The Plantar Fasciitis Book
The Plantar Fasciitis Book
Dr. Donald Pelto
Copyright © 2019 Donald Pelto
All rights reserved. No part of this book shall be reproduced or transmitted in any form or by any means, electronic, mechanical, magnetic, photographic, including photocopying, recording or by any information storage and retrieval system, without prior written permission of the publisher. No patent is assumed with respect to the use of the information contained herein. Although every precaution has been taken in the preparation of this book, the publisher and author assume no responsibility for errors or omissions. Neither is any liability assumed for damages resulting from the use of the information contained herein.
Requests for permission to make copies of any part of the work should be mailed to: Permissions, Donald E. Pelto, DPM, Central Massachusetts Podiatry, 299 Lincoln Street, Suite 202, Worcester, MA 01605, USA.
Thank you for your interest in the “The Plantar Fasciitis Book” This book is intended to help provide further education to you about plantar fasciitis.
By no means do we believe that this book takes the place of visiting the office; however, it can be used as a good reference source for information about treatments than can begin at home and what treatments are used in the office setting.
This book is set up with different sections and online resources and videos that can be helpful to your recovery from plantar fasciitis. You can view each of these resources by clicking the accompanying link. These are the same resources that I give to my patients in the office. If you are a visual learner, I would recommend starting by watching this video explanation of plantar fasciitis. This will help you better understand this book. The video is 27 minutes long. Click HERE to watch the video.
To your health,
Dr. Donald Pelto
Plantar Fasciitis 4
What is Plantar Fasciitis 4
Symptoms of Plantar Fasciitis 4
The Plantar Fasciitis Score CardⓇ 4
Causes of Plantar Fasciitis 5
Plantar Fasciitis Treatment Evaluator® 8
Treatment Categories 9
Reduce Inflammation 10
Reduce Tightness 14
Stabilizing Foot & Reduce Pressure 19
Surgical Options 24
Preventing Plantar Fasciitis 25
Video Explanation 25
Plantar Fasciitis Treatment Checklist 26
Frequently Asked Questions 26
Additional Resources 27
What is Plantar Fasciitis
Heel pain is most often caused by a problem called plantar fasciitis. This can also be termed heel spur syndrome, where a spur is present on x-ray evaluation. Heel pain can also be due to other causes such as a stress fracture, tendonitis, arthritis, nerve irritation or even a bone cyst. Since there are many probable causes, it is essential to have the heel pain properly diagnosed.
Symptoms of Plantar Fasciitis
The most common symptoms of plantar fasciitis are:
- Pain on the bottom of the heel
- Pain first thing in the morning when getting out of bed
- Pain that increases over a period of time
People with plantar fasciitis often describe the pain as severe upon rising in the morning and then improving as they become more active during the day. After they sit down and relax, their pain is lessened until they begin moving again. After walking for a few minutes, the pain decreases because they are stretching the plantar fascia. For other people the pain is worse when they are on their feet for long periods of time.
The Plantar Fasciitis Score CardⓇ
To help you better understand your symptoms I have put together a Plantar Fasciitis Score CardⓇ. To use this scorecard read each of the items on the column on the left and rank your symptoms and give it a score. Add the scores you have on the right column and read the information below.
0-24 - You probably don’t have a problem with plantar fasciitis at this time but you may have had a problem in the past. You don’t need any treatment but would benefit from wearing supportive shoes as well foam rolling on your own.
25-48 - You have mild symptoms of plantar fasciitis. You may be able to treat this on your own with some of the home therapies or treatments recommended below. If the pain becomes worse or more bothersome you should probably get help from a podiatrist to help with this condition.
49-72 - You have severe symptoms and are probably already getting treatment. If you are not receiving treatment you would benefit from treatment to help resolve your symptoms more quickly. The information below will help you start your own treatment before seeking professional advice.
73-96 - You have very severe plantar fasciitis and you need help urgently. You may have other conditions along with plantar fasciitis as well and should be seeking out help from a professional. You may be a candidate for advanced treatments or surgery.
Causes of Plantar Fasciitis
The most common cause of plantar fasciitis is too much motion in your foot causing excess pulling on the plantar fascia. The plantar fascia is a ligament-like structure that courses from the heel to the ball of your foot. When your foot has too much motion there is excess pull on the plantar fascia causing it to become inflamed. Feet that are overly flat (pronated) or have too much of an arch are more likely to develop plantar fasciitis.
Also, an overly tight Achilles tendon (equinus) in the back of your leg will cause excess tightness on the structures on the bottom of the foot. If you imagine two ropes pulling on the heel bone, the bottom one is the plantar fascia and the top one is the Achilles tendon. If the Achilles is pulling up, the plantar fascia will naturally become tighter making it more prone to injury.
