Plantar fasciitis

Plantar fasciitis

Mitsutoshi Hayashi

Mitsutoshi Hayashi

Doctor of Medicine, specialist in the Japanese Society of Rehabilitation Medicine, specialist in the Japanese Society of Orthopaedic Surgery, specialist in the Japanese Society of Rheumatology, staff to strengthen JOC, and sports physician certified by the Japan Sports Association

Doctor's Edition

Plantar fasciitis is commonly seen in athletes such as marathoners.

Disease Overview

Do you know the sports disorder that the more the runners run, the sorer the soles of their feet become painful as much as you can run? Plantar fasciitis (tendonitis) is a repetitive running disorder commonly seen in athletes such as marathoners and is likely to result from overuse in plantar part.

Cause and mechanism of onset


The plantar aponeurosis holds an arch in the foot and act as a spring to absorb shock when loading.
Therefore, if the weight irritates the foot by running or jumping, the plantar aponeurosis is likely to degenerate the tendon due to repetitive traction stimuli and develop microtear or inflammation. At the time of touching ground, the toes distal to the plantar aponeurosis extend, and the proximal calcaneus is also stretched by the triceps surae - Achilles tendon. Foot alignment is also important. The athletes with flat feet are more likely to have pronation feet and aching pain at the arch. Conversely, the athletes with high arch are less flexible and tend to damage the aponeurosis. Some of the causes include overuse, hard road surfaces (surface changes), and shoe changes (heel-up is preferred).



Plantar pain when bearing weight is most commonly seen in the following three sites: (1) the origin of the aponeurosis close to the heel, followed by (2) the central region (arch) and (3) the distal portion (shown in the Figure). The pain is particularly likely to occur on rising or at the start of exercise. Functionally, the alignment of the lower leg and calcaneus bone axis (heel-leg alignment) should be corrected by checking whether it is pronated (central pain) or supinated (pain at the origin). Running after careful stretching exercise should be done at the beginning of the practice. In particular, the origin of the plantar aponeurosis at the medial aspect of the plantar area innervated by the lateral plantar nerve, that is a branch of the tibial nerve then it may be constricted by induced aponeurosis and tenderness, swollen and sometimes induration can be seen.

Plantar aponeurosis flame

Treatment and rehabilitation


In the acute phase, controlling local inflammation should be top priority. In any case, the first treatment choice is local rest (stopping running, and jumping exercises), followed by taking anti-inflammatory analgesics. Conventional steroid injection should not be done frequently. Physical therapy, such as low-frequency, interference wave, and low-intensity lasers, may be given directly or indirectly (to the lower leg) to the sole to relieve pain. At the scene of sports, the form of the plantar arch is functionally and anatomically corrected to relieve shock by stretching from the sole to the lower extremities (Photo 1), taping, and use of insoles (Photo 2). Recently, there are some reports that hyaluronic acid injection and extracorporeal shock wave therapy are effective.
If conservative treatment is difficult, and pain by osteophytes at the calcaneal bone insertion site is severe, excision of osteophytes would be done. The basis of training in the acute phase is to perform non-weight-bearing exercises that are less stressful to the feet. It is recommended to actively take underwater walking and exercise bike in the initial phase of rehabilitation.

Plantar stretch

Photo 1 Plantar stretch


Photo 2 Insole can be used to correct the arch morphology of the sole to relieve shock.

Yasuhiro Nakajima

Yasuhiro Nakajima

Head coach of Shonan Bellmares Sports Club Triathlon Team, Head coach of Triathlon Team of Nippon Sport Science University, and Chairman of the Japan Triathlon Union Multi-sports Committee

