Plantar Fasciitis: Causes, Exercises and Treatment

Plantar fasciitis is the most common cause of heel pain, affecting approximately 10% of the population during their lifetime. It manifests with sharp heel pain, typically with the first steps in the morning. For more information, consult the guide on Exercises for Plantar Fasciitis: Complete Protocol.

Conservative treatment is effective in 90% of cases, but requires patience and consistency.

What is the Plantar Fascia?

The plantar fascia is a robust band of connective tissue that extends from the calcaneus (heel bone) to the base of the toes. It supports the plantar arch and acts as a spring during walking. For more information, consult the guide on ankle and foot anatomy. For more information, consult the guide on biomechanics of gait.

The more correct term today is plantar fasciopathy, because in most chronic cases there is no true inflammation but tissue degeneration (similar to tendinosis).

Causes

Mechanical Overload

• Flat foot or high-arched foot: both alter load distribution
• Calf and Achilles tendon stiffness: one of the most important and undervalued causes
• Sudden increase in activity: starting to run, walking much more than usual
• Overweight/obesity: the most significant risk factor
• Prolonged standing: jobs that require standing for hours

Footwear

• Shoes without arch support, flat soles, high heels
• Worn shoes that no longer provide cushioning

Biomechanical

• Kinetic chain alterations: glute weakness, pelvic imbalances
• Associated Achilles tendinitis
• Associated posterior tibial tendinitis

Risk Factors

• Age 40-60 years, overweight, running on hard surfaces
• Hallux valgus, Morton’s neuroma

Symptoms

• First morning steps pain: the most characteristic symptom. The heel pain is sharp and improves after a few minutes of walking
• Pain after rest periods: getting up from a chair after sitting for a long time
• Pain after prolonged activity: walking or standing for long periods
• Pain on palpation of the calcaneal insertion of the fascia
• Location: under the heel, on the medial side

Heel Spur

The heel spur is a calcification that forms at the insertion of the plantar fascia on the calcaneus. It is present in 50% of patients with fasciitis but also in 20% of the asymptomatic population. It is NOT the cause of pain (it’s a consequence of chronic traction) and its presence does not modify treatment.

Treatment

Physiotherapy

• Specific stretching: of the plantar fascia and calf (the most important)
• Eccentric strengthening of the calf
• Manual therapy: foot and ankle mobilization
• Shockwave therapy: in chronic forms (>6 months), solid scientific evidence
• Taping: temporary fascial offloading
• Laser, ultrasound, tecar therapy

Orthotics and Footwear

• Orthotics: with arch support and heel cushioning
• Silicone heel pad: reduces impact
• Shoes with good support: cushioning sole, arch support

Medications

• Topical or oral NSAIDs in acute phases
• Corticosteroid injections: effective but risk of fascial rupture with repeated injections. Max 1-2.
• PRP: promising in chronic forms

Exercises

The 2 Most Important Exercises

Exercise 1: Plantar Fascia Stretch (the most effective)

Difficulty: Easy | Equipment: None | Duration: 5 minutes

Starting position:
Sitting on a chair or on the edge of the bed. Cross the affected leg over the other leg (ankle on opposite knee), so that the foot is easily accessible.

Step-by-step execution:

1. Step 1: With the hand on the same side, grasp the toes of the affected foot
2. Step 2: Gently pull the toes toward the tibia (dorsiflexion of toes), putting the plantar fascia under tension
3. Step 3: With the other hand, palpate the tense fascia under the sole of the foot to verify it’s under tension
4. Step 4: Hold the position for 30 seconds, release and repeat

Sets and repetitions: 10 repetitions of 30 seconds — Perform before getting out of bed in the morning and after every prolonged rest period

Common mistakes to avoid:

• Pulling only the big toe: grasp all the toes for a complete fascial stretch
• Forcing excessively until causing sharp pain under the heel
• Forgetting to perform it BEFORE getting out of bed in the morning (the most important time)

How to know you’re doing it correctly:
You feel the fascia tense under the foot like a cord stretching from the base of the toes to the heel. After stretching, the first steps are significantly less painful. By palpating the fascia with the other hand, you should feel the tissue under tension.

