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[Picture of feet.]

Tried everything?

Maybe not yet. Plantar fasciitis can be stubborn, but many people with chronic foot pain have never even heard of the best treatment options …

Save Yourself from Plantar Fasciitis!

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

37,000 words, updated Apr 1st, 2014 — What’s new?
by Paul Ingraham, Vancouver, Canada bio
I am a science writer, a former massage therapist, and the Assistant Editor of Science-Based Medicine since 2009. I am nearly done with a long-procrastinated Bachelor of Health Sciences degree. I am a middle-aged runner and ultimate player with plenty of personal experience with athletic injury and chronic pain. Readers often want to know more about me and my qualifications, because my style and subject matter is controversial. Most importantly, yes, I used to actually believe and practice almost everything that I now debunk and criticize. I live by the ocean with my wife in beautiful downtown Vancouver.

illustrations by Paul Ingraham, Lindsay McGee

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 patients and professionals about stubborn cases of plantar fasciitis — it is thorough and scientifically current, but still readable and interesting. I explain all the theories, myths, and controversies and review all possible treatment options. Unlike many other conditions I write about, there are treatments known to be at least a little effective, even with some difficult cases.

Plantar fasciitis is a common and often persistent injury afflicting runners, walkers and hikers, and nearly anyone who stands for a living — cashiers, for instance. 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, and stretching, but not everyone. Severe cases of plantar fasciitis 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 it’s also for the professionals trying to help.) I can’t promise a cure for your foot pain. However, I can guarantee that this book will give you a much deeper 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, there has been an explosion of free information about it on the internet. Unfortunately, this has not resulted in patients or health care professionals being better informed!

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!Misconceptions about foot pain have been spread far and wide, thanks to the miracle of the internet!1 (That’s the first of 145 footnotes. Click it!)

Plantar fasciitis is infamously stubborn, and no one knows it better than I do. I suffer from an infinite, incurable case of plantar fasciitis myself. There’s no way I will ever fully recover, because my case is caused by a minor foot deformity — a slight twist in my foot bones. My arch is permanently challenged. 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 them all personally (except surgery). And I have helped many patients and readers with their persistent cases. So I know well, from both personal and professional experience, that the prognosis isn’t always good, and patients really need to be much better informed about their options when the going gets tough.

About footnotes. There are 145 footnotes in this document. Click to make them “pop up” without losing your place. There are two types: interesting extra content, and boring reference information.1Footnotes with more interesting and/or fun extra content are bold and blue, while dry footnotes (citations and such) are lightweight and gray. You can also close footnotes by just re-clicking the number.

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 et al. Acupuncture for Chronic Low Back Pain. New England Journal of Medicine. 2010. PubMed #20818865. ← 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

Plantar fasciitis is not well understood scientifically or biomechanically, and most health care professionals are not aware of the full range of treatment options.

Most manual therapists (physiotherapists, chiropractors, massage therapists) do not know what the latest research says and simply cannot offer patients advanced troubleshooting. I have a modern, impressive sports injuries text on my shelf which offers even less advice — just a couple of paragraphs! — than many of the inadequate articles on the internet.

In fact, many health professionals are not even aware of the basic evidence-based formula for plantar fasciitis rehab, never mind the options for severe and/or atypical cases. (And atypical cases are really what stubborn plantar fasciitis is all about.)

Massage for plantar fasciitis is popular, for instance, but not especially effective.

Would a rub help?

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

Massage for plantar fasciitis is popular, for instance, but not especially effective.

Would a rub help?

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

General practitioners are not prepared to treat plantar fasciitis, or most musculoskeletal conditions, really.2 Podiatrists (foot doctors) — especially in North America, where the profession is focussed on surgical procedures — often give poor quality advice about chronic conditions like plantar fasciitis. The occasional tough case of plantar fasciitis is simply not on their radar. That’s understandable, but it’s unfortunate for those patients.

How can you trust this information about plantar fasciitis?

I question everything and I have fun doing it. I assume that anything that sounds too good to be true probably is. I make no big promises, and I do not claim to know the “one true cause” of plantar fasciitis. When I don’t know something, I admit it. I actually read scientific journals, I clearly explain the science behind every key point (there are more than 150 footnotes here), and I always link to the original sources.

