Plantar Fasciitis: An Evidence‑Based Look at What Actually Works

Plantar fasciitis is one of the most common causes of heel pain, yet it remains one of the most misunderstood. Many patients arrive frustrated after months—or even years—of stretching, orthotics, rest, cortisone injections, or being told to “just give it time.”

The problem isn’t that these options never help. It’s that chronic plantar fasciitis is rarely just an inflammation issue. In most persistent cases, it’s a tissue capacity and loading problem.

This article explains the major treatment options patients should understand—and why our clinic uses a multi‑modal, evidence‑based approach frequently combining focused shockwave therapy with progressive loading strategies.

Understanding Chronic Plantar Fasciitis

In the early stages, plantar fasciitis may involve reactive inflammation. However, when symptoms persist beyond several weeks, research increasingly describes the condition as a degenerative or failed healing response of the plantar fascia rather than ongoing inflammation.

In simple terms:

• The tissue has lost load tolerance

• Blood flow and cellular signaling are impaired

• Pain persists not because the foot is weak, but because it can no longer handle normal daily stress

This distinction matters—because treatments aimed solely at reducing pain often fail to restore tissue health.

Common Treatment Options (And Their Limitations)

Stretching

Stretching can reduce short‑term discomfort and improve ankle mobility, but stretching alone does not rebuild tissue capacity. In chronic cases, stretching without strengthening may even prolong symptoms.

Orthotics and Shoe Inserts

Orthotics can reduce strain temporarily and may be helpful during painful phases. However, evidence shows mixed long‑term outcomes, especially when orthotics are used as a stand‑alone treatment. Inserts reduce load—but they do not teach the tissue to tolerate load again. For chronic cases we more often than not take orthotics out of the equation for a period of two weeks (and often see immediate symptomatic improvements...).

Rest

Relative rest can calm acute symptoms (think days not weeks), but prolonged rest leads to further deconditioning. Once normal activity resumes, pain often returns.

Corticosteroid Injections

Corticosteroid injections may reduce pain in the short term, but research raises concerns about recurrence, tissue weakening, and plantar fascia rupture. For this reason, injections are generally not considered a first‑line solution for chronic plantar fasciitis.

Why We Take a Different Approach

At Marathon Spine & Wellness, our goal isn’t just symptom relief—it’s restoring the foot’s ability to handle load.

That requires addressing two key components:

1. Tissue healing and biological signaling

2. Progressive mechanical loading

This is where focused shockwave therapy and structured loading strategies work best together.

Focused Shockwave Therapy: Stimulating Healing

Focused shockwave therapy delivers controlled acoustic energy into injured tissue. In chronic plantar fasciitis, this has been shown to:

• Increase local blood flow

• Stimulate cellular repair mechanisms

• Improve collagen remodeling

• Reduce pain sensitivity

Shockwave is not a painkiller. Its value lies in helping restart a stalled healing process—particularly in long‑standing cases where the tissue has failed to recover on its own.

Importantly, shockwave works best when paired with appropriate mechanical loading, not in isolation.

Progressive Loading: Teaching the Tissue to Tolerate Stress Again

Tendons and fascia do not heal through rest alone—they heal by being loaded correctly over time.

We guide patients through a structured progression based on current tendon and fascia research:

1. Isometrics

Early‑stage loading often begins with isometric exercises, where the foot generates force without movement.

Benefits include:

• Pain reduction

• Improved neural activation

• Safe introduction of load without aggravation

2. Concentric Loading

Once symptoms stabilize, we introduce concentric strengthening, where the muscle shortens while producing force.

This phase:

• Builds foundational strength

• Improves motor control

• Prepares tissue for higher demands

3. Eccentric Loading

Eccentric exercises—where the muscle lengthens under load—are a cornerstone of plantar fascia rehabilitation.

Eccentrics help:

• Improve tissue resilience

• Restore energy storage capacity

• Reduce reinjury risk

4. Functional and Activity‑Specific Loading

Finally, loading is progressed toward real‑world demands such as walking, work tasks, running, or sport. This ensures the tissue can tolerate the stresses that originally caused pain.

Why Education and “Self‑Treatment” Matter

A major reason plantar fasciitis becomes chronic is that patients are never taught how to manage load outside the clinic.

We emphasize education so patients understand:

• When to push vs. when to modify activity

• How footwear affects loading

• How to progress exercises safely

• How to prevent recurrence

This empowers patients to take control of their recovery rather than relying on endless passive treatments.

Treating the Entire Kinetic Chain (Not Just the Heel)

Plantar fasciitis rarely exists in isolation. In many patients, excessive stress on the plantar fascia is driven by limitations higher up the posterior chain—including the calf complex, Achilles tendon, hamstrings, and even the knee or hip. If the ankle lacks adequate mobility or the calf cannot absorb load efficiently, stress is often transferred directly to the plantar fascia. Over time, this compensatory overload contributes to tissue breakdown and persistent heel pain. For this reason, our assessment frequently extends up the leg and beyond the foot, depending on each patient’s movement quality and mobility restrictions.

Manual and Soft Tissue Interventions

As part of a multi‑modal approach, we may incorporate targeted therapies to improve tissue extensibility, reduce abnormal tone, and restore movement capacity, including:

• Dry needling to address myofascial trigger points, reduce protective guarding, and improve neuromuscular activation

• Instrument‑Assisted Soft Tissue Mobilization (IASTM) to improve tissue glide and stimulate local healing responses

• Myofascial release techniques focused on the plantar fascia, calf, Achilles, and posterior chain as indicated

These interventions are not used as stand‑alone treatments. Their role is to create short‑term improvements in movement and pain, allowing patients to more effectively perform strengthening and loading exercises.

Ankle Mobility and Mechanics Matter

Proper ankle dorsiflexion and foot mechanics are critical for normal gait and load distribution. Restrictions at the ankle often lead to compensations that overload the plantar fascia.

We address this through:

• Targeted mobility drills

• Joint‑specific interventions when appropriate

• Reinforcement of efficient walking and movement mechanics

Restoring ankle mobility helps ensure that loading forces are shared appropriately across the foot and lower limb rather than concentrated at the heel.

Not All Heel Pain Is the Same

One of the most important—and least discussed—truths is that not every plantar fasciitis case responds the same way.

Factors such as:

• Tissue quality

• Duration of symptoms

• Prior treatments

• Activity demands

all influence outcomes.

That’s why we focus on determining who is most likely to respond to shockwave and progressive loading before beginning care. Older age, history of diabetes or smoking, and activity levels are major factors in one's ability to improve their symptomatic presentation.

The Bottom Line

Chronic plantar fasciitis is rarely solved by a single treatment. Evidence increasingly supports a combined approach that restores tissue health and rebuilds load tolerance.

By pairing focused shockwave therapy with structured, progressive loading strategies, our goal is not just to reduce pain—but to help patients walk, work, and exercise confidently again.

If you’ve tried the usual options and are still dealing with heel pain, the most important next step is determining whether your foot is a good candidate for this approach.

That decision—more than any single treatment—is what ultimately drives results.