been hard to nail down over the years, and this is a good piece of the puzzle.

    Chronic heel wearers do have shortened calf muscles, stiffer Achilles tendons, and a smaller ankle range of motion, but these changes “seem to counteract each other since no significant differences in static or dynamic torques were observed.” In other words, high heel wearers are not progressively disabled: their ankles work fine, just differently. This doesn’t mean there’s no conceivable harm (for instance, Kerrigan found evidence of harm to the knees), but it does tend to downgrade concern on the topic.

    BACK TO TEXT
  29. Venkataraman VV, Kraft TS, Dominy NJ. Tree climbing and human evolution. Proceedings of the National Academy of Sciences of the United States of America. 2012 Dec. PubMed #23277565. PainSci #54672. BACK TO TEXT

There are 145 more footnotes in the full version of this book. I like footnotes, and I try to have fun with them.


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