I’ve worked hard for many years to publish the best information about plantar fasciitis available anywhere — better researched and referenced than anything else you can find, highly readable, and even entertaining at times. Every issue is explained in a clear, friendly style that’s just like coming to my office and having a nice long conversation about it, where all your questions get answered as well as possible.

If you’ve been struggling with a tough case of plantar fasciitis, I think this tutorial will feel like a “good find”!

Part 2

Nature of the Beast

What is plantar fasciitis?

Plantar fasciitis is a common kind of tendinitis: an inflammation and/or thickening5 and/or degeneration of the plantar fascia. It’s especially common in runners, and in women during menopause. “Many people are afraid of running because between 30 to 70 percent (depending on how you measure it) of runners get injured every year.”3 And roughly 10% of those are plantar fasciitis cases.4

I’ve just used the familiar terms “tendinitis” and “inflammation” to introduce plantar fasciitis in the most familiar and conventional way. However, these are misleading terms and the truth is more complicated. 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,” Many people are afraid of running because between 30 to 70 percent of runners get injured every year. 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. This applies equally in the Achilles, patellar, medial and lateral elbow, and rotator cuff tendons.”8

And in the plantar fascia, where the degeneration is “similar to the chronic necrosis of tendonosis.”9 Necrosis is bad. It’s Latin for “tissue death.” In plantar “fasciitis,” the plantar fascia is not just hurting, 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 essential for effective treatment.

[Diagram of the foot and plantar fascia to demonstrate the anatomy of plantar fasciitis]

Foot arch-ery

The arch of the foot functions like a bow (as in a bow and arrow), and 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… and when stretched too hard and too often, it gets irritated, and then it’s like a bow shooting you in the foot!

[Diagram of the foot and plantar fascia to demonstrate the anatomy of plantar fasciitis]

Foot arch-ery

The arch of the foot functions like a bow (as in a bow and arrow), and 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… and when stretched too hard and too often, it gets irritated, and then it’s like a bow shooting you in the foot!

So why does it happen? Plantar fasciitis is basically caused by chronic irritation of the arch of the foot due to excessive strain.

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:

  • 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.

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? Wrong.

Unfortunately for common sense, bone spurs aren’t very bone-y: they’re merely a modest calcification of the plantar fascia. The spur is brittle and thin. It’s not much more like bone than tinfoil is like a sheet of steel. It makes the plantar fascia a bit crispy and crunchy.13 So bone spurs aren’t as much of a painful mechanical problem as they sound: more like stepping on a cracker than a nail. A very thin cracker.

So perhaps 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, and the next will say it’s flat feet … sometimes about the same patient. Surprisingly, professionals often seem to have trouble deciding whether a given foot has a flat arch or a high arch!20

So why are experts contradicting each other? Probably because both flat and high arches are likely causes of plantar fasciitis.212223

For years, I incorrectly told plantar fasciitis clients with high arches that they were exceptional, because I knew only the conventional wisdom: namely, that plantar fasciitis afflicts the flat-footed. Now that I know better, it seems obvious that the plantar fascia can also be irritated by an excessively tall arch. 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.

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 problem24 — but that gets almost completely ignored. You never hear about supinating — there’s little research about it.

As much as the body likes things to be just right, it’s also remarkably 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.

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

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.25 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.26

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 shin27two 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

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Part 2.4

Appendices

Acknowledgements

This document and all of SaveYourself.ca 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. Steven Novella, Sam Homola, DC, Dr. Harriet Hall, Simon Singh, and Dr. Stephen Barrett.

Reader Comments

Here is what some readers have said about the plantar fasciitis tutorial over the years. Feedback is always welcome. I focus on the positive in this section, but I want to acknowledge that I certainly do receive some criticisms as well. In many cases I respond by making improvements to the tutorial. However, the vast majority of feedback is enthusiastic. Thanks, everyone!


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 special comment. In the Spring of 2009, I received an incredible endorsement from Jonathon Tomlinson, a GP in Hackney, East London, praising the whole website and every tutorial:

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’s new in this tutorial?

A basic version of this tutorial was first published in 2003 when I originally observed that many stubborn cases of plantar fasciitis could be cured by “power icing,” and I wanted to get that idea out into the world. The tutorial underwent a major upgrade in July of 2006, becoming what I still believe to be the best available single source of information on the subject. Numerous minor improvements have been made since then, and this record of changes was started on August 26, 2007. A particularly large number of improvements were made in the fall of 2012 while preparing to record the audiobook version.