Wearing non-supportive footwear on hard, flat surfaces puts an abnormal amount of strain on the plantar fascia and can also lead to plantar fasciitis. This is especially true for those that wear flip-flops over extended periods of time and for those who have a job that requires long hours on their feet. Obesity can also contribute to plantar fasciitis.
To properly evaluate heel pain, a complete medical history and examination of your foot and lower extremity mechanics is necessary. This will require an evaluation of your walking (gait) and possible video or photography of your feet. By doing this we are able to rule out all other possible causes of plantar fasciitis.
Also, diagnostic imaging such as x-ray, ultrasound, bone scan, and magnetic resonance imaging (MRI) may be used to distinguish among different types of heel pain. Sometimes x-rays can reveal heel spurs with people with plantar fasciitis; however, these are rarely a source of pain.
Image 1 - X-ray of heel spur
Image 2 - Ultrasound of plantar fascia showing thickness increased on the left side
Image 3 - MRI of plantar fascia showing thickening and inflammation
Plantar Fasciitis Treatment Evaluator®
Here is the Plantar Fasciitis Treatment Evaluator® I put together that evaluates the different treatments based on the type of treatment (Reducing Inflammation, Reducing Tightness, Stabilizing Foot and Reducing Pressure) and effectiveness of treatment. This is essential because many people who read about different treatments think that all have a similar effectiveness, which is incorrect.
Obviously, icing is not as effective as a cortisone injection yet they both work at reducing inflammation. Similarly, supportive shoes is not as effective as a custom orthotics at stabilizing your foot. However, when wading through the material presented either online or by your physician you have difficulty determining what treatment to try first.
I hope you find the Plantar Fasciitis Treatment Evaluator® helpful in determining the best type of treatment for your plantar fascial pain. The following resources are in order of effectiveness based on the table below.
Plantar Fasciitis Treatment Evaluator®
(5 is most effective)
Stabilize Foot and Reduce Pressure
5 - Most Effective
Amniotic Membrane Therapy
3 - Moderately Effective
Steroid Anti-Inflammatory Medications (Prednisone)
Home Therapy (Foam Rolling, Stick and TP Tools)
Over-the-counter Arch Support
Oral Non-Steroidal Anti-Inflammatory Medications (Motrin, Ibuprofen)
Strapping of Foot
Icing and Contrast Baths
Platelet Rich Plasma
1 - Least Effective
Topical Pain Reduction Creams (Voltaren)
There are numerous treatment options for plantar fasciitis. These are divided into different categories based on the purpose of the treatment. There are 3 purposes of treatment.
- Reducing Inflammation - These treatments focus on reducing the inflammation that is the main reason for the pain you are feeling. If you do not reduce the inflammation you may continue to limp and walk differently which can cause pain to other parts of your foot or your body.
- Reducing Tightness - This is focusing on reducing tightness of the fascia on the bottom of the foot but more importantly reducing tightness to the muscles that are on the back of your leg that insert either in the heel region or in the foot. This is the most misunderstood reason for plantar fasciitis.
- Stabilizing Foot & Reducing Pressure - Stabilizing the foot is essential to allow your foot to work better. If you have a foot that is flat or pronated it becomes unstable. As a result, the muscles in the foot and the back of the leg region have to work harder. The more stable your foot becomes the less work you have to put into walking and being active. Reducing pressure is the least important aspect of treatment in my opinion. If you have plantar fasciitis in only one foot and they both have the same pressure on them, why don’t they both hurt the same? Reducing the pressure can help initially but only if there is inflammation (as mentioned in item number one) but once the inflammation is improved there is less of a need to reduce pressure on the heel region.
After each treatment you will find an explanation of the treatment as well as the “Pros” and “Cons” of each, to help you better decide what is the best for you.
- Cortisone Injection: Many times, a corticosteroid injection can help reduce the inflammation and pain around the plantar fascia. Here is a document about information after steroid injections if you have any questions, click HERE to see the document.
Pros: For some patients this can resolve the issue of plantar fasciitis very quickly and minimize additional treatment.
Cons: Usually you can only have 3 injections per location, per year. These injections can weaken the fascia as well, and can delay the use of other treatments such as EPAT because of the effects on inflammation.
- Shockwave therapy (EPAT): This is a non-invasive surgical procedure that uses high intensity sound waves to break up adhesions on the plantar fascia and to help activate your body’s healing response. The benefit to this procedure is that there is less need for time off work following the procedure. Click HERE to watch a video about this treatment. If you would like to read more about this treatment there is some information on this website, click HERE.
