Plantar Fasciitis Rehab

Marc Surdyka

July 4, 2022

Do you have pain on the bottom of your foot when standing, walking, or taking that first step out of bed in the morning?

The purpose of this blog is to discuss plantar fasciitis, dispel the most common myths associated with the diagnosis, and teach you everything you need to know about managing the condition.

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Plantar Fascia Anatomy & Function

The plantar fascia is an expansive connective tissue located on the bottom of the foot that aids in stability and control of the foot. Activities that involve extension of the big toe, loading of the Achilles tendon, and weightbearing in general, such as standing, walking, and running, increase the tension experienced by the plantar fascia.

Plantar Fasciitis

Plantar fasciitis refers to inflammation of the plantar fascia. However, current research suggests that local inflammation is likely not the primary driver of the condition. Therefore, Riel et al suggest calling it plantar fasciopathy or plantar heel pain.

This is important to know because most people associate inflammation with the need to rest, ice, and take anti-inflammatory medication, which are not recommended treatments.

It’s also not recommended to aggressively roll or massage the bottom of your foot with the intention of breaking up scar tissue or adhesions because it’s actually not possible to do either. The plantar fascia is a dense, fibrous connective tissue that cannot be altered with our hands or other tools.

You can roll your foot on a frozen water bottle or lacrosse ball if it feels good for you and doesn’t take away from the primary goals of rehab, but neither are needed.

You may have also heard that the cause of your pain is a bone spur, but research by Hansen et al “found that a heel spur had no influence on either the development or prognosis of symptoms and that many patients had a heel spur without having symptoms.”

Plantar Heel Pain

To understand what is recommended, it’s important to discuss who gets plantar heel pain.

The condition generally presents along a continuum. On one end, there is the younger, more active population, such as runners. On the other side, there are the older, more sedentary individuals with a higher body mass index.

But why did you get plantar heel pain?

A simplified framework is that it’s thought to occur when the intensity, frequency, and volume of plantar fascia loading, such as when standing, walking, or running, exceeds your capacity to recover and adapt appropriately.

For the runners, it often comes down to doing too much, too soon. For example, perhaps you increased your pace or total running mileage as you were training for a race, which represents a spike in load.

For the less active individuals, it might be related to a gradual decline in general physical activity and overall well-being, which represents a decrease in capacity.

Therefore, the goal of rehab for either population is to balance out this equation, so that your capacity is greater than or equal to the various loads you’re experiencing on a day-to-day and week-to-week basis

It’s also important to point out that other lifestyle factors like sleep, stress, and nutrition can influence this equation.

Load Management & Activity Modifications (Recommended)

Based on this information, my first recommendation for rehab is to modify aggravating activities to reduce the load side of the equation.

If you’re a runner who can’t tolerate your current training program, you need to temporarily scale back by manipulating the frequency, mileage, or speed of your runs. Similarly, if you can’t tolerate a certain amount of walking or standing, you might need to do less, if possible. To maintain or increase your capacity, it may be helpful to swim, cycle, or perform the exercises demonstrated in this blog.

I also highly recommend tracking your daily steps because it helps you understand your baseline level of function and tolerance. You don’t need to hit a certain step count; you just need to determine how much is too much right now and very gradually build that up over weeks and months.

Understanding & Monitoring Pain (Recommended)

Another fundamental component of rehab is understanding and monitoring pain. Ask yourself 2 questions:

Is my pain tolerable during exercise? There’s not a universally acceptable answer. You get to decide what tolerable means.
Is my pain better, worse, or the same the day after exercise? If you feel fine during and immediately after exercise, but you have a significant worsening of symptoms the next day, that’s an indication that you’re doing too much and need to back off a bit.

You can assess your next-day symptoms with your first step out of bed in the morning. For example, you rate your pain on day 1 as a 2/10 pain. You then perform your exercise routine within tolerance, go about your day, and go to bed without any major issues. The next morning you wake up and rate your pain as a 5/10. This means that even though your symptoms were tolerable during exercise, you might have done a little too much. You didn’t do any harm, but doing less next time would be recommended.

Also, you can replace the word exercise with physical activity, work, or anything else that affects your symptoms.

Shoes & Orthotics (Optional)

Shoes and foot orthoses can be considered for attempting to reduce the load side of the equation by modifying the amount of tension experienced by the plantar fascia.

For example, you can trial a cheap heel cup or off-the-shelf orthotic that supports the arch of the foot to determine if it provides some short-term relief. If you’re working with a podiatrist, you can discuss custom foot orthoses.

In terms of shoe wear, I’d expect a minimalist shoe to increase plantar fascia loading and a motion control-type shoe to decrease plantar fascia loading. Theoretically then, it may be helpful to use a shoe that decreases the load on the plantar fascia early on when you’re highly symptomatic.

However, what you choose to wear will also be based on your comfort, preferences, beliefs, and other factors.

Exercises

For the exercises, I’m going to present two categories with different purposes. The first category is meant to provide short-term relief. One exercise is recommended based on the research, and the other two are optional add-ons. The second category is meant to improve long-term function and increase your tolerance to standing, walking, and running by gradually loading the plantar fascia. Once again, one exercise is recommended and the other two are optional add-ons.