A major feature of my tutorials is that I actively update them as new science and information becomes available. Unlike regular books, and even ebooks — which can be obsolete by the time they are published, and can go years between editions — this tutorial 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 53 major and minor updates worth logging since I started logging carefully in late 2009, and countless more minor tweaks and touch-ups.

Upgraded (Apr 1 '14, section #3.3)Much more information about the (minor) significance of bone spurs. They may not matter a lot, but it’s good, useful, evidence-based context. See section #3.3, Using other diagnostic technologies.

Major update (Jan 1 '14)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.

Minor update (Dec 11 '13, section #2.3)Added a fun science item about the amazing ankle mobility of the Twa people of Africa. See section #2.3, Probably my calves are too tight!

New recommendation (Jul 11 '13, section #3.3)Now recommending a specific type of MRI to scan for bone swelling. Thanks to reader R Russell for the suggestion. See section #3.3, Using other diagnostic technologies.

Minor update (Jun 4 '13, section #4.19)Added a terrific quote from a famous podiatrist about inconsistency in orthotics prescriptions. See section #4.19, Arch support, heel cups and orthotics.

Minor update (Mar 29 '13, section #4.7)Upgraded risk and safety information about Voltaren Gel. See section #4.7, Ibuprofen and friends: non-steroidal anti-inflammatory drugs (NSAIDs), especially Voltaren® Gel.

Product upgrade (Feb 4 '13)Audiobook version now available. See the announcement for more information.

Improved (Jan 11 '13, section #4.25)Expanded and edited. Reflexology and acupuncture added. See section #4.25, Don’t bother with ….

improved (Jan 11 '13, section #4.24)A little more and better advice. See section #4.24, Some tips on beating the morning pain.

Minor update (Dec 7 '12, section #2.4)More detail in my personal story of truly structural foot problem. See section #2.4, So what if you are a flat-footed, tight-calved pronator?

Expanded (Nov 29 '12, section #4.13)Added much more detailed self-help information for trigger points. See section #4.13, Trigger point massage for your feet, shins & calves.

Major upgrade (Nov 26 '12, section #4.13)Rewritten, modernized, expanded. See section #4.13, Trigger point massage for your feet, shins & calves.

Minor update (Nov 24 '12, section #4.15)Some customizing of “brain wrangling” for plantar fasciitis. See section #4.15, Brain wrangling: what to do about sensitization.

Science update (Nov 20 '12, section #4.20)Weak but interesting new evidence on natural running and injury prevention. See section #4.20, Should you run naked? On faddish running styles and running shoes (or the lack thereof).

Rewritten (Nov 9 '12, section #4.14)Bigger, better, more positive discussion of this option. See section #4.14, Friction massage the plantar fascia.

Major update (Oct 28 '12, section #4.22)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. See section #4.22, Beware of high heels.

Science update (Oct 25 '12, section #2)Unimportant but interesting science update about the forces required for arch muscles to activate for support. See section #2, Nature of the Beast: What is plantar fasciitis?

New section (Oct 17 '12, section #4.1)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. See section #4.1, So what’s the plan?

Rewritten (Oct 15 '12, section #4.8)Completely revised to reflect new science and new understanding of the interaction of ice with “inflammation.” See section #4.8, Icing: more is better?

New science (Oct 12 '12, section #3.2)Same content, more science support. See section #3.2, Ultrasonography and plantar fascia thickness.

New section (Oct 10 '12, section #5)No notes. Just a new section. See section #5, Now what?: An action-oriented round-up of my recommendations.

Science update (Oct 7 '12, section #4.10)References pretty much completely renovated and upgraded — and generally good news for once. See section #4.10, Know your stretches.

New section (Oct 7 '12, section #4.7)No notes. Just a new section. See section #4.7, Ibuprofen and friends: non-steroidal anti-inflammatory drugs (NSAIDs), especially Voltaren® Gel.

Like new (Oct 6 '12, section #4)Major upgrade, with a much more detailed introduction to this part of the book, and long and useful list of summarized treatment options. See section #4, Treatment: What can you do about plantar fasciitis?

Minor update (Oct 5 '12, section #3.2)Slightly expanded and clarified. Added a note about feeling a thickened plantar fasciitis with your fingers. See section #3.2, Ultrasonography and plantar fascia thickness.

