plantar fasciitis gone in 5 steps
Too good to be true…
You wake up in the morning after a great night of sleep and sit up at the edge of your bed. You can see the sun peaking in through the curtains. The birds are chirping outside. It’s going to be a great day.
But this glorious start to a great day is too good to be true…
You sit up and at the end of your bed. As you stand up, pain shoots from your heel into the arch of your foot…it feels like something is tearing in the bottom of your foot with every step.
It slowly starts to ease with the more steps you take…but you’re left feeling like you’re getting older and slowing down first thing in the morning.
This is commonly referred to as Plantar Fasciitis.
What is plantar fasciitis?
Plantar Fasciitis is defined by pain on the bottom of the foot the first steps after waking up or pain the first steps after not being on your feet for an extended period of time.
2 Million Americans every year will suffer from plantar fasciitis…
Once you’ve had it for a year, there’s a 45% chance you’ll have it for 10+ years!
But not if you keep reading this blog and follow the 5 plantar fasciitis principles below…
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 such as standing, walking, and running increase the tension on the plantar fascia.
The “plantar” part of plantar fasciitis makes sense as this refers to the bottom part of the foot…
The “fascia” makes sense as well as it is a facial connective tissue…
The “itis” part, on the other hand, does not.
“Itis” refers to inflammation…
Wrongly named
Researchers from Temple university studies tissue samples from 50 cases of heel spur surgery for chronic plantar fasciitis. They found that the tissue showed signs of degeneration and damage, rather than inflammation. Specifically, they observed that the tissue of those suffering from plantar fasciitis was broken down, weakened, and jellylike. 1.
These findings support the idea that plantar fasciitis is actually a degenerative condition (fasciosis) rather than an inflammatory one (fasciitis).
This is important.
Modern medicine still treats this type of foot pain like an inflammatory condition and it may be doing more harm than good.
This sort of misguided thinking is very common in our modern medical world. We prescribe medications even when we know the medications will not treat the actual problem. I can’t tell you how many patients go to urgent care with a virus and get prescribed antibiotics.
“According to the Centers for Disease Control and Prevention (CDC), approximately 30% of antibiotics prescribed in outpatient settings are unnecessary, and a significant portion of these prescriptions are for viral infections, against which antibiotics are ineffective. This misuse contributes to antibiotic resistance and disrupts the balance of healthy bacteria in the body.”
Treatments like repeated corticosteroid injections into the plantar fascia should be reconsidered, as they might cause the plantar fascia to weaken and potentially rupture…especially since there is no inflammation to treat.
Many people associate inflammation with the following:
rest
ice
anti-inflammatory meds
Those are effective treatment for inflammation, at least in the short term. But if you don’t have inflammation, anti-inflammatories will only work via placebo on a non-inflammatory condition like plantar fasciosis.
In fact, researchers compared the following 3 treatments:
steroid injections
doing nothing
and joint mobilizations and stretching techniques (which I’ll show you soon)
They actually found that steroid injections worked better…at first.
But in the long run (12-weeks to 1 year) the joint mobilization and stretching group fared the best. The wait and see group did second best. The steroid injection group the worst. 2.
Why?
Steroid injections stop inflammation, but they also prevent tissue healing and accelerate tissue breakdown.
…I’ll continue to use the phrase “plantar fasciitis” through this blog as it’s what most people call their pain and I want to speak their language.
What causes plantar fasciitis?
Plantar fasciitis sufferers often have multiple things contributing to their pain.
Here are a few of the most common:
Prolonged standing, walking, or running (especially adding too much too soon)
Limited ankle mobility or tightness in the calves (less mobility in the ankle means more is required in the plantar fascia = more stress)
Flat feet or too high of arches (stresses the plantar fascia in one extreme direction)
Being overweight
What I typically see is that plantar fasciitis starts when the intensity, frequency, and volume and plantar fascia loading exceeds our plantar fascias capacity…
In other words, when you standing, walking, and or running exceeds what your plantar fascia is capable of tolerating.
For the non-active person who gets this, it’s sometimes a function of a decrease in capacity more than an increase in load.
So now that we know a little bit about what plantar fasciitis IS and what causes it, it’s time to figure out how to solve it for good.
You have two options:
Reduce the load on the plantar fascia…
Increase your capacity…
I recommend doing BOTH! This is depicted in the second graph below:
FIRST reduce load and increase capacity soon after.