Exercise 2: Calf Stretch at Wall

Difficulty: Easy | Equipment: Wall | Duration: 4 minutes

Starting position:
Standing facing a wall, hands against the wall at shoulder height. Affected leg stepped back, knee completely straight, heel pressed to the ground. Front leg slightly bent.

Step-by-step execution:

1. Step 1: Push the heel of the back leg toward the floor, keeping the knee straight
2. Step 2: Shift weight forward until you feel tension in the calf (gastrocnemius)
3. Step 3: Hold for 30 seconds, then release
4. Step 4: Variation: repeat with the back knee slightly bent to stretch the soleus muscle (deeper)

Sets and repetitions: 3-5 repetitions of 30 seconds for each variation — 3 times daily

Common mistakes to avoid:

• Lifting the heel during the stretch (it must remain pressed to the ground)
• Rotating the foot outward: the foot should point straight ahead
• Forgetting the bent-knee variation (rigid soleus significantly contributes to fasciitis)

How to know you’re doing it correctly:
You feel a stretch in the back of the leg: with knee straight in the upper calf, with knee bent in the lower part near the Achilles tendon. You should not feel heel pain.

Strengthening Exercises

Exercise 3: Eccentric Calf Raise on Step

Difficulty: Intermediate | Equipment: Step or stair, railing or support for balance | Duration: 5 minutes

Starting position:
Standing on the forefoot on the edge of a step, with heels hanging in space. Hand on railing or wall for balance.

Step-by-step execution:

1. Step 1: Rise onto toes with both feet simultaneously (concentric phase)
2. Step 2: Transfer all weight to the affected foot, lifting the other foot from the step
3. Step 3: SLOWLY lower the heel of the affected foot below step level (eccentric phase, 5-6 seconds)
4. Step 4: Replace both feet and repeat

Sets and repetitions: 3 sets x 12-15 repetitions — 60-second rest between sets

Common mistakes to avoid:

• Lowering too quickly: the slow eccentric phase is the fundamental therapeutic component
• Using only the affected foot to rise (the rise should be done with both feet to reduce load)
• Not having secure support for balance

How to know you’re doing it correctly:
The descent lasts at least 5 seconds and is perfectly controlled. You feel muscle work in the calf and slight tension on the plantar fascia. Mild discomfort (not sharp pain) under the heel is acceptable in the first weeks. This exercise has strong scientific evidence for fasciopathies.

Exercise 4: Towel Curl

Difficulty: Easy | Equipment: Towel | Duration: 3 minutes

Starting position:
Sitting on a chair, affected foot placed on a towel spread on the floor on a smooth surface (tiles or hardwood). Heel in contact with the floor.

Step-by-step execution:

1. Step 1: Press toes downward, grasping the towel
2. Step 2: Curl toes pulling the towel toward the heel
3. Step 3: Release toes, extend them completely
4. Step 4: Repeat the grasping and curling movement

Sets and repetitions: 3 sets x 15 repetitions — 30-second rest between sets

Common mistakes to avoid:

• Moving the entire foot instead of using only the toes
• Lifting the heel during the exercise (heel must stay on the ground)
• Using a towel that’s too thick making it difficult to grasp

How to know you’re doing it correctly:
You feel muscle work in the sole of the foot and toes. The towel gradually moves toward the heel. With practice, toes become more agile and the grip stronger.

Exercise 5: Marble Pick-up with Toes

Difficulty: Easy | Equipment: 10-15 marbles or small objects, container | Duration: 2-3 minutes

Starting position:
Sitting on a chair, barefoot on the ground. Arrange 10-15 marbles (or small objects like bottle caps, pencils) on the floor in front of the foot. Position a shallow container to the side.

