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The Definitive Plantar Fasciitis Explanation: The Cause & The Cure

Samuel G Oltman, ND, RMSK


Plantar fasciitis is a foot weakness problem. It’s not a lack-of-support problem or a not-enough-stretching problem. There are many misguided and unexamined assumptions in foot health that persist today adding to the confusion for patients suffering with this debilitating condition. These ideas need to be corrected and that is what I set out to do here from beginning to end. The following is a comprehensive, detailed, and definitive explanation of the cause and cure for plantar fasciitis.



The Claim: The foot is designed to support itself. It is only through deformity and loss of strength (structurally and functionally) that the plantar fascia undergoes injury, inflammation, and degeneration.


The Solution: Restore and maintain evolved intrinsic support and strength mechanisms through proper alignment and progressive load.


Fasciitis vs Fasciosis

Most people refer to plantar fascia injury as “plantar fasciitis” but this term indicates an acute inflammatory response. Most people with this condition have had it for many months and years, meaning it’s in a chronic state of both inflammation and degeneration. The proper term for this is “plantar fasciosis”. The difference simply indicates acute vs chronic and inflammatory vs degenerative.

See this article for the full explanation. For the sake of clarity we’ll be using the term “plantar fasciitis/-iosis” for the remainder of the article to recognize and include both meanings of this distinction.


Evidence Base

The scientific evidence for plantar fasciitis/-iosis is imperfect and not definitive in any particular direction. This is likely due to the complexity of the problem and the particular question being asked: Is the goal to reduce pain or to heal? The combination of factors I will lay out as causes and cures lack a singular RCT, but there is evidence for each one independently. Additionally, there is evidence of what does NOT work. There are also decades of clinical experience backing up the combination therapy to not just temporarily improve symptoms but improve foot health by addressing the cause.

In the absence of perfect evidence, we can rely on a few basic, concrete principles:

  • Form is function: The human foot has arches for a reason: arches are extraordinarily strong structures. The arch form must be indicating something about foot function.

  • Muscle physiology: Progressive loading is how we gain strength. Length-tension relationship directly dictates the amount of force a muscle can produce. Use it or lose it.

  • Evolutionary Biology: Three hundred thousand years of Homo sapiens adaptation to bipedal movement with nothing but intrinsic support.

  • Anthropology: Natural experiments provided by people in various cultures with different shoe-wearing habits to our own show us the counterfactuals.

  • Fashion: Modern shoes distort and deform the intrinsic support mechanisms of the foot for explicitly aesthetic and historical reasons.

  • Logic: There is no arch in the world that we “support” by propping it up from underneath. There is no other part of the body we treat by causing its progressive weakening. Both of these violate basic principles, our embodied intelligence, and are antithetical to logic.

The Plantar Fascia

The plantar fascia is a fan-shaped sheet of collagen fibers that span from the bottom of the heel bone to the flexor tendons and toes of each of the 5 digits. Its normal function is to act as a tie-rod between the 3 corners of the tripod-arch anatomy of the foot (more on this later), stabilizing and stiffening the arches as force is applied through its very high tensile strength. It is a central component of the “posterior kinetic chain”, functionally connecting it to all the plantar arch muscles, the calf muscle, hamstrings, and gluteal muscles.

plantar fascia

How Arches Work

Arches derive their strength directly from their shape. An arch distributes compression forces over its length, toward the ends. As more force is applied, the arch gains stability by its components being more tightly compacted. Outward forces that would buckle the arch are buttressed by anchoring the ends via a tie-rod and reinforcing the sides.


There is no arch in the world, in any domain, that is supported by propping up material underneath it. This defeats the entire purpose of an arch.


foot arch

The human foot does not just have one arch– it has 3. Three separate arches, all strong independently of each other, oriented with each other in a tripod fashion. The encumbered, non-deformed human foot has a tripod-arch anatomical structure. That’s as structurally sound (and efficient, and elegant) as possible. There is a concept called “tensegrity” that is beyond the scope of this article that articulates this structural concept perfectly. The foot displays beautiful tensegrity that is both simple and anti-fragile.


foot arch

foot arch

The important difference between static arches for bridges and dynamic arches in the feet is that in feet a portion of the arch components are contractile: the muscles (and fascia to a lesser degree). The more force the muscles can exert, the more load the arch can bear by virtue of the muscles maintaining/reinforcing the arch curvature. In engineering terms, the muscles and fascia are the arch “buttress”.