Pros: You can avoid having a cortisone injection and may resolve the heel pain. There are no side effects with the treatments.
Cons: Sometimes it is not powerful enough to reduce inflammation and can be painful for some patients. Usually is not a covered procedure by most insurance plans.
- Amniotic Membrane Therapy: This is an injection that is done under ultrasound guidance into the area of maximal pain and inflammation. This therapy uses amniotic cells to help regulate inflammation in the body. To learn more click HERE to watch a video about this treatment.
Pros: This is a good alternative to surgery and can greatly reduce inflammation naturally.
Cons: Usually is not a covered treatment by most insurance plans.
- Medications: Oral anti-inflammatory drugs (NSAIDs), such as Ibuprofen, may help reduce pain and inflammation. Also, there are steroid type medications such as Prednisone that can help reduce inflammation.
Pros: These can help reduce inflammation for low level pain and inflammation.
Cons: Some people cannot take them due to stomach issues and they can cause other health conditions if taken long term. As well, they are not as effective as a cortisone injection.
- Ice: Putting an ice pack on your heel for 10 minutes a few times a day helps reduce the inflammation. An easy method of icing is using a frozen bottle of water to massage the bottom of your foot. If you would like to learn more about how to ice properly, here is a document that will go over a little more detail. Click HERE to see the document.
Pros: This is easy to do on the foot and heel region.
Cons: Many people find it less effective than a cortisone injection and tends to make the area feel better only while icing. For more longstanding plantar fasciitis or more severe symptoms it is less helpful.
- Contrast Bath: Another way to reduce inflammation is to switch from a bucket of cold water to hot water and this can help reduce the inflammation. Switch from one basin to another every 5 minutes ending on the cold. If you would like to learn more about how to ice properly here is a document that will go over a little more detail. Click HERE to see the document.
Pros: This can help reset the pain signals in your foot and ankle by causing vasoconstriction and vasodilation in the foot area and can reduce swelling and pain.
Cons: It is time consuming..
- Platelet Rich Plasma: The plasma portion of our natural blood has many healing components. This procedure uses the patient’s own blood in a concentrated form and injects it into the area of injury on the plantar fascia. Following the procedure, patient is immobilized in a removable walking cast and needs minimal time off work.
Pros: Uses your own blood platelets to reduce inflammation.
Cons: Expensive and conflicting research about the treatment.
- Topical Pain Creams: There are many compounded creams that are available to help with reducing pain and inflammation. Some are purchased over the counter and others are prescribed.
Pros: They do not involved any medications taken by mouth or injection.
Cons: These topical treatments are usually the least effective if you have much pain with your plantar fascial pain.
- Physical therapy: When stretching alone is not enough, either home physical therapy tools or a physical therapy evaluation may be beneficial. Click HERE to see what a Graston tool looks like. It is not recommended doing this on your own but rather having a trained professional perform this treatment on you.
Pros: Most patients who have physical therapy get better quicker and people are more consistent at doing home exercises with a therapist due to accountability.
Cons: There are some though that don't get better with physical therapy and it can be expensive if you have a high deductible healthcare plan.
- Trigger Point: Deep tissue massage using Trigger Point Tools is a dynamic treatment option when compared to static stretching exercises. The basis is on reducing soft tissue adhesions to the muscles in the back of the leg that can lead to heel pain. This treatment can be done in the convenience of your home with quick results.
Pros: Effective if used at home and if used properly. Works better if you track your home therapy.
Cons: You need to be motivated to use them and make sure you learn to use correctly. Still not as good as physical therapy in terms of effectiveness.
Click HERE to see a video to teach you how to use the trigger point tools.
Click HERE to see Trigger Point Tools on Amazon.com.
Click HERE to see a video to teach you how to Foam Roll properly.
Click HERE to purchase a Foam Roller.
Click HERE to see a video to teach you how to use a Stick Roller properly.
Click HERE to see the Trigger Point Stick on Amazon.com.
- Stretching exercises: Exercises that stretch out the calf muscles and the plantar fascia can help ease the pain and assist with recovery. Here is a video that will explain and demonstrate some of the most common stretches that are used for plantar fasciitis. However, I prefer the deep tissue massage tools over stretching that are discussed later in this book. Click HERE to watch the video explanation.
Pros: Easy to do anywhere you are without any tools.
Cons: Many people stretch incorrectly and can over-stretch causing more problems. Less effective than physical therapy or other tools that are used.
- Night splint: Wearing a night splint allows you to passively stretch your plantar fascia and calf muscles while sleeping. This can help reduce morning pain experienced by some patients. This is effective treatment when used with non-custom orthotics to prevent foot flattening (pronation) while in the night splint. Click HERE to see the Night Splint on Amazon.com.
