Category: Foot Problems


Why is plantar fasciitis so hard to manage?

By admin,

Its not hard to manage.
What is had is sorting out the good from bad information on what it is and how to manage it.

Plantar fasciitis occurs when the cumulative load in the plantar fascia exceeds what the tissue can take. Its a mechanical issue, so mechanical problems need mechanical solutions. Long term you really only have two key options:

  1. Reduce the load (eg strapping, stretching, foot orthotics, activity reduction, footwear modifications, loose weight etc)
  2. Increase the tolerance of the plantar fascia in its ability to take the load (eg mechanical overload and adaptation exercises, etc)

Pretty much every other treatment that gets used for plantar fasciitis will either help facilitate healing or do nothing (ie its snake oil). A simple web search will turn up plenty of unhelpful testimonials for pretty much anything to treat it. No matter what is advocated, there is always someone who will claim it helped. Equally, there is always someone who will claim it did not help.

The reason for all the bad information and misinformation is probably:

  • Initially plantar fasciitis is an -itis (inflammation) and then it becomes an -osis (degeneration). Different treatments are needed for an -itis vs an -osis. Recommending an -itis intervention for and -osis is bad advice (and vice versa). This is why some are advocating for this to be called plantar fasciopathy.
  • the natural history of plantar fasciitis is that it gets better on its own, eventually. “Eventually” may be as long as years and it hurts a lot in the meantime, so yes it should still be treated. This also means that using any treatment (good or snake oil) just as the plantar fasciitis symptoms improve, that the treatment used is going to get the credit when it was going to improve anyway (and lead to a positive testimonial or that treatment). That is why we really should be sticking to treatments that have been shown in clinical trials to do better than that natural history.
  • the symptoms are not ‘level’. The symptoms go up and down naturally over time. If you were to use a totally useless treatment just as a natural downswing in symptoms was about to happen, the useless treatment will be given credit when it was totally ineffective. Similarly, if a known effective treatment was used just as an upswing in symptoms was about to happen, then the treatment may halt that upswing, so the symptoms remain the same – that treatment is then considered useless as the symptoms are the same, when in reality it was actually effective. That is why we really should be sticking to treatments that have been shown in clinical trials to do better than that natural history, and not putting much weight on testimonials.
  • all plantar fascitis is not the same. There is the -itis vs –osis issue above. The longer term cases are going to respond differently to treatments than a short term case to different interventions. There are different thicknesses of the plantar fascia which are likely to respond differently. There are different amounts hypoechoic signal on ultrasound which are likely to respond differently to different treatments. No one treatment is going to be effective in all cases.

It is knowledge of these ‘reasons‘ and how to work with them that distinguish good clinicians from the poor online advice based on testimonials.