The key connection between arches and muscular strength is: the muscles do not need to support the feet/arches through brute strength. They just need to exert enough force to maintain the arch form because the arch itself is so strong by virtue of its shape. When the arch form is distorted its weaker and requires excessive strain from the muscles and fascia to maintain its shape and will eventually fail. Plantar fasciitis/-iosis is a foot weakness problem.

plantar muscles

How Muscles Work

Muscle physiology 101:

  1. Muscles become stronger with progressively increased demand.

  2. Muscle force is directly related to its starting length.

Progressive load and regular use is how muscles become and stay strong. This is why when you’ve been put in a cast the part that’s been casted shrinks by the time it’s taken off: it hasn’t been used and the muscles become smaller (called “atrophy”). The same thing happens in overly supportive shoes: the muscles shrink in size and strength from lack of use. They then cannot produce an adequate amount of force. This concept is very basic and the evidence is overwhelming. It is the basis of all strength training.


The starting position length of a muscle has a direct relationship to the amount of force it can produce in a contraction. This is referred to as the “length-tension relationship”. A muscle produces the maximum amount of force when it’s at a maximally overlapping mid-point in its length: over-stretched is weaker, overly shortened is weaker. Conventional fashion footwear and orthotic arch supports go in direct opposition of this basic physiology by distorting the foot in ways that pre-lengthen the arch musculature thereby reducing their maximum force production (more on this later).

foot muscles

By using overly supportive external devices, the muscles have less demand on them, which leads to weakness over time. By putting the foot in a bad position, the muscles are elongated and weak. Both of these interconnected phenomena lead to excess strain on the plantar fascia because the musculature cannot support/buttress the arch forces adequately. Plantar fasciitis/-iosis is a foot weakness problem.


Big Toe Alignment

Your big toe is a big part of your intrinsic arch support.

Arch shape/alignment and muscle strength depend crucially on the position of the big toe. Big toe position influences muscle force generation, structural integrity of the bony arch, and blood flow to the bottom of the foot.

The big toe extends the longitudinal arch giving it a longer lever arm and more stability structurally. Think of it like a kickstand on a bike. With the big toe aligned with the first metatarsal (impossible in conventional fashion footwear) the foot is less able to overpronate because of the counter force provided by the big toe (and first ray) resisting the motion. This is structural stability and strength provided for directly from alignment. See this video for a wonderful visualization of this concept of big toe alignment and arch integrity.


Try this yourself by rolling your ankle back and forth with your toes squeezed together, then do the same thing with your big toe abducted into good alignment. (VIDEO DEMO HERE)

plantar fasciitis caused by shoes

Many of the arch muscles are connected directly to the big toe: flexor hallucis longus, flexor hallucis brevis, and abductor hallucis (and the plantar fascia directly). When we distort the big toe through adduction and dorsiflexion (the position it gets put into when in most shoes), all of these muscles get stretched and weaker by virtue of the length-tension relationship. They are unable to perform their intended purpose to the fullest extent. This also happens with the other muscles of the arch like the flexor digitorum longus and brevis which connect to all the smaller toes. This weak positioning (caused by shoes) creates more movement in the arch, meaning more force and strain on the fascia.

plantar fasciitis caused by shoes

plantar arch muscles

Big toe position also influences blood flow to the plantar fascia, which when we’re talking about a degenerative fasciosis, blood flow is critical for healing. It also implies that there is a correct big toe alignment because why would we ever evolve in a way that cut off the main blood flow into the foot? This lack of blood flow makes the tissue more prone to injury in the same way that when you’re not warmed up you’re more prone to injury.


To summarize, when the big toe is in a bad position, (adducted and dorsiflexed) the foot becomes weaker 1) through loss of structural arch alignment that counteracts pronation and arch flattening forces, and 2) through over-extended musculature not able to produce adequate buttressing force simply by virtue of their starting position. Plantar fasciitis/-iosis is a foot weakness problem.


