Understanding Plantar Fasciitis: Symptoms, causes and treatment options

December 1, 2025

Understanding Plantar Fasciitis: Symptoms, causes and treatment options

Plantar fasciitis is one of the most common causes of persistent heel pain, especially in people who
lead active lives or spend long hours on their feet. The plantar fascia is a strong, fibrous band of
tissue that runs along the bottom of your foot from the heel to the toes. It supports your arch,
absorbs shock with every step, and plays a key role in normal foot mechanics.

While plantar fasciitis used to be described as an inflammatory condition, modern research now
shows that it is mostly a degenerative condition of the tendon —often called plantar fasciopathy.

This means the tissue becomes irritated, weakened, and overloaded over time, usually because it is
doing more than it is strong enough to handle.

Symptoms:

The main symptom of plantar fasciitis is heel pain, especially when you first wake up in the morning
or after a period of rest. Other symptoms include a dull or sharp ache in the arch or bottom of the
foot, pain that worsens with long periods of standing, and a burning sensation. The pain may
improve briefly after a few steps but can return after prolonged activity

Who Is Most at Risk?

Plantar fasciitis can affect anyone, but certain groups are more prone to it:

Athletes and active individuals (runners, dancers, field sport athletes)
People who stand or walk for many hours (teachers, healthcare workers, retail staff)
Middle-aged adults
People with specific foot postures such as flat feet, high arches, or tight calves
Individuals with increased load on the foot due to weight gain, pregnancy, or sudden
increases in activity.

In athletes, repetitive high-impact loading is a major factor. Several studies, including one by Ramya
et al. (2022–2023), show that runners and jumping athletes are especially vulnerable due to
repetitive stress through the plantar fascia.

Why Does Plantar Fasciitis Develop?

Think of the plantar fascia like a tension cable that supports your arch. When too much load is
placed on it—either from activity, footwear, foot shape, or strength deficits—the tissue becomes
overwhelmed.

Common triggers include:

A sudden spike in training or walking volume
Hard training surfaces
Weak intrinsic foot muscles
Tight calves or limited ankle mobility
Unsupportive footwear
Poor shock absorption
Repetitive high-impact sports

Over time, the tissue becomes strained and loses its ability to handle load effectively,
resulting in pain—especially during the first steps in the morning or after prolonged
sitting.

The Role of Footwear

Footwear can significantly influence both the development and recovery of plantar fasciitis. Shoes
that are flat, worn out, overly flexible, or lacking arch support increase the tension on the plantar
fascia, especially over long distances or extended standing.
During recovery, supportive footwear can dramatically reduce daily irritation. Because every foot is
unique, your physiotherapist can help you choose the best shoe based on your biomechanics and
lifestyle needs, that includes good arch structure, adequate heel cushioning, and a slight heel raise.

How Foot Mechanics and the Windlass Mechanism Influence Your Pain

To understand plantar fasciitis, it helps to look at how the foot works during walking and running. Your foot must absorb shock, support your arch, and become a rigid lever for push-off.

A key part of this process is the windlass mechanism.
When your big toe extends during push-off, the plantar fascia tightens—much like a rope winding
around a pulley. This lifts the arch and creates a stable, powerful base for propulsion.

But when the plantar fascia is irritated:

toe extension becomes painful,
the arch may not lift effectively,
the foot becomes less efficient, and
you may limp or shift your weight, causing further strain.

This explains why plantar fasciitis affects not only the heel, but your walking mechanics and balance
as a whole.

Evidence based treatment

Physiotherapy has evolved significantly, and we now have strong evidence guiding best practice for
plantar fasciitis management.

1. High-Load Strength Training (HLST) / Heavy-Slow Resistance Training (HSRT)

High-load strengthening is one of the most consistently effective, research-supported
treatments for plantar fasciitis. It involves slow, progressive heel-raise exercises—often with a
towel under the toes—to directly load the plantar fascia. This approach strengthens the
fascia–calf complex, improves collagen quality, increases load tolerance, and reduces pain.

The landmark RCT by Rathleff et al. (2014) showed significantly better pain and functional outcomes at 3 months compared with stretching alone. Supporting this, Ramya et al. (2022–2023)
demonstrated that high-load plantar fascia training produced faster improvements than intrinsic strengthening in athletes.

In short, HLST provides fast, meaningful, and lasting results.

2. Shockwave Therapy (ESWT)
Extracorporeal

Shock Wave Therapy represents a scientifically proven, non-invasive option for
chronic tendinopathy management. By activating tissue regeneration pathways, enhancing
vascularization, and providing pain relief without pharmacological intervention, ESWT helps restore
tendon structure and function — enabling a safe and lasting return to activity.

An educational blog article on Shockwave therapy can be found on our website, follow this link to access:
https://paarlphysios.com/shockwave-therapy-for-chronic-tendinopathy/

Multimodal Physiotherapy: The Most Effective Path to Recovery

Research and best-practice guidelines consistently show that a multimodal physiotherapy
approach—combining several evidence-based techniques—produces the strongest outcomes for plantar fasciitis.

A comprehensive rehabilitation plan may include:

high-load plantar fascia strengthening
calf and intrinsic foot muscle strengthening
plantar fascia manual therapy and stretching
shockwave therapy (when indicated)
footwear guidance, including orthotics or heel cushions
and structured load management.

This combination addresses both the symptoms and the underlying mechanical causes of plantar
fasciitis. A physiotherapist will perform a detailed assessment to determine which interventions are most suitable for each individual.

Recovery Timeline and Prognosis

Most people recover well with physiotherapy, with 70–80% improving within 3–6 months,
particularly when treatment begins early. Chronic cases may require more time but still respond effectively to structured strengthening and load modification—especially high-load strengthening, which has been shown to deliver rapid functional improvements.

Factors such as tight calves, improper footwear, demanding weight-bearing jobs, higher BMI, and delayed treatment can slow recovery.

The good news is that plantar fasciitis is highly treatable, and full recovery is the expectation.

With a personalised, evidence-based plan—including strength training, shockwave
therapy, stretching, and footwear optimisation—patients can achieve faster, more predictable, and
long-lasting relief.

If you’re struggling with heel pain, the most important step is to begin an individualised assessment
and structured treatment plan — your feet will thank you.

References

Rathleff, M.S., Mølgaard, C.M., Fredberg, U., Kaalund, S., Andersen, K.B., Jensen, T.T.,
Aaskov, S. & Olesen, J.L. (2014). High-load strength training improves outcome in patients
with plantar fasciitis: A randomized controlled trial with 12-month follow-up. Scandinavian
Journal of Medicine & Science in Sports.
Ramya, D., Anitha, A., Ramana, K. & Kamalakannan, M. (2022–2023). Effectiveness of High
Load Plantar Fascia Resistance Training among Athletes with Plantar Fasciitis. Sri Sai Ortho
General Clinic.
Morrissey, D., Cotchett, M., Said J'Bari, A., et al. (2021). Management of plantar heel pain: a
best practice guide informed by a systematic review, expert clinical reasoning and patient
values. British Journal of Sports Medicine, 55, pp.1106–1118.
Koc, T. et al. (2023). Heel Pain – Plantar Fasciitis Revision 2023: Clinical Practice Update.
Journal of Orthopaedic & Sports Physical Therapy, 53(12), pp. CPG1–CPG39. Available at:
https://www.jospt.org/doi/10.2519/jospt.2023.0303

For More Help:

For more information and help, please contact Janika at the Wellington Branch.

Janika

Physiotherapist & Practice Owner