Step-by-step execution:

1. Step 1: Grasp a marble with the toes of the affected foot
2. Step 2: Lift the marble maintaining grip with toes
3. Step 3: Move it to the container and release it
4. Step 4: Repeat until collecting all the marbles

Sets and repetitions: 2-3 minutes continuously (or collect all marbles and start again) — 1-2 times daily

Common mistakes to avoid:

• Using objects that are too large or heavy making it impossible to grasp
• Compensating with ankle or whole foot movements: the work should be from the toes
• Forcing toes if cramps occur (stop and resume after a few seconds)

How to know you’re doing it correctly:
Toe dexterity progressively improves and grip becomes more secure. You feel work in the intrinsic foot muscles. Initial cramps decrease with practice.

Exercise 6: Rolling with Frozen Bottle

Difficulty: Easy | Equipment: Frozen water bottle (or tennis ball) | Duration: 10-15 minutes

Starting position:
Sitting on a stable chair, affected foot placed on a previously frozen water bottle, positioned on the floor. Use a thin sock if direct cold is too intense.

Step-by-step execution:

1. Step 1: Gently press foot on frozen bottle with moderate pressure
2. Step 2: Roll bottle back and forth along sole of foot, from heel to base of toes
3. Step 3: Focus with slower movements and more pressure on the most painful areas
4. Step 4: Continue for 10-15 minutes, maintaining constant and comfortable pressure

Sets and repetitions: 10-15 minutes continuously — 2 times daily (ideal after physical activity and in the evening)

Common mistakes to avoid:

• Pressing too hard causing sharp pain (pressure should be comfortable)
• Using a glass bottle (risk of breakage: use only plastic)
• Rolling bottle too quickly without getting the massage and cold benefit

How to know you’re doing it correctly:
You feel a combined effect of massage and cold relief. After the session, the sole of the foot is less painful and less tense. The heel area appears slightly reddened from the cold, a sign that cryotherapy is working.

Kinetic Chain Exercises

Exercise 7: Glute Strengthening (Bridge and Clamshell)

Difficulty: Easy | Equipment: Mat, elastic (optional) | Duration: 6 minutes

Starting position:
Bridge: supine on mat, knees bent, feet on ground at hip width.
Clamshell: lying on side, hips bent at 45 degrees, knees bent at 90 degrees.

Step-by-step execution:

1. Step 1 — Bridge: Contract glutes and lift pelvis to form straight line from shoulders to knees. Hold 5 seconds, lower slowly. 10 repetitions.
2. Step 2 — Clamshell: Lying on side, feet together, open upper knee like a shell without rotating pelvis. 10 repetitions per side.
3. Step 3: Repeat circuit for prescribed sets

Sets and repetitions: 3 sets (10 bridges + 10 clamshells per side) — 45-second rest between sets

Common mistakes to avoid:

• In bridge: arching lumbar spine instead of activating glutes
• In clamshell: rotating pelvis backward during knee opening
• Underestimating the importance of these exercises for plantar fasciitis (glute weakness alters biomechanics of entire lower limb down to the foot)

How to know you’re doing it correctly:
You feel muscle work in the glute area, not in the lumbar region or back of thigh. A strong gluteus medius stabilizes the pelvis, improving alignment of knee, ankle and foot during walking.

Exercise 8: Single Leg Stance (Balance on One Leg)

Difficulty: Intermediate | Equipment: None | Duration: 3 minutes

Starting position:
Standing barefoot on a stable surface, upright posture, hands on hips.