To do so, you’ll need to follow my 5 principles for plantar fasciitis.
Principle 1: Modify
Remember our talk about capacity?
In the short term, you need to manage the load on your plantar fascia so that it’s less than your capacity.
It’s a bit of a guessing game to figure out what your capacity is.
But if you’re a runner who’s experiencing plantar fascia pain, you’ll likely need to scale back your training in the short term until the pain subsides.
If you have been dealing with plantar fascia pain from standing or walking, scaling back the volume of standing or walking is wise.
You can use the amount of pain you experience first thing in the morning or with activity as a guide. You should scale back (and follow the other 4 principles) until you no longer have foot pain before building back up.
Note: It may be helpful to take up an activity like strength training, swimming, biking, or rowing while you’re healing to build up your capacity and avoid stressing the plantar fascia.
I also tell my patients to track their daily steps and standing time using their phone or health watch so we have a gauge on how much load they putting on their plantar fascia.
Another important concept with rehab it to understand and monitor your pain. Pain in incredibly subjective and relative to the individual, but it can still be a very helpful guide.
If you feel fine during and after exercise but have worse symptoms the next day, you probably did too much.
I advise patients to use their first steps out of bed in the morning as a gauge for progress.
For example:
Day 1:
Pain = 3/10
Walking = 10,000 steps
Day 2:
Pain = 5/10
All other factors being equal, you can assume that the walking volume likely led to an increase in pain. Decrease walking volume until you have less pain first thing when waking.
Another example:
Day 1:
Pain = 3/10
Walking = 5,000 steps
Day 2:
Pain = 2/10
In this example, we can assume that the volume of walking (5,000) steps was appropriate and pain is less the next day.
Each day that the pain is less, you can continue adding volume by small increments (500 or so steps).
Shoes and foot orthosis can also be used in the short term to support the foot and reduce strain on the plantar fascia.
The right Shoe-wear and orthotics are highly dependent on the individual. However, here are a few I’ve seen folks have success with:
Shoes: Hoka
In 2022, me and friends trained for a week-long 30+ mile/day backpacking trip of the John Muir Trail in the Sierras. Talk about increasing plantar fascia load!
To offset the amount of loading on the plantar fascia (and other tissues) we all trained in and wore motion control shoes.
I did the trail in the shoes above, the Hoka Zinal (even the same color).
Orthotic basic: Superfeet
I’ve also seen patients have success with a basic orthotic like Superfeet.
Orthotic Advanced: Barefoot Science
For a more advanced option than Superfeet, try Barefoot Science’s progressive orthotics. These require slowing transitioning to less and less arch support and allow your foot time to adapt to a more barefoot shoe.
Principle 2: Manage Chronic inflammation
Plantar fasciitis is not inflammatory in nature.
Ice, anti-inflammatories, and steroid injections all treat inflammation. So these sort of treatments don’t make sense. Plus, there are side effects: NSAID’s and Cortisone slow healing and ice reduces blood flow.
But chronic inflammation will affect how your body heals
So it must be addressed to promote healing.
Many things contribute to chronic, systemic inflammation but three of the biggest players nutritionally are sugar, refined carbohydrates and seed oils.
Sugar and carbs
Carbohydrates, regardless of their glycemic index, turn into sugar in the bloodstream, disrupting its balance and necessitating a rapid insulin response. This rapid insulin spike can lead to a crash in blood sugar levels, leaving you feeling tired, irritable, and craving more carbs—a vicious cycle that can be difficult to break.
In a high-carb environment, the excess sugar molecules bind with proteins in our tissues through a process known as glycation. This binding forms advanced glycation end products (AGEs). These AGEs accumulate over time and are a significant factor in the development of chronic diseases.
AGEs are harmful because they “gum up” our tissues and trigger widespread inflammation throughout the body. Inflammation is the body's natural response to injury or infection, but chronic inflammation is a different story. It can damage tissues and organs, contributing to conditions like heart disease, diabetes, Alzheimer's, and even cancer. This inflammatory response can also exacerbate conditions like arthritis and plantar fasciitis.
Avoid the following foods to reduce systemic inflammation and optimize health:
Common Carb-Rich Foods:
Bread (especially white and whole wheat)
Pasta (including spaghetti, macaroni, etc.)
Rice (white, brown, basmati, etc.)