Minor update (Oct 5 '12, section #3.1)Several minor clarifications and improvements. See section #3.1, Several conditions that might get confused with plantar fasciitis.

New section (Sep 29 '12, section #4.15)No notes. Just a new section. See section #4.15, Brain wrangling: what to do about sensitization.

New section (Sep 28 '12, section #2.9)No notes. Just a new section. See section #2.9, Sensitization: the surprising role of brains in plantar fasciitis.

New section (Sep 25 '12, section #2.7)No notes. Just a new section. See section #2.7, Where’s the fire? The inflammation myth.

Edited (Sep 25 '12, section #2.6)Revision in preparation for audiobook production, with a focus on modernizing information about trigger points. See section #2.6, How trigger points can hurt like plantar fasciitis.

Edited (Sep 25 '12, section #2.5)Revision in preparation for audiobook production, with a focus on modernizing information about trigger points. See section #2.5, The general importance of muscle in plantar fasciitis.

Rewritten (Sep 18 '12, section #2.2)Merged information on arches and pronation, rewrote for clarity, and added a couple nice new supporting quotes. See section #2.2, Maybe it’s my pronation? Or flat feet?

Edited (Sep 18 '12, section #2.1)Longer and clearer than before. In particular, I came up with a much better way of explaining the fragility of “bony” spurs. See section #2.1, Getting to the root of plantar fasciitis: could it be bone spurs?

Science update (Jul 4 '12, section #4.19)Added good new evidence that customization of orthotics isn’t very accurate. See section #4.19, Arch support, heel cups and orthotics.

New section (May 11 '12, section #2.8)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. See section #2.8, Plantar fasciitis in the bone?

New section (May 10 '12, section #4.4)Substantive new section of about 1400 words, with several footnotes and new references. See section #4.4, Surgical options for plantar fasciitis: so many!

More expert opinion (May 5 '12, section #4.5)Added a particularly strong anti-steroids opinion to the section. See section #4.5, Steroid injections are promising but problematic.

Minor update (Dec 21 '11, section #4.23)Added some more detail to exercise description, and a whimsical ankle coordination challenge. See section #4.23, Mobilize your lower leg musculature.

Minor update (Dec 13 '11, section #4.2)Addressed some common fears about the threat of getting out of shape while resting. See section #4.2, The art of rest: the challenge and the opportunity for patients who have supposedly “tried everything”.

Minor update (Sep 28 '11, section #4.21)Added reference to Kong et al, about the effect of shoe wear. See section #4.21, More about reducing impact, especially with Oesh shoes.

New section. (Aug 26 '11, section #4.21)Now officially endorsing Oesh shoes for reducing impact. See section #4.21, More about reducing impact, especially with Oesh shoes.

Minor update (Aug 22 '11, section #4.22)Added a reference about high heels and knee pain. See section #4.22, Beware of high heels.

Minor update (Jul 29 '11, section #1.1)Added a reference about the poor overall quality of online information about common injuries. See Starman et al. See section #1.1, The plantar fasciitis misinformation explosion.

Major update (Jun 21 '11)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. Care for more detail? Really? Here’s the full announcement.

New section (Mar 20 '11, section #4.20)Finally, long overdue, a new section on this topic (for all the running injury tutorials, in fact). See section #4.20, Should you run naked? On faddish running styles and running shoes (or the lack thereof).

Important new info (Feb 8 '11)Where’s the fire? Recently I published a major new article about repetitive strain injuries (like plantar fasciitis), in which I explain that these injuries are rarely actually inflamed. Instead of being “on fire,” excessively stressed tissues tend to break down without inflammation — a kind of rot. This significant fact of biology is not yet given proper attention in this tutorial, and it should be. I learned the science of this myself only just recently, and it is going to take me a while to revise all of the tutorials and articles that are affected by it. Meanwhile the new RSI article is available, free to all, and I have also mentioned and linked to it where necessary throughout all tutorials. For the full scoop on inflammation and repetitive strain injuries, see: Repetitive Strain Injuries Tutorial: Five surprising and important facts about repetitive strain injuries like carpal tunnel syndrome, tendinitis, or iliotibial band syndrome.

Minor update (Jan 18 '11, section #4.19)Added a reference to a large, interesting study that showed that custom orthotics failed to reduce injury rates in marines. See section #4.19, Arch support, heel cups and orthotics.