Step-by-step execution:

1. Step 1: Lift one leg bending knee to 90 degrees
2. Step 2: Maintain balance on support leg for 30 seconds, distributing weight over entire sole of foot
3. Step 3: Focus on activating foot and plantar arch muscles
4. Step 4: Repeat on other side

Sets and repetitions: 3 repetitions of 30 seconds per side — 15-second rest between repetitions

Common mistakes to avoid:

• Placing weight only on outer or inner foot edge (distribute evenly)
• Looking down: maintain gaze fixed on point ahead to facilitate balance
• Gripping toes to floor: toes should remain relaxed

How to know you’re doing it correctly:
You feel subtle but constant work in sole of foot and plantar arch muscles. Balance improves over time. For progression: close eyes, or perform on cushion to increase proprioceptive challenge.

Recovery Time

90% of patients recover with conservative treatment, but it requires patience and consistency.

Prevention

• Daily stretching of plantar fascia and calf
• Shoes with good support, avoid walking barefoot on hard surfaces
• Weight control
• Gradual progression of physical activity
• Orthotics if indicated
• Glute strengthening and kinetic chain

You might also be interested in: Knee Pain: Complete Guide — causes, diagnosis and rehabilitation

Frequently Asked Questions (FAQ)

Frequently Asked Questions

Why is pain worse in the morning?

The plantar fascia shortens and tightens overnight during periods of rest. Upon taking the first steps in the morning, this tightened tissue is suddenly stretched, leading to sharp pain. As activity continues, the fascia may gradually loosen, and pain often diminishes.

How long does plantar fasciitis last?

Recovery time for plantar fasciitis varies, but conservative treatment is effective in approximately 90% of cases. With consistent adherence to a physical therapy program and appropriate footwear, significant improvement can often be observed within several months. Full resolution may require patience over a longer period.

Can I continue running?

Continuing high-impact activities like running with plantar fasciitis can exacerbate the condition and delay healing. It is generally recommended to temporarily reduce or modify such activities to allow the tissue to recover. A physical therapist can provide guidance on safe activity levels and a gradual return to sport.

Are orthotics necessary?

While not always necessary, appropriate footwear with arch support and cushioning, including over-the-counter or custom orthotics, can significantly help manage pain and support the foot. Their use should be considered as part of a comprehensive treatment plan, especially if biomechanical factors contribute to the condition.

For a broader overview of related conditions, see our our comprehensive foot and ankle guide.

Resources

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Summary infographic

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Scientific References

1. Martin RL, et al. Heel pain — plantar fasciitis: clinical practice guidelines. J Orthop Sports Phys Ther. 2014;44(11):A1-A33.
2. Rathleff MS, et al. High-load strength training improves outcome in patients with plantar fasciitis. Scand J Med Sci Sports. 2015;25(3):e292-300.
3. DiGiovanni BF, et al. Tissue-specific plantar fascia-stretching exercise. J Bone Joint Surg Am. 2003;85(7):1270-1277.
4. Rompe JD, et al. Plantar fascia-specific stretching versus radial shock-wave therapy. J Bone Joint Surg Am. 2010;92(15):2514-2522.
5. Trojian T, Tucker AK. Plantar fasciitis. Am Fam Physician. 2019;99(12):744-750.
6. Babatunde OO, et al. Effectiveness of therapeutic interventions for plantar heel pain. Br J Sports Med. 2019;53(3):182-194.
7. Irving DB, et al. Obesity and pronated foot type may increase the risk of chronic plantar heel pain. BMC Musculoskelet Disord. 2007;8:41.
8. Riddle DL, et al. Risk factors for plantar fasciitis. J Bone Joint Surg Am. 2003;85(5):872-877.
9. Luffy L, et al. Plantar fasciitis: a review of treatments. J Am Acad Orthop Surg. 2018;26(1):e18-e28.
10. Petraglia F, et al. Plantar fasciitis in athletes: diagnostic and treatment strategies. Res Sports Med. 2017;25(4):431-443.

Dr. Cosimo Pilotto — physical therapist | MyPhysioHelp.it

Related Articles:

• Achilles Tendinitis
• Posterior Tibial Tendinitis
• Morton’s Neuroma
• Hallux Valgus
• Kinetic Chain
• Retrocalcaneal Bursitis