Baked Goods (cookies, cakes, muffins, pastries)
Breakfast Cereals (including granola, cornflakes, etc.)
Common Names for Sugar:
Sucrose
Glucose
Fructose
Maltose
Lactose
Dextrose
High-Fructose Corn Syrup (HFCS)
Corn Syrup
Cane Sugar
Agave Nectar
Vegetable oils:
Vegetable oils, often perceived as healthy, undergo extensive processing that can result in the formation of trans fats. These oils, such as soybean, corn, and sunflower oil, are high in omega-6 fatty acids. While essential in small amounts, an excess of omega-6 disrupts the body's balance, leading to chronic inflammation.
Omega 6’s are like the gas pedal for the iflammatory response in the body
Omega 3’s are like the break pedal for the inflammatoryh response in the body
We need BOTH.
But the average american eats a diet with a ratio of 40:1 omega 6:3!
It’s like our immune system have the engine of a semi-truck with the brakes of a toy truck. It won’t end well…
The processing of vegetable oils often involves hydrogenation, which converts these oils into trans fats. Trans fats are particularly harmful because they not only increase low-density lipoprotein (LDL) cholesterol, the "bad" cholesterol, but also decrease high-density lipoprotein (HDL) cholesterol, the "good" cholesterol (SpringerLink) (FEHD) . This imbalance contributes significantly to chronic inflammation, a precursor to many common problems such as plantar fasciitis.
Studies have shown that during frying and heating, the formation of trans fatty acids increases, further contributing to the inflammatory response in the body (SpringerLink) . Chronic inflammation driven by trans fats damages cells and tissues, accelerating the progression of various chronic conditions.
Eliminating vegetable oils from your diet and opting for traditional fats like butter, ghee, and olive oil can significantly reduce inflammation. These healthier fats support cellular integrity and help restore the balance between omega-6 and omega-3 fatty acids. By making these dietary changes, you can lower your risk of chronic diseases and improve overall health.
Vegetable Oils to Avoid:
Soybean Oil
Corn Oil
Canola Oil (Rapeseed Oil)
Cottonseed Oil
Sunflower Oil
Safflower Oil
Grapeseed Oil
Rice Bran Oil
Margarine and Partially Hydrogenated Oils
Vegetable Oil Blends (often found in processed foods)
Healthier Alternatives:
Extra Virgin Olive Oil
Coconut Oil
Avocado Oil
Butter or Ghee (clarified butter)
Lard (from pasture-raised animals)
Tallow (beef fat, from pasture-raised animals)
Duck Fat
Principle 3: Don’t take a step in the morning without doing this…
While you’re sleeping, your Plantar fascia will be going through a healing process.
When you put your full body weight across the stiff, newly healed fragile tissue, first thing in the morning, it can cause small tears in the plantar fascia leading to pain.
Before putting the stress of your bodyweight on your planner fascia, you’ll want to warm up the tissue for the day bringing blood flow to the area.
Do this quick stretch 3X30 seconds first thing in the AM.
I’ve seen patients make pretty dramatic progress literally overnight, just by adding the stretch routine.
Sit at the edge of your bed and rest your ankle on the opposite knee, creating a triangle between your legs. Grasp the toes of the affected foot at the point where they meet the ball of the foot and pull back gently, in the direction of the shin, until you feel a stretch in the plantar fascia. (You should feel tension when you press lightly on the arch of the foot.) Hold the stretch for 30 seconds, and repeat 3 times.
Principle 4: Improve ankle/foot mobility and strength
One of the key factors contributing to plantar fasciitis is limited mobility in the ankle and foot. When the ankle's range of motion is restricted, it places additional stress on the plantar fascia, leading to pain and further degeneration. Here's how you can improve your ankle and foot mobility and strength to alleviate plantar fasciitis:
Increase Ankle Dorsiflexion
Ankle dorsiflexion refers to the movement of pulling the toes toward the shin. Limited dorsiflexion can cause the plantar fascia to bear extra stress, increasing the likelihood of plantar fasciitis. Modern footwear, particularly shoes with elevated heels, can contribute to chronic shortening of the calf muscles and Achilles tendon, decreasing joint range of motion.
Try this stretch:
Ankle Dorsiflexion Band Stretch:
Start with one foot elevated on a box or stair with a band attached around the bottom of your ankle as pictured.
Rock forward to the end of your ankle range of motion and pulse in and out of the end range for 2 minutes.