Pros: This is very helpful if you have morning pain with the first step out of bed in the morning.
Cons: If you are a belly sleeper this may not work for you. Also, for some patients they cannot tolerate it the whole night and end up removing it in the middle of the night. Another way to use the brace is at the end of your day while watching TV at night. There is another type of splint called an Anterior Night Splint that goes on the front of the foot that may work better in that case.
- Strassburg Sock: this type of a treatment is similar to a night splint but holds your foot in the dorsiflexed position while sleeping. For some people this is more comfortable than a night splint. Click HERE to see the Strassburg Sock on Amazon.com.
Pros: Similar to the night splint, this can help with pain with the first step getting up in the morning.
Cons: Can cause toe numbness for some patients due to the amount of pulling up on the toes. Also, this pulls on the toes and does not do as good of a job at dorsiflexing the whole foot.
Stabilizing Foot & Reduce Pressure
- Custom Orthotic Devices: Custom orthotic devices are specially molded to your foot and help correct the underlying structural abnormalities causing the plantar fasciitis. These are used to support the arch region but more importantly they are used to correct the heel alignment. As you can see with the picture below, the heel position is more aligned after the orthotics are placed on the patient. The big difference between inserts you purchase at the store is that they do no correct the heel position as well as a custom made device. However, a custom orthotic can be 5-10 times more expensive than an over the counter device.
Pros: If made correctly for your condition, it can help reduce pain but also prevent recurrence of the conditions. Custom orthotics usually last 5-10 years. Much longer than shoes or inserts.
Cons: If this is not fit or made to your foot, you may not be able to wear the device. Many times these custom orthotics take weeks to break in and feel comfortable. You may need to wear a less supportive shoe due to all the support in the orthotic. Many times, custom orthotics are not covered by insurance and can cost between $300-600.
- Removable Walking Boot: In more severe cases wearing a walking cast boot for a few weeks can allow your foot to rest and heal. This boot can help your foot, muscles, and tendons on the back of the calf region rest. Click HERE if you would like to see a walking boot on Amazon.com, you can also see the Even-Up HERE.
Pros: This boot is easy to wear and can make you slow down if you are very active. It is not made to wear for a long period of time but for many people can help greatly with pain.
Cons: You cannot drive with this boot if your right foot is injured. The boot has a little lift to it and sometimes you need another device called an Even-Up. The Even-Up is worn on the non-injured foot, over your shoe, to bring you to the same height as the boot. Or you may prefer to wear a shoe with a heel so that you do not develop other knee, hip or back pain while wearing the walking boot.
- Arch supports: Over-the-counter arch supports are non-specific to your foot type. Similar to over-the-counter eye glasses, they may help some people and are a good place to start treating heel pain. Keep in mind that unless you have new supportive shoes, arch supports will not help. One type that is quite rigid and helpful is an ALINE Orthotic you can see it on Amazon.com by clicking HERE.
Pros: Less expensive than custom orthotics and for many people they can give sufficient support to help with heel pain.
Cons: Very rigid and some people if they have a foot that is very inflamed can find them uncomfortable. They are not custom orthotics so if you have much pronation or your heel is tilted, they do not correct the foot as much as a custom orthotic.
- Shoes: Wearing supportive shoes that have good arch support and a slightly raised heel can help reduce the stress on the plantar fascia. When buying shoes, they should be comfortable the moment you buy them. Make sure you shop for shoes at the end of your day when your feet are the largest. A good shoe that is popular now is a Hoka shoe that has extra cushion to the bottom of the foot. Click HERE to see the Hoka shoes on Amazon.com. There are many shoes that are marketed to be for “plantar fasciitis” and this is only marketing. If you have quite a bit of pain and no shoe is comfortable buying another one will probably not help. You should focus more on reducing inflammation with other treatments explained elsewhere in this book.
Pros: These type of shoes are very supportive, have great stability and cushion, and many people find them comfortable.
Cons: They are higher up and some people who wear these shoes have some balance issues.
- Avoid going barefoot or wearing flip-flops without support: When you walk without shoes you put undue strain and stress on the plantar fascia. It is best to have a flip flop that has good support in the arch region.
Click HERE to see an example of a good supportive sandal on Amazon.com.
Pros: These offer more support to the arch region than a traditional flip flop.
Cons: The flip-flops that are more supportive usually don’t look as good as other ones.
- Strapping: Consists of placing padding and tape on the bottom of the foot to help support the foot and reduce the strain on the plantar fascia. Here is an example of the tape that will work well for strapping your foot. Click HERE to see this tape on Amazon.com. If you would like to learn how to strap your own foot if you have plantar fasciitis here is a good video explanation, click HERE.