Improved (Sep 30 '10, section #2)Beefed up with better explanations and science about how plantar fasciitis involves more “degeneration” of your foot than inflammation. See section #2, Nature of the Beast: What is plantar fasciitis?

New cover (Aug 6 '10)At last! This e-book finally has a “cover.” SHOW

Expanded (Jul 16 '10, section #4.5)Added a substantial chunk of content about a promising experimental treatment protocol. Unproven but interesting. See section #4.5, Steroid injections are promising but problematic.

Minor Update (Dec 30 '09, section #4.25)Some new comments on Graston Technique in response to a reader’s questions. See section #4.25, Don’t bother with ….

Minor update (Dec 30 '09, section #4.10)Added an answer to a reader question, “Are soft night splints good enough?” See section #4.10, Know your stretches.

New section (Dec 30 '09, section #4.5)No notes. Just a new section. See section #4.5, Steroid injections are promising but 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 and Pains. BACK TO TEXT
  3. 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
  4. Chandler et al. A biomechanical approach to the prevention, treatment and rehabilitation of plantar fasciitis. Sports Medicine. 1993. PubMed #8100639.

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

    BACK TO TEXT
  5. Karabay et al. Ultrasonographic evaluation in plantar fasciitis. Journal of Foot & Ankle Surgery. 2007.

    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 Thickened plantar fascia — really thick! for more information. BACK TO TEXT
  6. Lemont et al. Plantar fasciitis: a degenerative process (fasciosis) without inflammation. Journal of the American Podiatric Medical Association. 2003. PubMed #12756315. BACK TO TEXT
  7. Andres et al. Treatment of tendinopathy: what works, what does not, and what is on the horizon. Clinical Orthopaedics & Related Research. 2008. BACK TO TEXT
  8. Khan et al. Overuse tendinosis, not tendinitis, part 1: a new paradigm for a difficult clinical problem (part 1). Phys Sportsmed. 2000. PubMed #20086639. BACK TO TEXT
  9. Young et al. Treatment of Plantar Fasciitis. American Family Physician. 2001. 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 inflamation of tendonitis.” 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 tendonitis.” 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 400 pounds. 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 et al. Critical differences in lateral X-rays with and without a diagnosis of plantar fasciitis. Journal of Science & Medicine in Sport. 2006. 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 et al. Operative treatment of subcalcaneal pain. Clinical Orthopaedics & Related Research. 1996. 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 about three years later, their spurs had often reformed, 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. Calcaneal spurs and plantar heel pad pain. Foot. 2000.

    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 et al. The instep plantar fasciotomy for chronic plantar fasciitis. A retrospective review. Journal of the American Podiatric Medical Association. 2000. PubMed #10697969. In this study, surgical outcomes were similar — and generally good — with or without heel spur removal. BACK TO TEXT
  18. Beyzadeoglu et al. The effectiveness of dorsiflexion night splint added to conservative treatment for plantar fasciitis. Acta Orthop Traumatol Turc. 2007. BACK TO TEXT
  19. Overpronation: Accurate or Out of Date Terminology? Griffiths. www.kinetic-revolution.com. 2012. BACK TO TEXT
  20. That sounds strange, but it’s true. 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 therapist that they have no arch left, when in fact I could still easily get my finger under their arch up to the first knuckle — 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
  21. Huang et al. The relationship between the flexible flatfoot and plantar fasciitis: ultrasonographic evaluation. Chang Gung J Med. 2004. 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
  22. Kwong et al. Plantar fasciitis: Mechanics and pathomechanics of treatment. Clin Sports Med. 1988. 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
  23. Bolgla et al. Plantar fasciitis and the windlass mechanism: a biomechanical link to clinical practice. Journal of Athletic Training. 2004. PubMed #16558682.

    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
  24. Hertling et al. Management of Common Musculoskeletal Disorders. 1996. amazon.com 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
  25. Cheung et al. Effect of Achilles tendon loading on plantar fascia tension in the standing foot. Clin Biomech (Bristol, Avon). 2006. PubMed #16288943. BACK TO TEXT
  26. Csapo et al. On muscle, tendon and high heels. J Exp Biol. 2010. PubMed #20639419.

    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
  27. Venkataraman et al. Tree climbing and human evolution. Proceedings of the National Academy of Sciences of the United States of America. 2012. PubMed #23277565. BACK TO TEXT

There are 118 more footnotes in the full version of this book. I like footnotes, and I try to have fun with them.


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