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Saturday, January 2, 2016

Plantar Fasciitis:General Principles of Treatment

As I am beginning my seventh year of this blog, I will begin updating previous posts to improve on my teachings. Plantar Fasciitis is one of the most common problems facing podiatrists. 

Several Golden Rules of Foot are common.

Golden Rule of Foot: Plantar Fasciitis begins gradually over weeks and months before effecting athletic performance. It does not come on suddenly.

Golden Rule of Foot: Even bad cases of plantar fasciitis have no swelling. Heel swelling typically is a sign of something worse. 

This can be such a stubborn problem that it is easy to get very frustrated. Very few people need surgery for this since there are so many options for treatment. 30 years ago 1 in 10 patients required surgery, now surgery is less than 1%. The treatment options are so numerous that we are normally limited only by our time and imaginations to develop a successful treatment plan. Each week there should be improvement once active treatment begins. If improvement plateaus, a change in treatment protocols should be made. Analyzing what is working and what is not working should be part of the process.

The patient and health care provider deal constantly with the 3 areas of treatment---anti-inflammatory, stretching or flexibility, and mechanics (one being the transference of pressure from the painful areas to non-painful areas). Most cases of plantar fasciitis need simple solutions like daily icing (anti-inflammatory), plantar fascial and achilles stretching 3 times daily (flexibility), and arch support (either custom orthotics or store-bought arch supports). Some more stubborn cases of plantar fasciitis need the above along with physical therapy to improve flexibility and anti-inflammatory measures, custom-made orthotics if not already manufactured, night splints to gentle stretch out the plantar fascia, cortisone shots if a bursitis under the heel bone is found, and many other options.

In resistant cases, 3 months in a removable cast can help calm down the inflammation. The moral of the story with plantar fasciitis is never give up. Keep trying to find the right combination of anti-inflammatory, flexibility, and mechanical changes. Good luck. Also remember that 25 to 30% of all cases I see for plantar fasciitis for a second opinion, have something else. Neuritis, bursitis, stress fractures, and plantar fascial tears all head the list in the differential diagnosis. I hope this helps and gives you encouragement. Dr Rich Blake

Here is a video on the stretches to do and not do when you have plantar fasciitis.

When I talk about mechanical changes that effect plantar fasciitis, there are many Golden Rules of Foot and come into play.

Golden Rule of Foot: When designing an orthotic device, or using an OTC arch support, the patient must feel that the weight is being transferred into the arch (even borderline obnoxiously) and the heel is feeling protected.

Golden Rule of Foot: The most stress on the plantar fascia and achilles is when the heel just comes off the ground. Treatment of plantar fasciitis therefore typically involves staying in elevated shoes, orthotic devices, clogs, and remaining flat footed in some exercises like the elliptical, and not getting off the seat in cycling. 

Golden Rule of Foot: A negative heel stretch (where the heel drops below the ball of the foot) can irritate the plantar fascia with all of the body weight suspended at its attachment. This is in stark contrast with the same position of the Downward Dog in Yoga which never seems to bother the plantar fascia with body weight well in front of the plantar fascial attachment.

Golden Rule of Foot: Plantar Fasciitis patient hurt less walking on their heels than flat footed. If you think you have plantar fasciitis, try to walk barefoot normally, on the balls of your feet, and then on your heels. If you hurt the most on your heels, you probably do not have primary plantar fasciitis, and more bursitis, plantar fascial tears, or heel stress fractures. All three of these are diagnosed by MRI. 

The video below discusses heel evaluation.

My initial visit for plantar fasciitis typically includes:

  1. Teaching the patient Support the Foot taping ( and giving them a few extra strips.
  2. Rolling ice massage with frozen sport bottle 5 minutes 3 times per day
  3. Plantar fascial and achilles stretches (see video above) 3-5 times a day. Typically, gastroc and soleus stretches 1-2 times per day, and plantar fascial stretch 5 times. 
  4. Mechanical changes based on their activities, like no barefoot around the house, and staying flat footed on the elliptical. 
  5. Consideration of physical therapy, night splints, removable boot, all based on their symptoms, speed on healing needed, etc.
Please enjoy Adele and her beautiful song entitled "Million Years Ago"


  1. Dr. Blake,

    Do you have an opinion on minimalist running trends? I have read many of the studies and am impressed with the research, but mostly in terms of how running shoes may contribute to some over use injuries. In my case, running with shoes causes sharp pain (immediately) in the low back. Whereas without shoes there is none.


  2. Marc, since I have spent my entire podiatric life making feet more stable and more protected, this concept is a new paradigm. However, biomechanics is the basis of most problems and solutions in some many activities like running, cycling, swimming, etc, where there is repetitive motion. Running shoes in general have around 1/2" heel height, increasing low back curve (lordosis), and, in some patients, producing low back pain. The high heel effect also can cause many runners whom land on the lateral (outside) border of the running shoe to either excessively supinate (lateral instability), or rapidly pronate (arch collapse). Both of these problems can cause foot/ankle/knee/hip/low back pain. Both of these problems also get worse with as little as 200 miles of shoe wear. I will have a later post dealing with the weakest link in the chain syndrome. Serious, if not all, runners need to link up with a good running shoe store, and/or knowledgeable sports medicine practitioners, whom can evaluate the function of an athlete shoe purchased or possibly causing problems. I will also have a post on generalizations in choosing the right running shoe.
    So, yes, shoes can produce problems. I have mentioned only a few. But, does the answer lie in a minimalist approach to foot wear? For some, definitely. For others, a fatal running mistake. Who will help them decide? My best advice with any new device, shoe, technique, is to listen to your body (Golden Rule of Foot). Go gradual, and use common sense on what surfaces to wear them. Avoid pain. Any thing that causes pain weakens the body. Will feet get stronger with this type of shoe? I hope the physical therapist/runners out there will tell us. Is the answer more in prescribing foot strengthening exercises for every pair of stable running shoes and/or foot orthotic devices purchased or prescribed. I hope this helps. Dr Rich Blake

  3. Thanks for the advice...I believe we'll see ever more shoe options which should help those with special biomechanic and musculoskeletal needs...In may case, the elevated heel in running shoes causes a heel strike where forces collide...without running shoes (and I've video taped both) I land on the foot pad with a more reactive strike and quicker turn over...Love the Golden Run of Foot...great advice...

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Thank you very much for leaving a comment. Due to my time restraints, some comments may not be answered.I will answer questions that I feel will help the community as a whole.. I can only answer medical questions in a general form. No specific answers can be given. Please consult a podiatrist, therapist, orthopedist, or sports medicine physician in your area for specific questions.