PLANTAR FASCIITIS – WHAT IS THE TRUE CAUSE OF PAIN
                     PLANTAR 
FASCIITIS – 
WHAT IS THE 
TRUE CAUSE OF 
PAIN
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Plantar fasciitis is one of the most common diagnoses given to those suffering 
from heel pain, with almost 2 million Americans diagnosed each year. Those with 
plantar heel pain are usually between 35 and 65. They are often runners or 
slightly overweight and have occupations that require a lot of standing. But not all 
heel pain is the result of Plantar fasciitis, and many of today’s popular treatments 
have no merit. Physical Therapy for Plantar Fasciitis can help by first determining 
the underlying cause.
Plantar Fasciitis is a diagnosis 
given to most who have heel 
pain, yet rarely the cause of pain.
A mechanical assessment is required to 
properly diagnose the cause of heel pain 
instead of simply blaming the tissue where 
the symptoms are located. To determine the 
best treatment for Plantar Fasciitis, it is critical 
to first differentiate it from other conditions, 
so the actual problem can be treated. 
Other possible diagnoses:
 Ankle derangement
 Biomechanical strain in the ankle
 Severe’s in children
 calcaneal stress fracture
 fat pad atrophy in seniors
 Baxter’s nerve entrapment (first branch of the posterior tibial nerve) 
 Referred from the low back
Symptoms of Those Diagnosed with ‘Plantar Fasciitis’:
Those diagnosed with Plantar Fasciitis have a consistent pain at the bottom of the 
heel upon standing or weight-bearing. The morning is always the worst. After a few 
steps, the heel pain improves and may even go away. But the pain returns when 
initially getting up after a period of inactivity and is often described as tearing or 
stepping on broken glass. The pain may also appear more intense on bare feet or in 
shoes with minimal support. There is tenderness to the touch where the plantar 
fascia inserts over the bottom of the medial heel. The worst part of plantar fasciitis is 
that it does not go away quickly, instead lingers for months and even up to a year 
without proper treatment.
The pain is the worst with the first step in the morning and when resuming activity 
after rest. It tends to decrease with continued motion. (This indicates that more 
weight and more use of the plantar fascia reduces the pain. The problem does not 
appear to stem from stress on the fascia but from the rest period. What happens 
during rest periods that produces pain with initial weight-bearing but corrects after a 
few steps?) Answering this question is important in determining the best treatment 
for Plantar Fasciitis.
Risk factors
Plantar heel pain can develop without an obvious cause, but factors can increase your 
risk of developing this condition and therapy for plantar fasciitis can help eliminate 
some of these risk factors:
1. Foot mechanics. Excessive pronation, flat feet, a high arch or even an atypical pattern 
of walking because of the way weight is distributed when you’re standing 
2. Age. Plantar heel pain is most common in people between 35 and 65.
3. Certain types of exercise. Activities that place a lot of stress on your heel and the 
soleus muscle — such as long-distance running, ballet dancing, and aerobic dance   
4. Obesity. Excess pounds put extra stress on your ankle joint.
5. Occupations that keep you on your feet. Factory workers, teachers, and others who 
spend most of their work hours walking or standing on hard surfaces can be at increased 
risk.
Anatomy & Biomechanics:
Understanding what causes Plantar Fasciitis pain 
is essential to learn how to heel Plantar 
Fasciitis / heel pain quickly. The plantar facia is a 
tough, fibrous band of tissue that runs along the 
bottom of the foot, attaching to the heel bone 
(calcaneus) and the base of the toes. The 
plantar fascia helps maintain foot structure by 
supporting the arch and absorbs shock when 
walking. Weightbearing or standing increases 
tension in the plantar fascia. This tension 
further increases when you push off on the ball 
of the foot. The role of the fascia is to taunt not 
flexible.
During standing, 10-15 degrees of dorsiflexion is 
required as the lower leg glides over the foot. Joint 
mobility is necessary for proper loading and 
unloading of impact forces and in transferring the 
associated potential energy. If you do not have 
ankle mobility to allow the knee over the toes, the 
body will compensate by turning your foot out 
(walking like a duck), lifting your foot up early 
(bouncy gait), or pronating, making up the required 
motion by dropping your foot arch. Pronation 
causes the navicular bone to drop down and in. A 
slight amount of pronation is normal as pronation 
helps to absorb the initial shock of weight-bearing. 
