If your first few steps out of bed in the morning feel like walking on shards of glass, you are not alone. Millions of people experience foot and heel pain in their lifetime, with plantar fasciitis as the biggest culprit. Despite how debilitating that sharp, stabbing pain can be, it is important to remember that the plantar fascia is incredibly resilient. It isn’t broken; it is simply overloaded (most often by sudden changes in your routine). The good news is that while this condition can be stubborn, it responds really well to the right treatment.
Most people worry that their heel pain signifies permanent damage, torn tissue, or the need for invasive surgery, but the reality is quite different. A structured approach that balances relieving your symptoms, rest, and progressive exercise is the best way forward.
The remarkable engineering of the foot
Your foot is designed to be both a flexible shock absorber when your heel hits the ground and a rigid lever when you push off to take a step. This dual role is supported by the arch of the foot, which is a complex, bridge-like structure at the bottom of your foot.
Bones and Joints
The foot is made up of 26 bones and 33 joints. The arch is primarily formed by the tarsal bones (the midfoot) and the metatarsals (the long bones leading to your toes). They naturally fit together to distribute your body weight. Numerous ligaments connect bone to bone, acting as the glue that keeps the joints of the arch from shifting too far apart.
The Plantar Fascia
This is a thick, multi-layered band of connective tissue that runs from your calcaneus (heel bone) to the base of your toes. Think of it as a high-tension cable that prevents the bone arch from collapsing under your weight.
Muscles and tendons
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Intrinsic Muscles: These are small muscles located entirely within the foot and toes. They act like the “core” of your foot, providing fine-tuned stability with every step.
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Extrinsic Muscles and Tendons: These are larger muscles that start in your lower leg (like the tibialis posterior, flexor hallucis longus, flexor digitorum longus, and the peroneals) and send long tendons down into the foot. These tendons act like stirrups, pulling the arch upward and providing the power needed for gripping your toes, walking, and running.
Together, these muscle groups dynamically adjust and support your foot arch as you move.
The perfect combination of structure and movement: The Windlass Mechanism
As your big toe bends upward during a step, it pulls the plantar fascia tight, which automatically lifts the arch and locks the bones into a rigid, powerful position for push-off.
What changes with Plantar Fasciitis?
The term “fasciitis” implies inflammation of the fascia. But it is more of a loading issue where the fascia struggles to keep up with the demands placed upon it. The harmony between your passive (bones, ligaments, and fascia) and active support structures is disrupted.
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Plantar Fascia: Instead of being an elastic support structure, it loses its ability to stretch and recoil.
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Muscles: The intrinsic foot muscles and the calf muscles overwork to try to guard the foot and arch.
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The Windlass Mechanism: The coordinated tightening of the arch when you push your heel away becomes painful. As a result, your body subconsciously changes how you walk to avoid tensioning the fascia.
Ultimately, your ability to walk changes in many ways. Suddenly, you feel like you’ve lost the spring in your step, and you can’t stand or walk for too long. Walking feels heavy and tiring, and you can’t stretch or put weight on your foot like you used to.
Causes of Plantar Fasciitis
Plantar fasciitis develops due to repetitive or prolonged activities that place strain on the plantar fascia. The arch of the foot is three dimensional. It is formed by (1) the bones in the foot (metatarsals), from the ankle to the toes. (2) The medial arch (on the inside of the foot) runs from the inner heel to the big toe. This is the arch that is decreased if you have “flat feet”. Then you have (3) a lateral arch (on the outside of the foot) that runs from the outer heal to the little toe. The transverse arch connects the medial and lateral arches from the big toe to the little toe. The plantar fascia supports these three arches, like a dome from below.
You are at greater risk to develop plantar fasciitis if you are on your feet for long hours or walk long distances. People who work in health care (nurses), construction and sales especially. Sports that involve repetitive stress to the bottom of the foot on hard surfaces, like hockey, cricket, hiking and marathon running, can also cause plantar fasciitis. Long-distance runners and dancers are more prone to develop plantar fasciitis due to the excessive range of movement that is needed during these activities. Tight calf muscles cause more load through the plantar fascia and may lead to inflammation. Unsuitable shoes that do not cushion the foot sufficiently, or support the arch, or place the fascia in a stretched position (all heels, ladies!) are one of the main factors that lead to plantar fasciitis.
