top of page

Plantar Fasciitis Treatment

Updated: May 5, 2022

What Is Plantar Fasciitis?


Plantar fasciitis is a common pathology of the feet that can cause severe pain and disability with running, walking, jumping, and other movements. It is also one of the least understood conditions regarding diagnosis and treatment. I believe that plantar fasciitis is overdiagnosed and poorly treated by a majority of healthcare professionals. To start, let’s look at the anatomy of the bottom of the foot.


plantar fasciitis treatment plantar fasciitis exercises plantar fasciitis diagnosis
OpenStax College, CC BY 3.0 <https://creativecommons.org/licenses/by/3.0>, via Wikimedia Commons

This image shows the shallowest of the three commonly accepted layers of muscle in the foot. The plantar aponeurosis is another name for the plantar fascia. Fascia is a thick connective tissue that runs throughout our bodies and provides support to most structures. In some areas such as the bottom of the foot (also the IT band), we have thicker fascia to provide support and reduce stress. The plantar fascia is really strong, like really really strong. So strong that it takes over 1,000 pounds of force to deform it by 1% (this will be important later on).


The image above does not show that the flexor digitorum brevis actually inserts into the calcaneus (heel bone) by itself and is not completely connected to the plantar fascia. The flexor digitorum brevis helps curl your toes. It is important to understand that the plantar fascia is not a muscle. If you dorsiflex your foot as if you are stretching your calf, you will stretch the fascia, and squeezing your toes shortens it. However, it is not contracting in the same way that a muscle would.


Another purpose of the plantar fascia is to maintain your foot arch. We have arches in our feet for force absorption and creation. When you step, your foot pronates and your arch collapses to absorb force. As you progress to step forward, your foot supinates and your arch increases to propel you forward. Part of the impetus to tighten the arch comes from your big toe extending and tightening the plantar fascia. This is known as the windlass mechanism and it is pictured below courtesy of physio-pedia.com


plantar fasciitis treatment plantar fasciitis exercises plantar fasciitis diagnosis

So, the purpose of the plantar fascia is to absorb force in the foot, but also to maintain the arch and help distribute and produce force when walking. This is why it is so strong and resists deformation. Imagine how much force goes through your foot with every step you take, let alone if you are running. It is amazing how strong our bodies are!


Here are the other layers of the foot, starting with the middle layer of muscles:


plantar fasciitis treatment plantar fasciitis exercises plantar fasciitis diagnosis
OpenStax College, CC BY 3.0 <https://creativecommons.org/licenses/by/3.0>, via Wikimedia Commons

The lumbricals help you squeeze and separate your toes together. The quadratus plantae is an odd muscle whose entire function is to help another muscle. It pulls the flexor digitorum longus into a more optimal position to flex the toes. The flexor digitorum longus originates from the back of your tibia in your lower leg and runs through the bottom of your foot to your toes. The quadratus plantae helps keep it on an optimal line to flex your toes. Note where the quadratus plantae is located, almost directly under your plantar fascia.


The final and deepest layer of muscles is shown below:


plantar fasciitis treatment plantar fasciitis exercises plantar fasciitis diagnosis
OpenStax College, CC BY 3.0 <https://creativecommons.org/licenses/by/3.0>, via Wikimedia Commons

The flexor digiti minimi brevis flexes your little toe and helps maintain the outside arch of your foot. The flexor hallucis brevis flexes your big toe and actually originates from a few bones in your midfoot including your cuboid. The cuboid bone is pictured below:


plantar fasciitis treatment plantar fasciitis exercises plantar fasciitis diagnosis
BodyParts3D is made by DBCLS., CC BY-SA 2.1 JP <https://creativecommons.org/licenses/by-sa/2.1/jp/deed.en>, via Wikimedia Commons

The bone is in the middle of your foot on the outside. Therefore, the flexor hallucis brevis must travel from the outside of your foot to your first toe on the inside of your foot. This puts the muscle directly under your plantar fascia (hopefully you see where all of this is going).


How to Diagnose Plantar Fasciitis


There are several factors that lead to a diagnosis of plantar fasciitis. The primary sign is sharp, possibly stabbing pain near the heel. This pain is typically worse first thing in the morning because we usually point our toes while sleeping, which tightens the fascia and surrounding tissues. The first few steps provide a stretch on the tissues that have been shortened for several hours, usually resulting in pain. Pain can also be severe after prolonged sitting or if you run or walk for a long distance.


Imaging is not often used for plantar fasciitis as there is not much to see. X-rays can make sure that a stress fracture is not present in one of the bones in your foot. X-rays can also look for bone spurs at the heel. These spurs can occur from tight muscles and the plantar fascia pulling on the calcaneus or heel bone. Your body will lay down more bone to protect against stress, leading to spurs. Interestingly, the American Academy of Orthopaedic Surgeons notes that 10% of all people are shown to have heel spurs, but only 5% of those who have them actually suffer from pain. It is important to understand that just because imaging reveals a heel spur, it is not necessarily the cause of your symptoms.


plantar fasciitis treatment plantar fasciitis exercises plantar fasciitis diagnosis
https://www.lifesole.co.uk/

If you go to a healthcare provider with the symptoms described above, they will probably diagnose you with plantar fasciitis. If they take the time to have you remove your shoe, they will poke you around your heel and probably say “you have plantar fasciitis”. It is important to remember the anatomy that I showed you above. There are multiple muscles that run around and below the plantar fascia. A brief assessment can rule out a strain in those muscles, which should be treated differently than plantar fasciitis.


One of the easiest ways to assess whether the plantar fascia or muscles are causing your symptoms is to flex your toes. The plantar fascia should feel much more pain with stretching of your foot, and squeezing your toes should relieve some of the pain. However, if muscles are involved, this can worsen your symptoms. Stretching the foot can cause pain if there is muscular involvement, because you are stretching the muscles along with the plantar fascia.


A skilled clinician should also be able to palpate the individual muscles. The flexor digitorum brevis will contract if you squeeze your four toes other than your big toe. The flexor hallucis brevis will contract if you only squeeze your big toe. There are other muscles that can be involved, but these are two simple ones to rule out. If you feel along the bottom of your foot while flexing and relaxing your big toe, particularly on the middle and outside of your foot, then you should feel the flexor hallucis brevis. Similarly, if you flex your other four toes, you will feel the flexor digitorum brevis and longus contract. You do not need to necessarily isolate which muscle is the issue if you are self-diagnosing, but it is important to know if it is a muscular problem.


Plantar Fasciitis Treatment