Studies have shown that increasing ankle dorsiflexion can significantly reduce the stress on the plantar fascia. For example, researchers taped the talus (a bone in the ankle) of 10 patients with limited dorsiflexion and had them walk for 10 minutes. They found that this simple intervention increased ankle dorsiflexion and alleviated pain.
Strengthen The Calf
Researchers have found that strength training exercises, such as the calf below, can lead to significant improvements in plantar fasciitis symptoms. In a study comparing a strength group to a stretch group, both improved after three months, but the strength group reported significantly less pain.
Strengthening the intrinsic muscles of the foot can provide better support to the plantar fascia, reducing pain and improving function. Strengthening exercises can be more effective in the long run compared to stretching alone.
Calf Raises:
Stand on a step or sturdy platform, raise up as high as you can on both feet.
Lift one foot. slowly lower down on one side.
Repeat 15X on both sides.
Principle 5: Move Away from Cast-Shoes…and Get Barefoot
All tissues within the body follow a stress-adaptation curve. Humans, in general, adapt to the stresses placed upon them.
What doesn’t kill us (or flare us up) will make us stronger...
Like we talked about in principle 1, you want to modift with shoes and orthotics to provide short term relief.
But in the long run, you’ll want to transition to more minimalist shoes to increase load and build strength.
Wy Move to Minimalist Shoes?
Ever broken a bone or had surgery? What happened to the muscles in that area of your body? They atrophied! The same can happen to your feet if they are overly supported by modern footwear. The small stabilizing muscles in the feet can weaken, leading to atrophy.
Researchers found that within six months of wearing minimalist shoes, people who had previously worn normal Western footwear increased the strength of their feet by 54%. By the end of six months, their foot strength was comparable to those who had been wearing barefoot shoes for 2.5 years or more. In other words, within six months, you can get your feet back to their natural strength.
I personally switched to barefoot shoes about 10 years ago. About a year after making the switch, I tried to put on some dress shoes that had previously fit fine. They were unbearably tight in the front of my toes and on the sides. My feet had actually grown from wearing barefoot shoes. The foot naturally wants to spread out, providing a wider base of support and allowing it to function normally. Modern shoes, however, constrict the foot into an unnatural position, making it smaller.
How to Transition to Barefoot Shoes
Switching to barefoot shoes should be done gradually. This gradual stress introduction allows your plantar fascia and other tissues within your feet time to adapt and get stronger.
Steps for Transitioning:
Start Slowly: Begin by wearing barefoot shoes for short periods each day.
Increase Gradually: Gradually increase the amount of time you spend in barefoot shoes.
Listen to Your Body: Pay attention to any discomfort or pain and adjust accordingly.
Incorporate Barefoot Walking: Walking barefoot on natural surfaces like grass can also help strengthen your feet.
You can also use an orthotic like the ones from Barefoot Science mentioned above to transition.
Barefoot Walking
A study involving 20 patients who enrolled in a 12-week barefoot running program on grass showed significant improvement in symptoms at 6 and 12 weeks, as self-reported foot pain decreased. Study Link
By moving away from overly supportive shoes and gradually transitioning to minimalist footwear, you can rebuild the strength and resilience of your feet, ultimately reducing pain and preventing future issues. Remember, the key is to transition slowly and allow your body to adapt to the new stresses.
a final lesson from limp trees…
Have you ever heard of Biosphere 2 and its limp trees?
Biosphere 2 was an artificial closed ecological system in Arizona, designed to study self-sustaining environments. Inside, trees grew rapidly but fell over before reaching maturity. The scientists realized that the lack of wind in Biosphere 2 caused a deficiency in stress wood, a vital component that helps trees grow strong and stable. Without the challenge of the wind, the trees couldn't support themselves.
So, what does this have to do with plantar fasciitis?
Just like the trees in Biosphere 2 needed the wind to grow strong, our feet need the right amount of stress to stay healthy.
When it comes to plantar fasciitis, it’s not just about gettting the most supportive shoes, giving up running, and buying fancy inserts.
It’s about understanding how to manage and adapt to stress properly.
The wrong kind of stress, like excessive inflammation, can be harmful, but the right kind of stress, like appropriate exercise and gradual transition to minimalist shoes, can strengthen your feet and alleviate pain.
Find the right amount of stress and allow your body the time to adapt.
Take back your health,
Dr. Matt