The Foot Is Designed To Support Itself

Taken all together, the human foot has a tripod-arch tensegrity anatomy; muscles to buttress the forces through the arches; the big toe providing structural stability and muscle leverage; and a plantar fascia to tie and buttress the arch ends. With all of these elegant and synergistic support strategies, how do we end up with the foot weakness that causes plantar fasciitis/-iosis?


Fashion Footwear

All three intrinsic foot support/strength dynamics (Arch form, muscular strength, and big toe alignment) are disrupted by 4 features of conventional fashion footwear:

  • Tapered toe box that squeezes the toes together putting the big toe into adduction.

  • Raised heel that dorsiflexes the toes and over-stretches the arch musculature and fascia.

  • Toe spring that further dorsiflexes the toes, lowers force generation, and increases arch movement.

  • External arch supports propping up the foot and weakening the muscles through lowered demand/activation.

Why are shoes like this?

Modern shoe designs are a remnant of 15th century European status symbols. We can trace the advent of narrow toe shoes and heels to specific points in history as they conveyed specific things about someone’s status in society.

These conventions eventually became what shoes were expected to look like, largely disconnected from their original meaning, but still used explicitly for fashion reasons. As fitness and jogging culture boomed in the 1970s, these same fashion principles got carried over into athletic shoes because “that’s what shoes look like”. It becomes a self-fulfilling prophecy when the shoes you’re accustomed to are uncomfortable and disruptive to normal foot function, then feeling the need to get shoes that instead of correcting the problem, double-down on the error by “supporting” a foot that is in a bad position.

Nowhere along this timeline was there a consideration of what is best for foot health because it was never separated from fashion and why shoes look the way they look. It’s telling that there are pithy advice columns about how to handle the discomfort of high heels for the sake of fashion. It is also yet another way women are pressured into aesthetic standards that damage the body. Your athletic shoes are not different from high heels: They have all the same features, just less.


plantar fascia shoes
Left: Not shaped like a foot. Right: Shaped like a foot.

The counterfactual is also in plain sight: we can observe the feet of people in societies that don’t wear modern shoes. This provides a natural experiment where we don’t see toe deformity, we see exceedingly rare heel pain despite no external support, and these people tend to be far more active than most people in Western countries. This is how the foot is supposed to function.


We uniquely burden the feet with body-deforming fashion.


Arch Supports

First introduced around 1900 as a concept, the modern version of orthotic arch supports were popularized in the 1970s during the fitness/jogging boom. Interestingly, this is when the use of foot-deforming shoes become the basis for more recreational activity.

There has never been a study showing long term benefit from orthotic arch supports. It doesn’t exist for plantar fasciitis/-iosis or any other condition. Please Google it and let me know if you find it. Ask ChatGPT, ask your healthcare provider. It’s not there because the benefit is a mirage of short term symptom relief. There are many studies and meta-analyses showing the absence of long term benefit, here and here and here.

The use of arch supports could be justified if: 1) it made sense logically, or 2) had studies showing long term benefit. Neither of these criteria are met with orthotic arch support.

They are illogical because there is not another arch structure in the world that is “supported” by being propped up from underneath. It defeats the entire purpose of an arch. There is also no internal coherent logic as arch supports are used for both “high arches” and “low arches”, which if you follow the logic of why they are used in the first place, contradicts itself. Arch supports do not make sense from an engineering standpoint or from a muscle physiology standpoint.

This illogical approach could be accepted as simply counter-intuitive if there were studies showing long term benefit of arch supports. However, there is not a single study showing long term benefit of arch supports.

There are studies with the headlines “orthotics show long term benefits…” but when you read the study there is symptom relief at 6 weeks and no difference by 12 weeks (and variations of this pattern, as seen here and here and here). There are multiple large meta-analyses concluding there is no evidence to support the use of orthotic arch supports over the long term– only that they decrease pain in the short term. Even a study showing no benefit compared to sham device. This study shows improved arch form and larger muscles with LESS orthotic use. Yet they persist as a long term strategy, ignoring shoe-induced deformity, degrading foot health, and promoting plantar fascia injury.


We uniquely weaken the feet when they have pain unlike any other part of the body.