Whether you decide to do 1, 2, or all 6 of the movements depends on your symptoms, goals, time availability, etc. Tailor the exercises, and all of this information, to suit your individual needs.

Plantar Fascia Stretch (Recommended)

The first recommended exercise is a plantar fascia stretch, researched by DiGiovanni et al in 2003 and 2006. After periods of prolonged inactivity, such as sleeping or sitting, you can perform this stretch with the intention of decreasing the pain you experience upon standing or walking.

Place the affected foot on the opposite leg and pull the toes up toward the shin. Hold the stretch for 10 seconds and repeat 10 times.

Toe Curls and Toe Yoga (Optional)

Two optional exercises that you can perform after the plantar fascia stretch are toe curls and toe yoga.

Toe curls involve flexing and extending your toes, with or without the use of a towel.

Toe yoga involves tapping your big toe and other toes in an alternating fashion.

You can do one or both exercises for up to a minute at a time.

Heel Raises (Recommended)

The recommended exercise for improving long-term function is a heel raise because it’s weightbearing, requires extension of the big toe, and involves loading of the Achilles tendon and calf complex.

In the research by Rathleff et al in 2015 and Riel et al in 2019, a single leg heel raise was performed on a step with a towel under the big toe. Here is a progression you can do with or without the use of a towel or object under your toes.

Level 1 – Double Leg Heel Raises on Flat Ground. Aim for 3 sets of 25 slow and controlled repetitions. Use your hands for balance as needed.

Level 2 – Single Leg Heel Raises on Flat Ground. Aim for 3 sets of 15 reps.

Level 3 – Single Leg Heel Raises on a Step. Aim for 3-4 sets of 8-15 reps. Over time, you can add weight as needed.

Split Squats (Optional)

An optional exercise for improving the strength, range of motion, and control of your feet and ankles is a split squat progression.

Level 1 – Bodyweight Squat. Gently tap your butt to a chair and stand back up. If it’s too challenging, shorten the range of motion or use your hands for assistance. Aim for 3 sets of 20 reps.

Level 2 – Split Squat. Start in a stride stance and lower yourself down so that your back knee taps an egg that you don’t want to crack. If it’s too difficult for your front or back leg, shorten the range of motion or use your hands for assistance. Aim for 3 sets of 15 reps.

Level 3 – Front Foot Elevated Split Squat. Elevate the front leg using a 2-4” object. Drive your knee as far forward as tolerable. Aim for 3-4 sets of 8-15 slow and controlled reps. Over time, you can add weight as needed.

Single Leg RDLs (Optional)

Another optional exercise for improving long-term function is a single leg balance progression.

Level 1 – Single Leg Balance. Work your way up to standing on one leg for 3 sets of 60 seconds.

Level 2 – Single Leg RDL. Stand on one leg while keeping a slight bend in both knees, hinge at your hips until your trunk is almost parallel with the ground, and then return to the starting position. Repeat this movement without touching your foot to the ground. If this is too challenging, use your hands to help with balance, shorten the range of motion, or tap your foot to the ground. Aim for 3 sets of 12 reps.

Level 3 – Single Leg RDL w/ Knee Drive. You can progress the previous movement by adding a knee drive. Aim for 3-4 sets of 8-15 slow and controlled reps. Over time, you can add weight as needed.

Inchworm (Optional)

If you like to stretch before exercising, the inchworm is a great dynamic option. Start in a plank position, slowly walk your feet toward your hands, and drive your heels into the ground so you feel a stretch in your feet, calves, and hamstrings. Reset your position and repeat for a few reps.

Summary

In summary, plantar heel pain is characterized by symptoms on the bottom of the foot with standing, walking, running, or taking that first step in the morning. It generally presents along a continuum with runners on one end, and older, more sedentary individuals with a higher body mass index on the other end.

Since local inflammation isn’t thought to be the primary driving factor of the condition, ice, anti-inflammatories, and complete rest are not recommended. Contrary to popular belief, managing plantar heel pain is also not about breaking up scar tissue, removing heel spurs, or changing the structure of the foot. You can roll your foot on a frozen water bottle or lacrosse ball if it feels good for you and doesn’t take away from the primary goals of rehab, but neither are needed.

My core approach involves modifying aggravating activities, keeping track of daily steps and monitoring symptoms, and maintaining or progressing tolerable physical activity over time.

To aid with short-term relief, plantar fascia stretching can be performed for 10 reps of 10 seconds after periods of prolonged inactivity, such as sleeping or sitting.

Following this movement up for a minute or two of toe curls and/or toe yoga is optional.

To improve long-term function of your feet and ankles, consider performing heel raises every other day. Incorporating the split squat and single leg balance progressions to further improve function are optional, as well as the inchworm as part of a dynamic warm-up.

Regardless of what you decide to do, it’s important to tailor the plan to your individual goals and needs. There is no quick fix for plantar heel pain, so it’s helpful to set realistic expectations and plan for the process to take a minimum of 3 months.