Trainer’s Edition

Prevention of injury and recurrence

Cause and remedy

Plantar aponeurosis inflammation results mainly from increased strain on plantar aponeurosis (overuse) due to increased training or weight gain, but it may also result from flat feet, high arches, pronation feet, or decreased muscle strength or flexibility in the soles of the feet. I have heard some stories that some marathon runners got spina on heel bone due to plantar aponeurosis inflammation and they were surgically removed. There are signs of plantar aponeurosis inflammation, so we need to cope with them as soon as possible without missing signs.
The symptoms may include a strong feeling of tightness or pain on the soles of the feet during walking immediately after awakening or after sitting for a prolonged time. The pain often goes away if the person continues to walk a while, and it often becomes advanced without doing anything. It is important to review the intensity and time of the training at that time.
It is also recommended for people with flat feet, high arches, pronation feet, or decreased plantar strength or flexibility, to reduce the strain by proactively using shoe insoles and tape, doing exercise to maintain and improve muscle strength such as towel gathers, and relaxation exercises, massage of the soles such as using golf ball and the bamboo step.
It is recommended to place the bamboo step in front of the washbasin and step it regularly when brushing the teeth.

On-site evaluation and first aid

A doctor may suspect plantar aponeurosis inflammation when a patient feels pain or discomfort while walking or as soon as the foot step on the ground when the patient continues training as described above, and when the patient feels pain or discomfort while walking.
If you have any of the above signs or pain, you may need to temporarily stop the sole-bearing training. It is recommended to ask the doctor to diagnose the problem and discuss whether to stop or reduce the training and when to return. Adequate icing should be done while the patient has inflammation or pain. If running needs to be stopped temporarily, cardiorespiratory endurance loss may be prevented by not stressing the soles of the feet, such as swimming or walking or cycling. Basically, thenar of the foot is put on the pedal when riding on a bicycle. If symptoms are severe, pedaling with the heel can reduce the strain on the sole.


Prevention of injury and recurrence exercises

First, stretching is preformed to relax the muscles that affect the plantar aponeurosis. Stretching of the flexors of the lower legs and toes (Photo 1) is the main focus, but fatigue accumulation and poor movement of the thighs may increase the strain on the lower legs and soles. Therefore, exercise should be careful to stretch the entire body and to improve the movement of the hip joint in different directions. Strong stretching or massaging of the plantar muscles may wait until the symptoms are relieved and stretching or exercising the upper part of the heel may reduce the strain on the soles.

As the symptoms become less severe, the plantar muscles are gradually strengthened. The first step is to allow the toes to move freely, with no stress at all. Move the toes to exercise “rock, scissors and paper”, open the toes wide, repel the toes, bend the toes, and move them freely (Photo 2). Next, exercise is performed using a towel or tube. The towel is pulled by the toes. At first, do it with a towel only, and along with the improvement of the symptoms a plastic bottle containing water is placed at the edge of the towel to increase the load. This exercise is called a towel gathering exercise. Tube exercises include not only plantar flexion and dorsiflexion, but also bending of the little toe down the inside (varus, plantar flexion) and raising of the little toe up from the outside (valgus, dorsiflexion) (Photos 3 and 4) to improve muscle strength to assist the arch.

In addition, exercise with a balance board or a balance disk (Photo 5) is performed to achieve stable muscle strength. Balance disk exercises include gently bending the knee and ankle joints and applying forces that help stabilize the ankle. Environmental considerations, such as shoes, floors, and ground surfaces, must also be taken into account. It is recommended to run on grass and soil. When a doctor gives the go signal to resume sports, the patient returns to competition, and an insole or an arch-assisted tape can be used for prevention.

Insoles are either ready-made or custom-made to fit the feet. Custom-made insoles respond to differences in foot shape among people, such as the shape of the left and right legs. In winter, I think there are many cases that the athletes involved in ball sports are particularly engaged in running. It is recommended to use running shoes instead of shoes for ball sports when training. The athletes who run on a road paved with asphalt should be particularly careful. Running with barefoot on the sand is a good use of the toes, so it is recommended to take even a short time to improve your athletic skills.

Photo 1: Stretching of the flexors of the toes (toes)

Photo 1: Stretching of the flexors of the toes (toes)

Photo 2: Toe (toe) training

Photo 2: Toe (toe) training

Photos 3 and 4: Towel gather (performed with slow, large movements)
Photos 3 and 4: Towel gather (performed with slow, large movements)

Photos 3 and 4: Towel gather (performed with slow, large movements)

Photo 5: Balance disk

Photo 5: Balance disk

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