The feet are the only part of the body that are progressively weakened as a “treatment” for pain. Knee pain? Stronger quads and hamstrings. Back pain? Stronger core. Shoulder pain? Stronger rotator cuffs. But foot pain? The mainstream treatment remains interventions that deform and progressively weaken the foot. Plus, we have the counterfactual yet again: Increased intrinsic muscle strength with less external support.

It’s a trap: Putting your foot in a bad position so it can’t support itself, thinking this justifies more external support, which causes further weakness, which leads to thinking you need evermore external support until the foot no longer functions. If you put the foot in a bad position and the arch falls, it doesn’t prove that it needs arch support. It proves that it needs better positioning.

The fascia bears the brunt of this failure and is eventually injured.


Other Misguided Ideas

Other common treatments for plantar fasciitis/-iosis include stretching, strengthening, shockwave, various injection therapies, lasers, and other tools that work on the soft tissue. They have their benefits in various situations but every study on these treatments is done in the context of bad shoes. Isn’t it strange that the stretching and strengthening done for plantar fasciitis/-iosis is done barefoot, then you are told to go walk around in a shoe that distorts all the tissue you were just working to improve?

The “tight achilles causes plantar fasciitis/-iosis” idea is very common and therefore you see calf stretching recommended commonly. This is because tight achilles tendons and calf muscles create more tension in the plantar fascia. Developmentally, the achilles tendon and the plantar fascia start out as one continuous structure and functionally behave in tandem. However the solution is not just stretching– it’s wearing shoes that are zero-drop (without a raised heel) because shoes with raised heels shorten the calf muscle. If you’re calf stretching to help plantar fasciitis/-iosis but then wearing a shoe with a raised heel that shortens the muscles and tendon, you are in a self-defeating cycle.

Arch height is used as a scapegoat for foot. Flat feet do not cause pain. High arches do not cause pain. Weak feet cause pain. Do not try to “correct” flat feet.

Soft tissue work is great, I recommend it to most of my patients in some form but it’s not curative if you continually put the tissue you’re working on into weak positions. It also doesn’t work if you’re doing stretches that reinforce the dysfunctional dynamics explained above, like toe dorsiflexion stretching.

The ground-breaking massage device, the magic ankle wrap, the high-tech sock, the mythical foot warmer– none of it matters if you’re always putting your foot in a deforming shoe. It’s not a tightness problem, it’s a strength problem that leads to tightness.


Summary Of The Cause

The human foot has amazingly elegant foot support/strength strategies that we have developed over many hundreds of thousands of years. When these strategies are disrupted, we see excess strain put onto the plantar fascia. Modern fashion footwear is the prime culprit for these distortions. The primary mainstream treatment for plantar fascia injury, arch supports, are illogical, without a shred of supportive evidence, and further distort our feet– creating a positive feedback loop that makes the plantar fascia worse over time. A healthy foot is a strong foot and the only way to become strong is through proper alignment and use.


Questions

If what you’re saying is true, why are arch supports so popular?

Because they can provide short term symptom relief. It's like eating junk food: it can feel good in the short term but is detrimental over the long term. Someone who is supposed to be helping you move better (podiatrist, PT, chiropractor, etc) recommending "just wear shoes/supports that feel comfortable" is like a dietician/nutritionist recommending "just eat food that tastes good."

Imagine if you had a rotator cuff injury and the healthcare provider you saw said “OK, it’s clear you have a tendinitis of your rotator cuff, let’s support it. We have a number of slings you can choose from, different colors and styles. In fact, Nike just made a sling with a new design that is endorsed by your favorite athlete– very cool. The plan is to just wear this forever because your shoulder obviously needs support. You should never use your shoulder without this support and you’ll need to come back every few years to get a customized one that ensures the proper fit.”

This is verbatim what people are told to do with their feet. It’s the only part of the body that we talk about in these terms: we weaken and ask less of it in states of dysfunction. Every other part of the body we would do progressive loading to rehab and strengthen the area.

They remain popular purely out of short term symptom relief, marketing, and unexamined assumptions.


If what you’re saying is true, why do the world’s best athletes wear these shoes?

It’s true that Lebron James wears and sells Nikes. He also sells McDonald’s and Sprite. LeBron is human and subject to the same errors we all make, despite being one of the greatest athletes to ever live. His endorsements should not be confused with what produces peak athleticism (although that’s what the marketing team would like you to believe). There is also not a strong relationship between peak performance and long term health, meaning top athletes do not provide a template for longevity.