In some cases the pain may develop suddenly due to a high force going through the plantar fascia like a sudden push off out of the starting blocks or falling from a height and landing on your feet. Mostly the inflammation builds up because of repetitive strain. Being overweight or a sudden increase in weight (training or pregnancy) increases the tension on the plantar fascia and may lead to inflammation.
Symptoms of Plantar Fasciitis
Plantar fasciitis causes pain on the bottom of the heel. This pain is severe in the morning, when you take that first step out of bed. Pain may stop during exercise and return afterwards. You will feel pain after resting when you place weight through the foot again.
- Stiffness or dull burning ache (like a cramp)
- Pain underneath the heel along the arch of the foot
- Stiffness over the arch of the foot that increases with rest (typically in the morning or after sitting)
- Pain during activities like walking, running, sprinting, jumping or landing
Mild
Moderate
Dangerous
During the initial stages
You will feel stiffness over the arch of the foot with minimal pain. As time goes by the pain will focus on the bottom of the heel. The stiffness will ease with movement, only to come back after rest. Common phrases we hear our patients say:
“The pain is only there when I start running, then it goes away but afterwards the stiffness comes back.”
“When I’ve been working and sitting for a few hours, that first few steps is the worst and then it gets better as I walk around.”
When it gets worse
Stiffness and pain in the foot that takes longer to ease, is a tell tale sign of worsening inflammation in the plantar fascia. The pain can be so severe that you are unable to put weight on the foot, and walk with a limp. You may also experience swelling and tenderness when touching the inner aspect of your heel. Stretching the calf muscles may also produce a sharp pain that radiates into the shin or calf.
Heel spurs & Plantar Fasciitis
Excessive and continuous load through the plantar fascia can lead to calcium deposits on the calcaneus (heel bone). These heel spurs occur where the heel bone is irritated at the spot where tendon of the plantar fascia attaches to the heel bone. This can be diagnosed with X rays.
Diagnosis
Physiotherapists are trained to examine the structures of the foot, including the bone, ligaments and tendons. We will be able to guide you if further investigations are necessary. X-rays enable us to see the bony structures of the foot, and a heel spur can be diagnosed this way. The plantar fascia is soft tissue and can be visualized with an ultrasound (sonar). The ultrasound will show thickening and damage to the the structures.
Risks and complications
If left untreated plantar fasciitis will usually worsen. You may experience severe pain when placing weight on your foot. This can then lead to limping, in an attempt to reduce the weight you take on the foot. Limping can then influence your ankle, knee, hip and eventually your back too.
Recovery time
Plantar fasciitis should heal within 3 months with treatment. If you have surgery, you should wait three to six months before returning to sport.
If you think you may have Plantar Fasciitis you should:
- Stop aggravating activities (walking/standing/jogging)
- Use ice and rest to reduce the inflammation
- Call us to set up an appointment to confirm the diagnosis and guide you through a rehabilitation program
Physiotherapy treatment for Plantar Fasciitis
Early stage
- Electrotherapy to reduce local inflammation (ultrasound/LASER/TENS)
- Soft tissue mobilisation to relieve your symptoms (myofascial release/dry needling)
- Immobilization with strapping or taping
- Night splints can be warn to reduce morning stiffness
- Orthotics (insoles) may be necessary
- Specific exercises and ice application at home
You may begin:
- Deep water pool running to maintain your cardiovascular fitness
If your Plantar Fasciitis fails to respond to physiotherapy treatment
Your GP can prescribe medications to alleviate your pain and reduce inflammation.
We may refer you to a specialist for injection directly into the tendon.
If your plantar fasciitis symptoms persist for 12 months, as a last resort, we will recommend surgery to relieve tension and information from the plantar fascia.
I have a … How did it happen?
What was the event, or buildup, that led to this __________ (condition)?
Choose one mechanism of injury and take the patient through a slow-motion event that describes the pathology.
- The circumstances that led up to the point of failure, the order of dominoes that must fail one after the other to end up with this.
- Slow motion description of how the structures fail under pressure, force, tension, and angular force.
- The condition of the tissue, pre-event and as it deteriorates into this condition state.
- You are responsible for highlighting the secondary fallout that they might not even consider.
- Examples are the physiological breakdown of the structures, failure of one system, and then the next.