But excessive pronation pulls on the plantar facia, 
leading to stress and possible micro-tears and 
progressive abnormalities, including the formation 
of heel spurs.
Tightness in your calf muscles will cause a loss of dorsiflexion. The calf is made up 
of two muscles, gastrocnemius and soleus muscles which taper and merge 
forming the Achilles tendon. The gastrocnemius is the larger with two heads 
forming the bulge that we normally associate with our calf. It is a powerful muscle 
enabling heel raises and jumping. The soleus is a smaller, flat muscle that lies 
underneath the gastroch. The soleus functions in prolonged running and is also a 
major postural muscle designed to stop the body from falling forwards at the 
ankle during stance. Risk factors for developing plantar heel pain include long 
distance running and occupations that require prolonged standing, both of which 
over use the soleus muscle.
Another cause of loss of dorsiflexion is a bony block due to the talus bone being 
shifted slightly anterior. The talus is fascinating because it is like a floating bone in 
that it has no muscle or tendon attachments. Because of this, it is also prone to 
shifting with trauma and sustained pressure. The talus can shift anteriorly due to 
its shape. When the talus shifts anteriorly, it blocks dorsiflexion. It feels like a 
“hard stop” at the end range of motion with tightness and sometimes pain at the 
anterior ankle. Physical therapy for Plantar Fasciitis will address loss of 
dorsiflexion.
What causes Plantar Fasciitis / plantar heel pain?
Today’s common perception is that tension and stress on the fascia cause small 
tears until, eventually, the fascia becomes inflamed, causing heel pain with 
weight-bearing. But research has found that plantar fascia tears are NOT 
associated with plantar heel pain. Instead, heel pain was associated with: 
thickened and abnormal plantar fascia and thickened plantar fat pad when 
loaded. Continued stress on the plantar fascia as it attaches to the heel may 
cause a spur to develop.
It is believed that heel spurs is what causes Plantar Fasciitis pain, but contrary to 
what you may think – the bigger the bone spur, the less pain! The body 
responds to stress by laying down calcium, and spurs result from excessive 
stress on a tissue. But to find the best treatment for Plantar Fasciitis, you need 
to determine first what is causing the stress on the plantar facia? 
Heel pain is a symptom located at the insertion of the plantar facia to the 
calcaneal bone. Instead of assuming the plantar facia is the cause of pain, we 
need to uncover and address the actual problem!
Proper treatment requires uncovering the root cause of 
pain
What Causes plantar fasciitis pain?  #1 Risk Factor for developing Plantar 
Fasciitis is reduced ankle dorsiflexion. 
Ten degrees of dorsiflexion* is required to walk and at least fifteen degrees is 
required to run (5 deg in subtaylor neutral). Without adequate dorsiflexion, the 
body will compensate so that the knee can translate over the foot from stance 
to swing. When the calf and ankle lack adequate mobility to allow this 
translation, the body must make up motion in other ways, leading to pain and 
overuse injuries. Common compensations include excessive foot pronation and 
knee valgus (knocked knee).   (Limited ankle dorsiflexion is also associated with 
Achilles and patellar
Pronation is the most common compensation for 
lack of ankle dorsiflexion.
If your foot pronates too much, the ankle rolls 
too far downward and inward with each step. 
Over time, compensating with pronation can 
cause the arch to collapse and muscles and 
supporting tissues to over‑stretch and lengthen. 
The thick fibrous band of the plantar fascia is 
pulled with each compensating step of excessive 
pronation, causing strain and eventual abnormal 
changes. In response, the bone may also develop 
a bony growth (heel spur) right in the center of 
the heel. 
Large heel spurs and plantar fascia tears are not associated with heel pain.
If the plantar fascia and heel spurs are not the cause of heel pain, what is?
Faulty biomechanics appears to be the trigger that causes damage to the plantar 
fascia. The plantar fascia may cause some pain but is not the primary source. 