Regardless of his athletic prowess, do you want your feet to be like his?

plantar fasciitis
Nike Feet?

The recent marathon winner and world record setter, Kelvin Kiptum, wore Nikes when he set the world record this year. Does this refute my point? Not at all. Kelvin grew up in the distance runner mecca, the Rift Valley in Kenya, herding his family’s cattle and trail running BAREFOOT. He developed his foot strength and running prowess BEFORE wearing Nikes, not because of them.


What about concrete and hard modern surfaces that we weren’t evolved to walk and run on?

The hard surfaces of modern urban living are novel, evolutionarily speaking. How sedentary we are is also novel. So do we walk too much or not enough?

I am “cushion agnostic”, meaning all of these principles and biomechanics can be achieved with cushion under your feet. No need to “go barefoot” dogmatically, that won’t work for a large portion of people. Nothing about hard surfaces justifies deforming your feet.

Additionally, hard surfaces alone do not come close to explaining modern foot dysfunction and plantar fasciitis/-iosis. They can make an active case feel worse, but all of the foot dynamics explained thus far are independent of the surface. The stronger your feet are, the better they will be at handling hard surfaces. It’s simply a matter of exposure.


If this is true, why are companies like Nike, Adidas, and Hoka so successful?

Commercial success has no bearing on the health effects of the product. Look at McDonald’s and Coca-Cola (Or Phillip Morris). High sales does not mean what you’re selling is good for people– it means people have been convinced for any number of reasons (short term relief, fashion, conformity, etc) that it’s better than the known alternatives.

Wearing Hokas is to your feet what drinking a Coca-Cola is to your metabolism. The incentive is to sell products, not to improve your health. Comfort is not a good proxy for health.

I am not claiming that Hokas are detrimental to your health to the same degree as soda or cigarettes, just that the same commercial dynamic applies: high sales and popularity has no relation to health benefit.


Yes, but arch supports work for me and/or my patients. How can you explain that?

What do you mean by “work”? They decrease pain? Do your feet function at all without external devices? How many patients who wear orthotics for years end up getting surgery?

Claiming that a reduction in pain proves they are good for your feet is like claiming that a food that tastes good proves it’s good for your metabolism. We cannot confuse short term relief with long term benefit. A wheelchair would help your foot pain too. You need to pick what feels comfortable for you within the bounds of what we know promotes natural foot function.


If this is true, how could so many “experts” be wrong?

“It is difficult to get a man to understand something, when his salary depends on not understanding it.” Allopathic medicine, by definition, is concerned with alleviating symptoms. Arch supports inside foot-deforming shoes can do that in the short term.

It is not that these questions are asked and the majority of doctors get it wrong– it’s that the question is not asked at all. There is no conception of optimal health– just the alleviation of immediate symptoms.There is no attempt to connect the effects of fashion, or anthropology, or evolutionary biology. They behave as though human history began in 1900: people keep coming in with deformity and pain, the foot must have a fundamental flaw that we must conquer.

Foot-deforming fashion footwear creates a market full of dysfunctional feet to “fix” with more deforming interventions, and more dysfunction-promoting measures, culminating in surgery and the complete loss of foot function. If the cause is ignored, or not looked for, this wheel continues to turn.

“Evidence Based Medicine” is a term used to describe the aspiration of modern medicine to use scientific research to rationally choose and justify medical treatment. It is often used as a bludgeon to discount anything that is not a mainstream drug/surgery. But most of medicine today is not evidence based– we’re simply not there. Especially in orthopedics and sports medicine, a recent review showed only 11% of clinical practice has high level evidence backing it up. Patients are told all the time “there’s no evidence for that” in reference to any heterodox idea (like this article, or regenerative injections), then are recommended a treatment (likely a drug or a surgery or orthotic) that is also totally without evidence. Evidence based medicine is a good goal, but it's also a facade for justifying things with no evidence simply because "that's the way we've always done things and it fits the drug-surgery-symptom alleviation model."

Foot “experts” are humans susceptible to marketing and lack high-level evidence to back up all of the most common treatments in this arena. Let’s start with first principles and work toward evidence.