- Why the tissue damage takes place: Rotational force, Pressure force, sudden twisting, e.g. Sideways pressure along the length of the bone is like stomping on a toothpick; the bone will crack, splinter, and shatter, shearing into surrounding ligaments and muscles.
- Muscle tension is to the max, then tears. The passive structures are the backup system (ligaments) that takes up the slack but then rips through it, splits the ligament, and prys through any resistance. This all occurs in a split second, in the blink of an eye.
- Pathophysiology
EXPLAIN on a cellular level what goes wrong – Friction, Pressure, Bleeding, Forces, Tension - Explain the defect & bring it back to function.
- Backwards, regression of a chemical irritant, nociception leading into chaos, damage, destruction, loss of function, loss of _____
This is not a bullet section. This is the explanation part – the “causes section” is for listing the bullet points
Causes of
This is the primary factor that determines the likelihood of developing ….
Predisposing factors that lead to this problem can be linked directly or indirectly.
Look at your patient Demographics and see if there’s any correlation in research.
Meaning the activities, movements, and positions, systemic underlying conditions that directly flare up, worsen and keep on causing the problem to get worse
This is the core message I want you to understand, think about after you’ve read this article
Stating something is in a bad state is Information.
Explaining the influence of a bad state is Knowledge.
Symptoms of
Symptoms are the words your patient will use – in a subjective assessment.
Try to resonate with the exact words used by your patients to describe it to you. Then reread your symptoms and imagine a patient reading it to you… (Does it fit into the Title Diagnosis?) Can you describe it even better (signs they haven’t even noticed yet)
Remember – Symptoms are the patient’s subjective feelings. Use the words you expect a fractured fibula patient will say… Clicking, Stinging pain, Wabble, – Not “Abnormal movement of your lower leg”. Rather, please describe what you expect to hear them say.
In this section, more vague includes more scenarios than specifics.
Use emotions to describe what they might feel:
- Hesitant to even open a door
- Scared to lie on that side, climb over a step
- Difficult to work on your computer
- Uncertain if you can train
- Use words like:
- Time: persistent, sudden, lingering, Constant, Worse at night
- Characteristic: Sharp sting, Annoying, Intense
- Location: Area, around, particular spot
- Visible: Puffiness, Blue, bruising,
- Restriction in ADL: Hesitant to …, Cannot …., Avoid …., Unable to
- Load (High vs Low): at rest, during ….,
Tests that you can do to see if you have a …
Self-test your … at home with these modified tests and see if you might have a ….
Use your key phrases abundantly here, if you need a few more.
- Load progression in your tests.
- Do not use “try to..” – keep to clear instructions. It’s an ‘must do’ instruction. These are tests, must be clear and simple, and avoid words like: “attempt” “try”
“attempt to cross your painful leg”, “attempt to bend”, “try and twist”.
Describe at least:
- Weight-bearing
- Loaded
- Unloaded
- Stretch/ End of Range
How severe is my….?
Choose 4/6 of the below signs and DISCUSS why you (as a professional) use to identify and classify the … into: Severe vs Not severe
EXPLAIN WHY it is a serious type of injury ~ This describes the scope of … to a patient in order to understand if it’s worse or better than another person with …
Meaning: Imagine there’s a group of 20 patients, all with … and you must rank them from ‘less severe’ to ‘more severe’ ~ What markers/ signs will you look for to make your hierarchy and group them?
- Frequency – Intermittent/Constant/recurring
- Movement or static positions (rest) flare pain.
- Duration – Days, Weeks, Sudden, Short burst, change position of your … eases the pain.
- Size – Radiate – Shoulder, Upper back, Head…
- Intensity (pain) – bearable, pain doesn’t stop you, hesitant to
- Colour: Bruising, Blue, Red,
- Loading: Contraction, Low load required to bring on pain, High load (jump)
- ROM: Limitation? Less than 10 degrees limitation (not a problem) vs completely locked up.
- Stiffness
- Swelling
- Intensity: Discomfort – Painful – Sharp sting
On a scale from 0-10 describe a picture of Regression.
- Ligament tear Gr 1 – 3
- Muscle strain, micro tear – complete separation split in fibers
- Tendon phase of degeneration
- Cartilage erosion, plugging, tears
Diagnosis
Physiotherapy diagnosis
Describe a sentence to give the patient confidence that we’re the equipped/best at diagnosing this problem.
