Plantar Fasciitis

What is Plantar Fasciitis?

Plantar fasciitis is a condition in which the origin of the plantar fascia, where it attaches to the heel bone, becomes irritated and degenerates. The plantar fascia supports the arch and absorbs shock when you walk.^[1] Despite the "-itis" in the name, tissue studies show mainly chronic degenerative change rather than active inflammation.^[2]

Common symptoms

The classic symptom is sharp pain at one spot on the heel, usually worst with the first steps of the day or after prolonged standing.^{[1, 3]}

• Pain that eases as you warm up and may return after long periods on your feet
• Tenderness at the bottom of the heel, sometimes along the arch
• Occasionally a heel spur visible on an X-ray^[1]

Causes and risk factors

Plantar fasciitis has several causes, and most cases result from overuse stress.^[1] Repetitive strain from running or long hours standing on hard surfaces, reduced ankle flexibility, and mechanical load on the foot are the factors most often cited.^[2] Higher body weight, flat or high arches, tight calf muscles, unsupportive footwear and age between about 40 and 60 are also commonly listed.^[1]

How it is diagnosed and treated conventionally

Plantar fasciitis is diagnosed from your history and examination. Routine imaging is not recommended at first and is used mainly to rule out other causes of heel pain.^[3] Ultrasound can show a thickened fascia.^[2]

Most people improve with non-surgical care, with over 80% improving in one review, although it can be slow and recurrence is frustrating.^{[1, 2]} A best-practice guide based on a systematic review and expert opinion suggests taping, plantar fascia stretching and education as the core approach. Shockwave therapy and custom orthoses are the next steps for people who do not improve.^[4] Injections and surgery are reserved for stubborn cases.^[2]

Why Plantar Fasciitis calls for a whole-person approach

Plantar fasciitis is not just a sore spot on the heel. How the whole leg moves, how much load the foot carries and how the tissue responds over time all affect how long it lasts, which is why it is "not easy to treat" for many people.^[1]

Care that looks at these factors together is a reasonable addition to the treatment your clinician directs.

Load and overuse

Most cases come from overuse stress, so running volume, standing time and surface all matter.^[1] Gradual changes in activity are part of standard advice.

Tight calves and limited ankle movement

Reduced ankle dorsiflexion, the ability to bring the foot up toward the shin, is a recognized contributor alongside repetitive stress.^[2] This is one reason stretching and physical therapy for the calf and foot are central to care.^[4]

Tissue change rather than inflammation

Because the problem is mainly degenerative, treatments aimed only at calming inflammation may not be enough.^{[1, 2]} Taping, stretching and education are the core of best-practice guidance.^[4]

Body weight and footwear

Excess weight and unsupportive or worn-out shoes add load to the heel and are standard risk factors.^[1] These are matters to review with your physician or podiatrist alongside any complementary care.

Acupuncture for Plantar Fasciitis

What the research shows

Acupuncture may reduce heel pain in the short term, but the evidence is limited and comes from small trials of mixed quality. A 2012 systematic review of 5 randomized and 3 non-randomized studies reported that the higher-quality studies showed significant benefit, including improved pain and function when acupuncture was added to standard treatment.^[5] A 2017 review found three trials against standard treatment and one against sham acupuncture. They showed less pain between four and eight weeks, with minimal side effects, but there was not enough evidence to draw conclusions about longer-term effects.^[6]

Individual trials point the same way. In a trial of 120 people with long-lasting plantar fasciitis, 56.7% of those who received acupuncture had at least 50% less pain at week 4, versus 33.3% of a no-treatment waiting list. The effect continued to week 16 and was larger with high-intensity acupuncture.^[7] In an 80-person trial, six sessions of electroacupuncture with warm needling reduced first-step pain more than waiting-list controls, and no related adverse events occurred.^[8] A trial of 30 people found that electroacupuncture added to conventional treatment gave a higher success rate than conventional treatment alone, with benefit lasting at least six weeks.^[9]

Electroacupuncture was not better than manual acupuncture in a trial of 92 people. Both groups improved over 4 weeks of treatment.^[10] Most of these trials compared acupuncture with waiting lists or usual care, so some of the improvement may reflect expectation and the natural course of the condition.

A related technique, dry needling of trigger points, is not acupuncture, but a meta-analysis of 6 trials found low- to moderate-quality evidence that it reduces heel pain and disability. The authors advised caution because few trials were available.^[11]

How acupuncture may work

We did not find a study explaining how acupuncture works in plantar fasciitis specifically. In general pain research, acupuncture is proposed to strengthen the body's pain-inhibiting pathways, act on several signaling pathways including the endogenous opioid system, and locally lower inflammatory chemicals.^[12] These are proposed explanations, not settled facts.