A Definitive Diagnosis

Many of the studies and clinical guidelines use “heel pain” as the stand-in for plantar fasciitis/-iosis. It is assumed to be the cause of most heel pain. Generally a patient will get an x-ray that is almost always negative (x-rays do not visualize the fascia), then it is assumed plantar fasciitis/-iosis is the culprit based on symptom pattern. However, there are other causes of heel pain.

Ultrasound imaging provides a definitive diagnosis. An ultrasound can image the plantar fascia completely and provide a complete qualitative and quantitative analysis. There is an established reference range for plantar fascia thickness that is used to precisely diagnose the condition. In true plantar fascia injury it is darker and thickened beyond 4mm. We can also compare this to the unaffected foot to use as a control. I do all this in-office during your visit for a fraction of the cost of an MRI– which is not as sensitive in determining the diagnosis. This is another area of expertise for me and what my RMSK credential signifies. Most podiatrists don’t have ultrasound in their office. It all starts with the correct diagnosis and often the patients I see haven’t even had that part done correctly.


Patient Story

I recently saw a patient whose care went like this (which is common and the most mainstream approach): She had heel pain; Her podiatrist ordered an x-ray and it was normal (no fractures, it can’t see any soft tissue); Then she was given stretches (that reinforce the muscular dysfunction); Then it was suggested she wear “more support”; When that didn’t work, they did a cortisone injection without image guidance into tissue that still had not been looked at; Then the doctor proposed surgery (to simply cut the fascia, not fix anything). This is normal foot care that your insurance will cover.

When I saw her, I ultrasounded the fascia, measured it on both feet, and it was all completely normal. She had a muscle strain issue from weak feet. No injury to the plantar fascia, no plantar fasciitis/-iosis. But her insurance would have covered a surgery to snip the perfectly healthy fascia and doom her to increasingly absurd orthotic measures until her feet ceased to work. All of this without anyone actually looking at the fascia!

Fortunately for her, my expertise in musculoskeletal ultrasound revealed the correct diagnosis, helped her get onto a path that will resolve her symptoms, and lead to vastly improved foot health. It all starts with the correct diagnosis.


The Cure

We’ve now covered how the foot is designed to function, how plantar fascia issues arise, why the conventional common knowledge is incorrect, and how to make sure you actually have a fascia issue.

Now, how do I treat a patient with a confirmed case of plantar fasciitis/-iosis?


1) We reverse engineer all of the above causes to restore natural foot function. This is different for different people and there isn’t a one-size-fits-all approach. This is why people that have heel pain just “going barefoot” often does not work well. The changes in function, biomechanics, and exposure to stress need to be incremental and progressive. The emphasis for different people is different depending on anatomy and history.

However, as long as you have human feet, the common principles of footwear are:

  • Big toe in the correct position, coming straight (or as straight as possible) off the 1st metatarsal bone. This requires wearing a shoe that is shaped like a foot, or wide-toe box. This also requires for most people utilizing a toe spreader like Correct Toes to correct the deformity that has already happened up to this point.

  • Shoes that are flat from heel to toe (“zero drop”) to put the musculature in the optimal resting length position and ensure equal weight/stress distribution from front to back. This also includes reducing toe spring.

  • Removal (or minimizing) extrinsic “arch support” in order to use and activate the foot muscles, improving strength and arch function.

  • Cushion: take it or leave it. You can do all of the above with plenty of cushion under your feet. The goal is not to be barefoot. The goal is pain-free function. We do that by working WITH the body, not against it.

There is a reason you have not heard the term “barefoot” up to this point in reference to a solution or treatment. Being actually barefoot is great if you have the requisite foot health. But it is not a goal unto itself for many people. The goal is pain free function. That’s it. We can get all the strength and alignment we need with cushioned shoes if that's what it takes. So don’t be scared off by thinking “He’s just going to tell me to be barefoot all the time.” We want strength and alignment. Not a dogmatic belief in an endpoint that might not work for everyone.

There are always going to be fashion and sport specific reasons to wear non-perfect shoes. Exceptions prove the rule. Do the best you can.

You are free to wear whatever shoes you like, but don’t be fooled into thinking that “it’s good for you”. People are free to eat whatever they want too, but most people know that junk food is not the best choice. In foot health, we are making a fashion decision without knowing the health consequences. This is your informed consent.