“We can handle it” vs “Our knowledgable expert physiotherapists are well versed, confident, and experienced in their approach to diagnosing your…”
We follow a structured plan to diagnose, classify the severity, and determine the hierarchy of priority that your knee needs. We stress, screen and scan all the possibilities that could be causing your pain. Identify any other injuries to surrounding structures. If there is an injury to the ligaments, meniscus, muscles or nerve, or cartilage we will find it.
We understand the physiological healing stages you’ll go through, and custom-fit your treatment program. By knowing the extent of the tissue damage we can guide you through a structured program to recover faster and safely return to the things you love doing. That’s why our physiotherapists are the best at diagnosing this type of problem.
Why is it crucial to get/understand a diagnosis? Does it mean anything? Or is it a death sentence? or will you treat it differently if you know what you’re dealing with?
X-rays
Muscles cannot be seen on an x-ray, so it will not be effective to diagnose a muscle spasm. X-rays will however show the integrity and alignment of joints in your spine. This will enable us to see if something is wrong with the structure of the bones in your spine or if there is a loss of disc space.
What are you looking for on an X-ray? Cortical stress lines, Displacement measurements, What Classification is done via X-ray?
Your physiotherapist can refer you to get x-rays taken if necessary.
Diagnostic ultrasound
Diagnostic ultrasound can be used to show the presence of a muscle tear (muscle strains), inflammation, swelling or simply increased contraction of a muscle (muscle spasms).
If you need an ultrasound, your physio will refer you.
MRI
An MRI scan can image all of the structures in your lower back, including soft tissue, discs, nerves and bones. However, for a muscle spasm an image like this is unnecessary and very expensive. If your physiotherapist suspects anything more than just a muscle spasm, you will be referred to the right specialist.
Is an MRI necessary for this diagnosis – if not when could it become a necessity?
Why is the pain not going away?
Why will this condition NOT resolve or recover on it’s own
Discuss 3 Problems that are OUT of the patient’s control but can, with guidance, be leveraged to accelerate and control healing or limit setbacks or regression.
A prompt to ask Gemini: Search medical journals published to Rank the risks of complications and secondary fallout caused by with a… treated using non-surgical rehabilitation not limited to, but including predictable compensation patterns, joint stiffness, specific muscle weakness, physiological complications due to anatomical structure, swelling, non-union, malunion, rupture, tendonitis, arthritis, accelerated joint erosion. Also, indicate the percentage likelihood of the development of these complications.
Expected compensation, adaptation
- This section assumes that NO intervention/ treatment/ personal care/medical attention is applied….
- A patient who leaves his … untreated, undiagnosed, what will happen next…
- Pathology:
- If you don’t take the warning signs seriously, you risk more critical and possibly irreversible damage.
- Discuss physiology that slows down your recovery (severed nerves, swelling impede arterial bloodflow & nutrients, venous clearing of debris
- Discuss – Non-union, Malunion, Prolonged healing, Abnormal Callus formation, etc.
- You become stuck in a cycle of pain, not knowing if it is safe to move or not.
- Without intervention or treatment, why is the tissue state not improving?
Problems we see when patients come to us with …
Discuss 3 Problems that are WITHIN the patient’s control with guidance, which can be leveraged to accelerate and control healing or limit setbacks or regression.
Complications (guaranteed, or high probability of developing with this problem/diagnosis/condition.
- One concept per paragraph. Explain what resistance or problems you can encounter during the treatment process. Stay to the core message.
- These are not bullet points —they are only to guide your thoughts. Choose a few (not all) and explain why.
- Themes range from: Ignoring… , Accurate Diagnosis, Immobilisation, Too much rest, Too little rest, Medication use,
- Speak to your patient as if each of these is happening to them.
- Without treatment, a “wait and see” approach. – What’s wrong with it, and what problems will they face?
- Explain why it’s a problem. Not only state “it’s a problem” but explain why.
- Reasons that delay recovery time
Pain medication (how long is normal/ acceptable)
Misconceptions about treatment
Physiotherapy treatment
Please inspire confidence in your ability to test, identify, diagnose and treat/ deal with this.
Example:
Our priority is to determine the extent of the damage to your piriformis muscle. Then, we test the structures surrounding your hip and lower back to clear the nerve pathway and resolve the sciatic nerve pain. Avoiding nerve compression is crucial to prevent relapse and restore the sciatic nerve’s regular sliding. We must protect the muscle from overworking by differing forces away from the piriformis muscle, strengthen the surrounding muscles, correct the compensation, and retrain the correct firing pattern. This allows time for the piriformis muscle to adapt and heal. Our practitioners bring on a change and monitor the results until it’s working, and then we magnify the effects to get even better outcomes.