What treatment involves

Treatment uses fine, sterile, single-use needles placed around the heel and foot, along the calf and lower leg, and at points elsewhere on the body, usually left in place for about 20 to 40 minutes. The trials above gave 6 to 12 sessions over about four weeks. A typical course involves several visits with reassessment.^{[8, 10]}

Serious problems are rare. In prospective studies, about 9 in 100 patients had a minor reaction such as brief bleeding, soreness or redness at a needle site, and serious events occurred in about 1 in 10,000 patients.^[13] Tell the practitioner first if you have a bleeding disorder, take blood thinners, are pregnant, or have a pacemaker (relevant to electroacupuncture). Needling a painful heel can briefly be uncomfortable.

Ayurvedic medicine for Plantar Fasciitis

The Ayurvedic view

In Ayurveda, heel pain with a pricking sensation is described as Vatakantaka, a Vata-type disorder named for a thorn-like pain in the foot, traditionally linked to improper foot placement and strain.^[14] Vata is the principle said to govern movement. These are traditional categories, not biomedical diagnoses.

Therapies that may be used

Care is chosen for the individual and traditionally combines:

• Diet and daily routine intended to calm Vata, such as warm, regular meals and steady sleep hours
• Warm oil massage of the feet and calves, and warm foot soaks
• Herbs used traditionally for pain and stiffness, prescribed individually by a practitioner

Herbal preparations applied to the skin (transdermal medication therapy) may be considered for local heel pain. We make no claim of benefit for it. Panchakarma procedures are not appropriate during pregnancy, acute illness or frailty, and are not usually needed for heel pain.

What the research shows

The research on Ayurveda for plantar fasciitis is very limited. We found no clinical trials and no systematic reviews. The only published reports are single-patient case reports, one on a calcaneal spur and one on a related heel condition, using procedures such as bloodletting, needle-piercing and therapeutic heat that are not part of the care described here.^{[14, 15]} Case reports cannot show that a treatment caused improvement.

Herbal medicine for Plantar Fasciitis

Herbs and formulas that have been studied

No herbal medicine has been tested in plantar fasciitis in the research we found. The nearest evidence concerns turmeric (Curcuma longa, or its component curcumin) and the ginger family for pain in general and for musculoskeletal pain. Chinese herbal formulas are also used traditionally for foot and heel pain, but we have no plantar fasciitis studies to cite.

What the research shows

Evidence from pain studies of other types does not establish a benefit for heel pain. A meta-analysis of 8 placebo-controlled trials found that extracts of turmeric, ginger and related plants reduced chronic pain, mostly in other conditions.^[16] A systematic review of curcuminoids for musculoskeletal pain found insufficient evidence to recommend them, citing small, short trials of variable quality.^[17]

Safety and herb-drug interactions

Herbs are active substances and can interact with medicines. Case reports describe bleeding when warfarin was combined with herbs including ginger, dang gui (Angelica sinensis), dan shen (Salvia miltiorrhiza) and Boswellia.^[18] Reviewers of ginger-family extracts also note a raised bleeding risk, as with anti-inflammatory drugs, that has not been compared head to head.^[16] People taking blood thinners or anti-inflammatory drugs need a practitioner's review before using herbs for pain.

In one study, about one fifth of Ayurvedic products bought online contained detectable lead, mercury or arsenic.^[19] Herbs should come from tested sources. Tell us if you are pregnant or breastfeeding, have liver or kidney disease, or have surgery planned.

Translating traditional medicine into modern biological language

The links drawn here are interpretation, not equivalence. Chinese medicine describes chronic heel pain as obstruction of qi and blood in the channels of the leg and foot, sometimes with Kidney deficiency, since the Kidney channel begins on the sole of the foot. Researchers studying acupuncture for pain measure things that loosely parallel this picture: local inflammatory chemicals and the way the nervous system processes pain.^[12]

Ayurveda's aggravated Vata describes pricking, thorn-like pain that limits walking.^[14] No study has shown that a dosha corresponds to a specific biological process.

How this care fits with your medical care

Integrative care for plantar fasciitis is complementary. Keep your physician, podiatrist or physical therapist, and continue the stretching, footwear and activity advice you are given. Do not stop or change prescribed medicines or injections without your prescriber. We do not diagnose the cause of heel pain, so new or worsening heel pain should be medically evaluated.

Please bring your diagnosis, any X-ray or ultrasound reports, a full list of medicines and supplements, and details of any injections, orthotics or surgery.

When to seek urgent medical care

Some heel and foot symptoms point to a problem other than plantar fasciitis, such as a fracture, infection or nerve or circulation problem.^[3]

• Sudden severe heel pain after an injury, or inability to bear weight
• A hot, red, swollen heel or foot, especially with fever or chills
• Numbness, tingling or burning across the foot that is spreading or getting worse
• A cold, pale or blue foot, or a foot wound that is not healing, especially with diabetes
• Heel pain at night or at rest that is steadily worsening, or with unexplained weight loss

If any of these occur, call 911 or go to the nearest emergency department.