What shoes do I recommend?

2) After footwear and toe alignment correction, I move into rehabilitation exercises and various ways to promote more foot strength through using the muscles more. Bigger muscles means less plantar fasciitis/-iosis. Targeted stretching that is aimed at reversing deformity and promoting better biomechanics is also implemented. This takes time but is crucial and in-line with how we treat every other part of the body: strengthen the muscles around the problem area to induce a greater ability to compensate.

Strengthening exercise can also just be walking in Correct Toes without any external support. Barefoot on grass is great for this. We want to promote normal, healthy function. If you haven't done something like this in a long time, you need to go very slowly and incrementally.

3) I also recommend as many things as I can to promote circulation. Circulation is a huge benefit of proper big toe position but any degenerative and chronically constricted tissue is starving for blood flow. It also helps muscle recovery as they gain strength. So we do heat (stop icing your heel!), epsom salt soaks, topical capsaicin, and self-massage. I also often recommend copious amounts of fresh ginger to patients with cold feet and hands because it’s a powerful warming plant that increases circulation and lowers pain with a bunch of beneficial side effects (lowers inflammation, helps digestion, etc).


4) There are injection therapies that can help both the degenerated tissue and the pain. There are pros and cons to each, some are better than others for different people. In the case of any injection, I use ultrasound-guidance so there is no guess work. I also do nerve blocks so the discomfort of the injection is minimal. Neither of these measures are done routinely in other clinics.

PRP can be a great solution for persistent fascia issues that haven’t responded to conservative measures. If you’ve had a cortisone injection that didn’t work for your heel pain, you probably either don’t have a fascia injury (because nobody actually looked at the fascia), the person injecting missed the target because they did it without image guidance, or it got to the right location but you were put right back into the shoes that caused it in the first place. Cortisone can be a great tool in plantar fasciitis/-iosis to give people a break from the pain as they engage in the necessary rehab, alignment, and strengthening. But cortisone is not a solution if you’re not changing the factors outlined above.


Not everyone will achieve “perfect” foot health/alignment/strength. For many, I see them after 6 (or more) decades of their feet being deformed and dysfunctional. But we can still get massive improvements. We do not want to allow perfection to be the enemy of good. These principles exist on a spectrum and we get an enormous amount of improvement without being perfect.

Regardless of how unhealthy you think your feet are, we can resolve the pain of plantar fasciitis/iosis. The final solution may be a mix of rehab exercises, Correct Toes, a foot-shaped shoe with plenty of cushion, and a low arch support with long activity for years (because the muscles can take that long to unlearn a lifetime of bad habits). For others it may be a smooth transition into nothing more than a minimalist shoe and regularly wearing Correct Toes.

Lastly, having really strong/healthy feet doesn’t make you immune to injury– just like any other part of the body, injuries can happen. But this approach provides a template for both rehab and prehab through any potential injury.


While this article focuses on the plantar fascia, these same principles apply to every common foot condition and cause of pain: bunions, neuromas, metatarsalgia, Achilles tendinosis, etc.


Plantar fasciitis/-iosis is a foot weakness problem. Restoring structural stability and muscular strength through alignment is the cure.


At Cascade Regenerative Medicine we utilize first principles thinking; we prioritize health over covering up symptoms; we back up what we do as much as possible with evidence, by actually reading the evidence; we do not do things just because that’s how they’ve been done before; we treat YOU, not an algorithm; we always consider multiple perspectives; we integrate physics, anthropology, evolutionary biology, psychology, philosophy, and are always learning; we value your time and give you the tools to make the best medical decision for yourself; we are constantly looking for better ways to serve you and to help you live a better life.


Do not settle for what constitutes mainstream care today. Nobody has the level of expertise that I do at the intersection of foot health, injection therapy, and ultrasound. If you or someone you know has plantar fasciitis/-iosis, Schedule with us today to see for yourself how much better your feet can feel.


Much of this knowledge, experience, and expertise comes from my years of friendship and tutelage with Dr. Ray McClanahan, DPM. He was inspired by the work of Dr. William Rossi, DPM to invent Correct Toes and pioneer the medical space of natural foot health. Many thanks to Dr. McClanahan and all the wonderful people working in this space.


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