Patient asks you:
“So why should I come see you for … ?”
Your answer is…
- We can provide the best treatment for, provide guidance and answers., Implement a very effective and structured plan of action like
- Use the antonyms of the words the patient complains of. Instibility – stability/stable, Fear – confidence, worried – calm/carefree, anxiety – serenity
- And we will also look at (muscle strength, joint range of motion, flexibility, ligament stability, and nerve control.)
- Gradual strengthening, control, and conditioning.
Phases of rehabilitation
Keep your focus on the primary problem structure.
As long as I can see progression & functional expectations changing, Example:
- crutches
- 20% Weight (limited ROM)
- 50% weight (FROM)
- 100% weight with concentric & eccentric contractions
- Speed & Power (Jump)
Please work the PEACE & LOVE protocol into the Plan of Action (Not all in the first phase)
- Balance on one leg
- Perform a lunge
- Squat to 90 degrees
- Balance reactions (stepping out sideways, forwards & backwards)
- Jump & Land from a step
- Do a Single leg jump
- Sit in a crouched position & get up
- Jump over a hurdle
1st Phase: What you want to achieve (Week 0 – 1)
Functional expectation, what we’ll do.
E.g. “Our first aim is to get the proper diagnosis and identify and prioritize any contributing factors to your unique problem. Now, we can guide you in avoiding any aggravating activities for the time being and managing your symptoms. This includes a list of things that are safe to do and some that are not. ”
To progress to the next stage you should be able to …
2nd Phase: What you want to achieve in Week 1 – 2
What needs to happen in the tissue/ pathology to fix it
This is the thing you should be able to do by now
3rd Phase: What you want to achieve in Week 2 -3
Treatment elaborated
This is what you need to be able to do with ease so we can progress to the next phase of treatment.
4th Phase: What you want to achieve in Week 3 – 4
Re-inforce, strengthen, guide,
What you should be able to do by this stage is ….
5th Phase: Test return to normal life Week 4 – 6
To makes sure you’re safe to turn to
- Driving you should be able to
- Jogging you should be able to
- Run you should be able to
- Work
6th Phase: Final medical clearance tests (Week
By now, you should be able to jump and throw, but there are some specific stress tests you should be able to do.
By now, you should be able to return to your routine. During the final week of your …….. treatment, we want you to be able to train at your full capacity. ………….. should be able to handle stretch stress, max load, and compressive forces.
So we can sign off on your recovery, knowing you’re safe.
Healing time
Physio protocol time frame for healing (weeks/months)
- A full recovery and return to sport will take longer and should not be confused with the healing period.
- It takes about 3 to 4 months to return to exercise and sports.
- You will need physiotherapy treatment twice a week for the first two weeks.
- After this, your treatment sessions can be …
- Remember: “Non-operative Treatment” or Non- Surgical Not
conservative
Other forms of treatment
This section is about other treatments that can help the process services that can help – but we don’t provide.
- Your doctor (GP) will probably
- Pain meds, injections,
- Getting your back or neck ‘aligned’ or ‘clicked’ in the hopes of improving the … will not improve the state of the muscle or change your pain. It could even worsen or trigger a muscle spasm. You need to look at the bigger picture.
- A biokineticist will be able to help you in the final stages of your rehabilitation and get you back to training for your sport.
- Wearing a back brace won’t be the solution to your problem.
- Stretching or foam-rolling might ease your pain temporarily, but
Is surgery an option?
Surgery is necessary when …
- These surgical checkboxes must be ticked before surgery is even considered.
- What is considered a failure of conservative treatment when surgery must be considered?
- Give the components of clinical measurements that indicate surgery
- Surgery is only the Halfway mark for a successful surgery; the rest is reintegration, strengthening, and adapting your body to the change.
- Why is rehab important after surgery?
What else could it be?
- Only mention a few (up to 5) differential Diagnosis
- Describe one symptom or difference between the two that sets them apart
- This section is for very similar Conditions but one or 2 differentiating factors.
Also known as
- Synonyms
- List key phrases (careful – start each bullet with different word)
