Plantar fasciitis can be a nuisance to treat and, to date, we’ve had little high quality evidence to guide us. Today’s blog represents an exciting new direction in treating this stubborn condition. For some time we’ve noted the similarities between plantar fascial problems and tendinopathy. Back in 2006 Scott Wearing wrote an excellent paper on how the two structures shared similar pathology and similar response to load. However, no one has tested whether we might be able to treat plantar fasciitis like a tendinopathy, that is until now… Michael Rathleff and colleagues have just published an exciting new paper that is the first of it’s kind and represents a new treatment approach for plantar fasciitis, so I was delighted when Michael very kindly agreed to share his findings with us in a guest blog. Michael’s work includes excellent papers on hip strength and patellofemoral pain and patellofemoral pain in adolescents. To find out more about Michael’s research check out his Google Scholar Profile and follow him on Twitter via @MichaelRathleff.

Most of us who have experienced plantar fasciitis know first hand how debilitating and frustrating it can be. Every morning resembles being forced to walk on broken glass and you quickly become grumpy and dissatisfied. The prevalence in the general population is estimated to range from 3.6% to 7% [1 2], and may account for as much as 8% of all running-related injuries [3 4]. The life time prevalence may be as high as 10% which means that quite a big proportion of us will at some point be affected by plantar fasciitis or see these patients in the clinic.

Most previous treatment studies on plantar fasciitis have used a combination of orthotics, plantar specific stretching or similar non-exercise intervention. These interventions have proven successful to some degree and we know they are superior to placebo treatment. However a large proportion of patients still have symptoms two years after the initial diagnosis. Most clinicians who see these patients in the clinic will agree that they can be quite the challenge – especially if they have a long symptom duration. So we definitely need to start thinking about new effective treatments. An interesting thing is that we are starting to realise that there are some similarities between plantar fasciitis and tendinopathy. We know from the literature that high-load strength training appears to be effective in the treatment of tendinopathy [5]. A similar approach to plantar fasciitis therefore seems to be relevant to test. We recently completed a study where we investigated the effect of a high-load strength-training program compared to a standard plantar specific stretching program in the treatment of plantar fasciitis.[6]

Our main question before initiating the trial was how we could induce high tensile forces across the plantar fascia to resemble the loads induced to the patella tendon during e.g. single leg squat. Our approach was to exploit the windlass mechanism during single-leg calf-raises by using a towel to dorsal flex the toes. In theory, the windlass-mechanism would cause a tightening of the plantar fascia during dorsal flexion of the metatarsophalangeal joints while high-loading of the Achilles tendon is transferred to the plantar fascia because of their close anatomical connection [7-9].

We recruited 48 patients with ultrasonography verified plantar fasciitis. They were randomised to either high-load strength training or plantar specific stretching. In addition both groups received a short patient information sheet and gel heel-inserts. The patient information sheet covered information on plantar fasciitis, advice on pain management; information on how to modify physical activity; how to return slowly to sports and information on how to use the gel heel-inserts. On a side note, I think that one of the key things in successful management of plantar fasciitis is to educate the patient. The advice we used can be seen below in table 1.

Table 1: Advice given to the patients

The plantar-specific stretching protocol was identical to that of Digiovanni (2003) [10]. Patients were instructed to perform this exercise whilst sitting by crossing the affected leg over the contralateral leg (Figure 1). Then, while using the hand on the affected side, they were instructed to place the fingers across the base of the toes on the bottom of the foot (distal to the metatarsophalangeal joints) and pull the toes back toward the shin until they felt a stretch in the arch of the foot. They were instructed to palpate the plantar fascia during stretching to ensure tension in the plantar fascia. As in Digiovanni, patients were instructed to perform the stretch 10 times, for 10 seconds, three times per day [10].

Figure 1: Plantar-specific stretching

High-load strength training consisted of unilateral heel-raises with a towel inserted under the toes to further activate the windlass-mechanism (Figure 2). The towel was individualised, ensuring that the patients had their toes maximally dorsal flexed at the top of the heel-rise. The patients were instructed to perform the exercises every second day for three months. Every heel-rise consisted of a three second concentric phase (going up) and a three second eccentric phase (coming down) with a 2 second isometric phase (pause at the top of the exercise). The high-load strength training was slowly progressed throughout the trial as previously reported by Kongsgaard et al. [11]. They started at 12 repetition maximum (RM) for three sets. After two weeks, they increased the load by using a backpack with books and reduced the number of repetitions to 10RM, simultaneously increasing the number of sets to four. After four weeks, they were instructed to perform 8RM and perform five sets. They were instructed to keep adding books to the backpack as they became stronger.