Could faulty biomechanics also cause stress elsewhere, triggering pain? It 
appears so. 
Those with plantar heel pain note that their symptoms are always worse with the 
first steps in the morning. While sleeping at night, the foot rests downward. This 
plantarflexed position allows the Achilles tendon to tighten and also opens space 
for an anterior derangement. (A derangment is a disruption within the joint due 
to a particle or the talus bone moved anteriorly.) Night splints are one of the best 
treatments for Plantar Fasciitis because the splint keeps the ankle in a neutral 
position preventing the Achilles from tightening, and also avoids an anterior joint 
derangement. Night splints work because they address the Achilles tendon and 
the talus bone, not the plantar fascia.
A lack of ankle mobility is usually secondary to tight Achilles OR a joint 
derangement in which there is a bony block to normal joint mobility. 
Best TREATMENT for Plantar Fasciitis:
Most common therapy for Plantar Fasciitis include anti-inflammatories and 
plantar fascia stretching. But do they address the problem of plantar heel pain?
1. Anti-inflammatories:   Heel pain comes and goes, so it 
cannot be caused by inflammation because pain from inflammation is 
constant and short-lived, similar to a toothache. Instead, plantar heel pain is 
worse with initial steps but relieved with continued walking.
2. Plantar fascia stretching: The role of the plantar fascia is to be tight and stable 
to hold and support the foot arch. Stretching goes against the basic role of this 
dense tissue. The plantar fascia functions like a ligament; its role is to be taut to 
maintain the stability of our arch. Massaging the tissue, on the other hand, may 
help to break up abnormalities found with chronic plantar heel pain.
The most common therapy for plantar fasciitis are not the most beneficial 
because they do not address the root cause of symptoms. Plantar heel pain is 
usually diagnosed based simply on the location of pain rather than performing an 
in-depth assessment to determine the true problem. Treating the area where the 
symptoms are located, rather than the true culprit increases the risk of chronic 
symptoms. 
Key Focus:
Reduced ankle dorsiflexion is the #1 risk factor for developing plantar heel pain 
or what causes plantar fasciitis pain. This is then a key focus. When there is a loss 
of dorsiflexion, the required motion must be made up by altering mechanics and 
the most common is excessive pronation. The plantar fascia will then be 
stretched too much due to excessive pronation pulling on it to compensate for 
the loss of motion in the ankle. 
A mechanical assessment investigates any loss of motion and altered 
biomechanics and determines why. 
Varying research has demonstrated improved 
plantar heel pain to static Achilles stretching for 
the best treatment for Plantar Fasciitis. In contrast, 
another has shown more benefit to quick high 
load Achilles strengthening, but recent research 
has suggested slightly better outcomes with 
progressive loading. These variations on which is 
best treatment for Plantar Fasciitis boils down to 
the specific cause of pain. Is the heel pain 
secondary to a tight Achilles tendon or a stiff ankle 
joint secondary to the talus bone shifted 
anteriorly? Static Achilles stretching would aid 
Achilles flexibility, while dynamic strengthening 
and progressive loading would be more effective in 
reducing an anterior derangment.
Achilles stretching with the knee bent is much more effective therapy for Plantar 
Fasciitis than plantar fascia stretching. 
This indicates that the soleus muscle is more involved than the gastrocnemius or 
an anterior talus benefits from more pressure over the midfoot. The soleus 
muscle plays a major role in distance running, as well as, the major postural 
muscle designed to stop the body from falling forwards at the ankle during 
stance. 
What Causes Plantar Fasciitis pain is closely linked to abnormal tightness in the 
soleus muscle.
Validated Treatments:
1.Depending on the patient’s specific limitation, dorsiflexion 
stretching targeted at either the soleus muscle or the ankle 
joint.
2.Posterior shift mobilization of talus with a band (*if talus 
anterior – needs to be screened by PT)
3.Night splint
4.Proper shoewear with arch support
5.Biomechanical assessment of running to assure proper 
form – supination and heel out during swing.
6.Modification of activity and progressive plan to return to 
sports/ function.
 
Schedule an appointment with one of our specialists to get 
relief now!
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PHYSICAL 
THERAPISTS
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