Pros: This can help support your foot and reduce pain by increasing support.
Cons: This is cumbersome to do on your own and makes it difficult to shower.
- Padding: An Aircast AirHeel pad can be placed under the heel to help minimize the pain but correction of the mechanical abnormality is still necessary. I don’t recommend simply using an insert made of gel or just a cushion. It may make you feel better in the short term but does not provide any correction of your foot and will not help long-term.
Pros: This works well if you have lots of heel pain but there are other treatments that work better to reduce the inflammation.
Cons: This usually is not worn long term and there are other treatments that are more beneficial.
- Compression Sleeve: Many patients with plantar fasciitis feel better with additional compression on the foot. This is similar but not exactly the same as taping the foot. There are compression sleeves that work very well for this. Click HERE to learn about compression sleeves.
Pros: These can offer support similarly to strapping as noted before and they can be removed and placed on again.
Cons: They can be a little expensive or bothersome because they are very tight.
- Lose weight: Reducing extra pounds will help decrease the strain on the plantar fascia. Many people come into the office with plantar fasciitis because they are exercising to lose weight. There is a new concept I am sharing with many of my patients called “Intermittent Fasting.” If you would like to learn more about this method for weight loss HERE is a book that I recommend. Also, HERE is an interview of a patient of mine that used intermittent fasting to lose over 60lbs.
Pros: This can help in general and will reduce pressure on your feet but weight loss by itself rarely cures plantar fasciitis.
Although most patients with plantar fasciitis respond well to non-surgical treatments, a small percentage of patients may require more advanced or surgical treatments. If after many months of conservative treatment you continue to have pain, these are other options that can be considered:
- Endoscopic plantar fasciotomy: this is a procedure that uses a small incision to identify and then surgically cuts a portion of the plantar fascia to help relieve the pain.
Pros: Smaller incision and quicker recovery.
Cons: Sometimes can have a nerve injury. Sometimes does not resolve the problem of the plantar fascial pain.
- Open plantar fasciotomy: this procedure is similar to the one above except that a larger incision is made.
Pros: Easier to see the fascia and cut through a portion of the fascia.
Cons: Larger incision usually a little longer recovery. Sometimes does not resolve the problem of the plantar fascial pain.
Preventing Plantar Fasciitis
No matter what type of treatment is used to treat plantar fasciitis, the underlying causes that led to this condition may remain. Therefore, you will need to continue with preventative measures such as soft tissue works to the back of the calf region, supportive shoes and custom orthotic devices for long-term treatment for plantar fasciitis. Recurrence is common especially when using cortisone injections if no other treatment is done. The cortisone injection can reduce the inflammation temporarily but if no other treatment is used the inflammation can quickly return.
Here is an overview video that is recorded about plantar fasciitis. This video will go over the same treatment options as in this book in an organized format. The video is 27 minutes long. Click HERE to watch the video.
Online Product Recommendations - Amazon
Here is a list of products that I recommend for my patients if they have plantar fasciitis. You may be unable to come to the office but you will find on this recommendation page the most up to date treatment options for treating your own plantar fasciitis. Click HERE to see the recommendations.
Plantar Fasciitis Treatment Checklist
Here is a checklist you can use with your doctor to go over the different treatment options for treating your plantar fasciitis.
Frequently Asked Questions
Q: Do I need orthotics to get rid of plantar fasciitis?
A: Each patient is different and even though the pain may subside, the mechanical instability and excess movement of the foot that caused the problem still need to be addressed. Using supportive shoes and orthotics are very effective at controlling foot motion.
Q: Will I need surgery for plantar fasciitis?
A: Most of our patients DO NOT advance to surgery due to plantar fasciitis. However, if you have been treated for six months to a year, then some surgical options may be considered.
Q: When should I seek treatment for plantar fasciitis?
A: Since there are so many home treatment options to try, that is a good place to start. However, keep in mind that seeing a doctor can help you get better faster than on your own. If you have it for over a month and it is not improving with the home treatments, it is best to make an appointment.
Q: How do I reduce the pain I have in the morning when getting up?
A: The best way to reduce the pain in the morning when getting up is to either sleep with a night splint on your leg or stretch with a towel for a few minutes before getting up out of bed. Finally, you can put on a shoe or a sandal first thing out of bed to reduce the pain when getting out of bed.
Here are some other resources that are credible and helpful when treatment plantar fascial pain.
- ACFAS (American College of Foot and Ankle Surgeons) publication on the diagnosis and treatment of heel pain - Click HERE to download the article.