A key clinical point is that the calf-raises need to be done slowly to decrease the risk of symptom flaring.

Figure 2: High-load strength training

We used the Foot Function Index as our primary outcome after three months but also did follow-ups after 1,6 and 12 months. At our 3 months follow-up we saw that patients randomised to high load strength training had a 29 points lower Foot Function Index. This is far greater than the minimal relevant difference and suggests a superior effect of high-load strength training compared to plantar specific stretching. An important aspect is that we saw no difference between groups at 6 and 12 months indicating no superior long-term effect. However, if you ask patients to choose between two treatments that have similar long-term effect but one will give you a quicker reduction in pain, I am certain that all patients would choose the treatment, which provides them with the quickest reduction in pain.

There are still lots of unanswered questions about why high-load strength training may work in the treatment of plantar fasciitis. One explanation could be that high-load strength training may stimulate increased collagen synthesis which help normalise tendon structure, increase load tolerability of the plantar fascia and thereby improve patient outcomes. Another explanation may be that the exercise help improve ankle dorsal flexion range of motion as well as improving intrinsic foot strength and ankle dorsal flexion strength. When I completed the high-load strength training program as part of our pilot studies I developed good DOMS in the intrinsics which suggest they are active during the exercise. The questions are many and hopefully other researchers will take a critical look at our findings and confirm or contradict our findings.

The loading paradigm for treatment of plantar fasciitis is by no means a miracle treatment. However, it does provide us with the first evidence that high-load strength training may be the road towards more effective treatments for plantar fasciitis. The key message to the patients is that they need to perform the exercises (otherwise they are unlikely to work) and they need to be performed slowly (3s up, 2s pause at the top and 3s down) to decrease risk of symptom flaring and with enough load starting by 12RM for three sets and working their way down to 8RM for five sets.


1. Hill CL, Gill TK, Menz HB, Taylor AW. Prevalence and correlates of foot pain in a population-based study: the North West Adelaide health study. J Foot Ankle Res 2008;1(1):2 doi: 10.1186/1757-1146-1-2[published Online First: Epub Date]|.

2. Dunn JE, Link CL, Felson DT, Crincoli MG, Keysor JJ, McKinlay JB. Prevalence of foot and ankle conditions in a multiethnic community sample of older adults. Am J Epidemiol 2004;159(5):491-8

3. Taunton JE, Ryan MB, Clement DB, McKenzie DC, Lloyd-Smith DR, Zumbo BD. A retrospective case-control analysis of 2002 running injuries. Br J Sports Med 2002;36(2):95-101

4. Lysholm J, Wiklander J. Injuries in runners. Am J Sports Med 1987;15(2):168-71

5. Malliaras P, Barton CJ, Reeves ND, Langberg H. Achilles and patellar tendinopathy loading programmes : a systematic review comparing clinical outcomes and identifying potential mechanisms for effectiveness. Sports Med 2013;43(4):267-86 doi: 10.1007/s40279-013-0019-z[published Online First: Epub Date]|.

6. Rathleff MS, Mølgaard CM, Fredberg U, et al. High-load strength training improves outcome in patients with plantar fasciitis: A randomized controlled trial with 12-month follow-up. Scand J Med Sci Spor 2014:n/a-n/a doi: 10.1111/sms.12313[published Online First: Epub Date]|.

7. Stecco C, Corradin M, Macchi V, et al. Plantar fascia anatomy and its relationship with Achilles tendon and paratenon. Journal of anatomy 2013;223(6):665-76 doi: 10.1111/joa.12111[published Online First: Epub Date]|.

8. Cheung JT, Zhang M, An KN. Effect of Achilles tendon loading on plantar fascia tension in the standing foot. Clin Biomech (Bristol, Avon) 2006;21(2):194-203 doi: 10.1016/j.clinbiomech.2005.09.016[published Online First: Epub Date]|.

9. Carlson RE, Fleming LL, Hutton WC. The biomechanical relationship between the tendoachilles, plantar fascia and metatarsophalangeal joint dorsiflexion angle. Foot Ankle Int 2000;21(1):18-25

10. DiGiovanni BF, Nawoczenski DA, Lintal ME, et al. Tissue-specific plantar fascia-stretching exercise enhances outcomes in patients with chronic heel pain. A prospective, randomized study. J Bone Joint Surg Am 2003;85-A(7):1270-7

11. Kongsgaard M, Kovanen V, Aagaard P, et al. Corticosteroid injections, eccentric decline squat training and heavy slow resistance training in patellar tendinopathy. Scand J Med Sci Sports 2009;19(6):790-802 doi: 10.1111/j.1600-0838.2009.00949.x[published Online First: Epub Date]|.


  1. Hello Tom – thank you very much for passing this along, this is brilliant! As you & I discussed briefly, in our internal trials we had found that strengthening the toe flexors / intrinsics and eccentrically loading the plantar fascia had great results on PF (9 out of 10 returning to normal activity). The main difference is that we had subjects starting fully plantar-flexed / toe flexed against resistance and then eccentrically loading all the way through to full dorsiflexion / full toe extension. I’ll get in-touch with Michael and pass-along our findings. Thanks again Tom, Running Physio is such a great resource for patients and practitioners.

  2. I suffered this a few years ago and it still plays up if I don’t wear the correct shoes .
    Losing weight for me has been the major reason for the condition being manageable these days . I did these types of exercises and after would roll a bottle of frozen water back and forth under my feet .

    It really is something that gives warning , any foot pain first thing in the morning should be treated asap .

    I worked standing so by the days end I was actually crawling around the house the pain was so bad .

    Not something I wish on anyone .

  3. This is exciting Tom. Given the overlap in patho-anatomy b/w PF and AT injuries a natural progression should exist with some cross-over for treatment. Thanks as always for sharing.

  4. Thank you for this paper. How is this approach different from the eccentric training protocols that many of us have been using the past few years? I know the eccentric protocols are having patients perform the exercises everday, but other than that, I don’t see much of a difference. You’re reply is appreciated.

    • Hi Sam,

      Thanks for your comment and interest in our paper. An eccentric exercise protocol targets the eccentric part of an exercise, while our loading paradigm consists of both concentric, isometric and the eccentric contraction phase.

      At least in Denmark and surrounding countries I have not heard that an eccentric training program have been commonly used to treat plantar fasciitis (only achilles tendinopathy). Would be great if you could elaborate.


      • Hi Michael-

        Thank you for the response.

        I cannot speak for all of the U.S., but it has been relatively common where I live for PTs to utilize eccentric strengthening (often preceded by IASTM) when patients present with plantar fasciitis. Those of us utilizing this protocol are basing it on anecdotal evidence. As another person who posted mentioned, we tend to use 3 sets of 15 reps two times per day, and the load is increased when minimal discomfort is experienced.

        I have also heard interviews with physios from Australia who utilize eccentric training for plantar “fasciosis,” as some say it should be called.

        Kind regards.


        • Dear Sam,

          This sounds very interesting. Can you send me a link to the protocol with pictures or a description of how the eccentric strengthening is performed?


  5. I’m dissapointed. I can think of a thousand things that may compare favourably to non loaded, self stretching with a small lever arm. Does anyone really give those stretches?? I would like to see how the loading programme compares to active and dynamic stretching in weight bearing as prescribed routinely in clinical practice. I suspect there would be little difference.

    • Hi Mark, thanks for your comments. I understand your point but actually the research doesn’t support weight-bearing stretching. If you read the review by Sweeting et al. (2011) or the work of DiGiovanni et al. (2003 and 2006) you’ll see where evidence exists for stretching it’s in the favour of the plantar fascial stretches used in Michael’s study.
      Generally the evidence for treatment of PF has been poor and so I think we need to give credit to people making the effort to research new directions based on current theory.

  6. Nice Paper, thank you!
    I know this program similar to the high load excentric training we do for tendinopathy (Achilles tendon, Patella tendon) for 3 Sets, 15 Reps, rythm 1 sec concentric, 3-5 excentric, 1-2sec break at highload position. 3 up to 6 times per Day. Performed for 12 Weeks.

    Why this diffrence in treatment? Isnt it basically similar to the other Tendinopathies?

    Kind regards, Beat

    • Hi Beat,

      Thanks for your comment. There is still a bit of debate about the optimal dosage in treating tendinopathies. Peter Malliaras and colleagues gives a nice overview of the different loading paradigms used in the literature:
      Malliaras et al. Achilles and patellar tendinopathy loading programmes : a systematic review comparing clinical outcomes and identifying potential mechanisms for effectiveness.

      The older loading paradigm by Alfredson was twice daily while some of the newer studies use 3 weekly or every second day with one of the goals to get a good balance between loading and adaptation.


  7. Nice paper, thank you!

    We treat the plantar fasciitis similar to achilles tendinopathy with heavy load eccentric training, 3 sets 15reps, eccentric phase is 3-5 sec and a 2 sec break in the lower position.
    Great results after 6-12 weeks.

    Why is your strength program diffrent to the existing heavy load theories? Is there a certain reason you didn’t take the normal dose? Let me know – maybe we can improve our results. Or we can all improve results with achilles and patella tendinopathy.. 🙂

    • Hi Beat,
      Are you guys performing the same exercise as Tom highlights in this article? AKA are the toes maximally dorsal flexed at the top of the heel-rise or is it just a basic heel rise?
      Thanks, I would be interested to learn.

      • gold. I think this is great advice. I am also one church hda dragon attack. I will return to the site soon. 1 Once again thank you for the article…

  8. Hi Tom and Michael
    Thanks for an excellent article and very interesting paper. I have a question about planter fascitiis and heel spurs. I cant seem to find any good research on this matter. I see that planter fasciitis may sometimes cause a heel spur by the entethesis pulling on the calcaneus, But of course not all patients with PF have a heel spur and some people without pain at all can also have heel spurs. My question is: Do heel spurs cause pain and is there any research on this matter?

  9. I just have a couple of small questions. If ”An important aspect is that we saw no difference between groups at 6 and 12 months indicating no superior long-term effect. ” and there is no difference in the thickness of the plantar fascia after treatment then one wonders whether the result is a short term pain modulation masking the underlying conditon rather that a treatment that fixes things. I do understand that this is not a tendon but rather a quasi ligamentous structure. The question I have is that if the foot takes up to 3-4 times body weight through the plantar fascia when running then why wouldn’t one opt for a treatment that was better able to replicate and train this? It would seem that the slow heavy resistance type training program might replicate the forces at play more realistically while avoiding the acceleration components that might be aggravating. Since the evidence does not support the research being discussed as being ”superior” what do you think the next direction would be to look at or go in? Do you think that this one study is enough of a basis to have people change their treatment methods?



  10. Is there anywhere or anyway to access the journal article for free? I’m a PTA student currently doing a rotation in an ortho based OP clinic and was interested in conducting an inservice based on the findings in this article and comparing them to the techniques used by the staff at the clinic. Thanks

  11. Had plantar fasciitis a couple of years ago, saw numerous physio’s, did numerous stretches had conflicting advice, but the best advice came fron a junior physio who said ‘Get back running it will burn itself out’ SO I DID AND IT DID!
    No insoles, strapping or stupid stretches with towels / tennis balls needed. Now completely healed up!

    • I was told the same thing by an Ortho. I think that is the best advise. I did the all the stand stuff just to come back to the same conclusion. I hope it burns out soon. I can run about 7 miles before the pain sets in, I can’t run as fast yet though. I have been trying these eccentric lifts with the towel. It helps but not a cure per se.

  12. Great — thanks! Just started tonight!

    Quick question: should stretching be done IN ADDITION to the exercises? Or should I just do the exercises alone?

    I’ll keep you updated with my progress. Thank you!!!

  13. Hi Michael,

    Great paper, I’ve been getting some good results with this – I must admit I’ve usually been a bit more reserved with loading too much. But by taking consideration from Cooks suggestion of compression playing a role in tendinopathy and utilising this to reduce compression factors at calcaneus, this appears to work quite well. Future studies of PF loading using sub groups and variation to load would be interesting.

  14. Hi! I agree this is a very interesting and exciting study. I’ve learned a lot and am eager to try this approach (although I admit I know nothing of tendinopathy yet but will explore it too!)

    Just a quick question, during the course of your study, have you observed if there is any other treatment that complements or supports the outlined approach here– and yield the best results in terms of alleviating pain from PF?

    Thank you again.

  15. Hi Tom,

    I am rehabbing my knees as I have bilateral patellar tendinopathy so I can vouch for the effectiveness of eccentric loading protocol.

    I have picked up an acute case of PF in my arches (actually it is tendinosis of the flexor hallucis longus to be precise) as a result of probably gojng too hard and fast at a combination of barefoot squats on a slanted board + lots of barefooted leg exercises. Accordingly, I am very interested to see how this protocol can rehab my feet.

    2 questions if you are able to answer:
    1) my current first ever case of PF started 2 weeks ago, i have daily pain in both feet but it is reducing 5% or so each day now. At what stage could I start this protocol do you think? Assuming I am still in the acute injury phase Do I still need to rest the tendon for a few more weeks?

    2) my pain is coming directly from the flexor hallucis longus…..specifically from in between the arch to where the tendon attaches to the ball of the foot (big toe). Would I be right in stating it is this very tendon which is maximally dorsal flexed – and subsequently loaded – during this loading protocol highlighted in your article? Nett: if anything, this exercise will be more relevant for me?


  16. For the “high-load strength training” were the subjects performing the concentric phase of the exercise on both feet and then the eccentric on 1 foot? This is what the picture depicts, but the wording makes it sound as if both the concentric & eccentric phases were done on a single leg.


  17. Pretty good article. I think what works for some doesn’t for others. I think its worth mentioning, if it hurts too much for too long don’t do it. Some people become worse for wear after all the stretches, some need just cold and rest and others keep running to work through the pain.

  18. We need to be cautious before hailing this paper as the new great treatment. In this paper there were no differences between groups at 1, 6, and 12 months. At 12 months, the Foot Function Index score was actually lower in the stretch group. So if all our patients were just interested in how they functioned at 3 months post commencement of treatment it may be more relevant. There could be a variety of reasons for this transient difference at 3 months including chance, the sensitivity of the instrument, sample size etc. There may have been no difference at 4 months and it was a transient ‘blip in the data. Perhaps an explanation of reported improvements at 3 months but not at 1,6 & 12 should have been hypothesised in relation to the high-load’ model.

    Too often we are told of the next great step in treatment based on limited science and then have to readjust it and confuse our patients yet again. It’s great to see this type of research but the authors need to temper their enthusiasm for their theory with the scientific rigour behind the results and accept the limitations of the study. 48 subjects randomised to two Rx groups is only 24 subjects per group and their are several reasons, as previously discussed, why there may be a difference at one time point, including chance, before we all jump on the bandwagon that this is the next new panacea. We all acknowledge that some form of loading is important during rehabilitation of injured structures but the evidence of this type of loading over other forms is still conjectural based on the current evidence.

  19. […] single leg calf raises with toweling following the recommendations in this article: The study observes effect over 3 months; I hope it doesn’t take me that long to resolve the […]

  20. Is it possible to get video on these exercises being done, I find it helps so I am doing them properly, thanks

  21. Enjoyed the article and study design. I am not surprised with your study outcome but don’t see any commentary on the role of the exercise you chose in strengthening and stretching the soleus muscle, (which, in my experience and that of others in sports medicine, physical therapy, osteopathsy, podiatry, Asian medicine and strength and conditioning), is causative to plantar fasciitis.

    Travell and Simmons identified the soleus trigger points role in plantar fasciitis 30+ years ago.

    Your exercise would also be prescribed for soleus/gastroc therapy and the stretch aspect of the motion, would decrease tension through Achilles and plantar surface as well- as it has done in your study.

    Also, regarding your suggestion for a gel heel support, I’d like to ask if you have experience with the “lemon wedge” shape arch supports in alleviating heel/plantar pain? I find them to be most effective, but particularly for those whose plantar fasciitis is not just in the heel but in the arch and other areas of the foot. Have you any experience with different types of supports that lead you to like the heel support the best?

    items such as this:

    Look forward to your reply

    Thomas H. Bailey Jr. D.O.M, A.P., L.M.T Florida, USA

  22. Hi, there. I have a question.

    I’m pretty sure I have insertional achilles injuries in both legs (they really flared up after a 2-hour walk up a volcanic island in Auckland), and I’ve been using standard straight-leg eccentric loading (up on two legs, down on one) to improve it. I’ve done that in the past and it worked.

    I also have a bit of plantar fascia pain in my right foot. Not major, but it’s a concern.

    My question is, would this variation on the eccentric exercise work to help both my achilles *and* my plantar fasica at the same time? I’m assuming the achilles is still worked, even when the toes are dorsiflexed?

    Even with the standard exercise (without the toes dorsiflexed), I can feel the plantar fascia being worked, but perhaps not as much as if my toes were dorsiflexed as a above.

    Looking forward to your reply!

    I notice even with the standard exercise I’m doing, the plantar fascia is worked.

    • Hi Chris,

      Insertional tendionopathy is a different animal to mid portion, and you need to ensure that there is no associated systemic cause with these e.g seronegative arthropathy. Eccentric programmes for insertional problems are advised to be to neutral only and not below the level. It can also be associated wth a retrocalcaneal bursitis. Have you had an ultrasound to look at it? They also do quite well with shockwave therapy if not settling (as does plantar fasciopathy!)


  23. Thanks so much for bringing us your wonderful paper. In fact, I used to be a victim to Plantar Fasciitis for such a long time. Its symptoms are not too easy to be recognized but its consequences on our health and body are extremely serious. That’s the reason why physical exercises play such a vital role in curing this condition. The exercises that the author recommends in this article, for me, is practical and helpful for me and those who get Plantar Fasciitis. But there is one thing that everyone should notice is that the calf-raises need to be done slowly to decrease the risk of symptom flaring.

  24. As someone who has suffered from plantar fasciitis many time throughout my life it’s great to see a new technique to try out. I think I am going to try these calf raises tonight after work.

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