Plantar Fasciitis: The Runner’s Complete Evidence-Based Guide

Updated May 2026. Written by the Upwell Health Collective clinical team. Clinically reviewed May 2026. Next review due November 2026. For educational purposes only.

The runner’s most common heel problem — and why so many get the management wrong

Plantar fasciitis is one of the most frequently encountered musculoskeletal conditions in both runners and the general population. It contributes to approximately 15% of all foot pathology and is particularly prevalent in runners, affecting people across a wide age range and activity level. The characteristic presentation — sharp, stabbing heel pain with the first steps of the morning or after prolonged sitting, gradually easing with movement but returning with sustained activity — is so consistent that most runners self-diagnose it before they see a clinician.

The self-management that typically follows that self-diagnosis, however, is frequently wrong. Stretching aggressively. Complete rest from running. Expensive orthotics as the only intervention. Cortisone injections as a first-line treatment. These are the approaches that keep runners in a prolonged cycle of partial improvement and recurrence — when the evidence-based approach produces consistently good outcomes.

This is the complete guide. What plantar fasciitis actually is, what the current 2023 AOPT clinical practice guidelines recommend, the most effective interventions, and how runners specifically should manage load and return to training.

What is plantar fasciitis?

The plantar fascia is a thick band of connective tissue — actually a specialised aponeurosis — that spans the underside of the foot from the heel bone (calcaneus) to the base of the toes. Its primary mechanical function is to maintain the longitudinal arch of the foot during weight-bearing and to act as a tension spring that stores and returns energy during walking and running. The Windlass mechanism — the way the plantar fascia tightens as the toes extend during push-off — is one of the key mechanisms of normal foot function.

Plantar fasciitis, despite its name, is increasingly understood as a degenerative rather than purely inflammatory condition — particularly in chronic presentations. Like Achilles tendinopathy, the histological picture of chronic plantar fasciitis shows collagen disorganisation and degenerative matrix changes rather than the classical cellular inflammatory infiltrate. The 2025 comprehensive evidence-based treatment review (Nweke, Cureus, PMC12294660) confirms this updated pathophysiological understanding.

In runners, plantar fasciitis is most commonly associated with:

• Repetitive high-volume loading of the plantar fascia beyond its tolerance
• Sudden increases in running volume or intensity
• Tight calf musculature limiting ankle dorsiflexion (which increases plantar fascia tension during running gait)
• Weak intrinsic foot muscles and reduced foot arch control
• Training on hard surfaces
• Running in worn-out shoes with inadequate heel cushioning
• Rapid transition to lower-drop footwear

How to tell if it’s plantar fasciitis

The clinical diagnosis of plantar fasciitis is based on history and examination. Imaging is generally not necessary for initial diagnosis in typical presentations.

The classic features:

• Localised heel pain, typically at the anteromedial calcaneal tuberosity (the medial heel, not the centre or back of the heel)
• First-step pain: worst pain with the first steps of the morning or after prolonged sitting. This “post-static dyskinesia” is one of the most diagnostically useful features
• Pain that warms up with activity but returns with sustained loading or after activity
• Tenderness on palpation at the medial calcaneal tuberosity (where the plantar fascia inserts into the heel)
• Positive Windlass test: dorsiflexing the toes while the patient stands and pressing on the plantar fascia produces the concordant pain

Red flags that suggest an alternative or additional diagnosis:

• Heel pain that is bilateral and symmetric in a young athlete — consider calcaneal apophysitis (Sever’s disease) in adolescents
• Burning, shooting, or tingling pain — may suggest Baxter’s nerve entrapment (a branch of the lateral plantar nerve running under the heel) or tarsal tunnel syndrome
• Pain that does not follow the first-step pattern and does not ease with movement — may suggest calcaneal stress fracture
• Positive heel squeeze test (pain with medial and lateral calcaneal compression) — calcaneal stress fracture

What the 2023 AOPT Clinical Practice Guidelines recommend

The Heel Pain – Plantar Fasciitis: Revision 2023 clinical practice guidelines (JOSPT, November 2023) are the most current evidence-based guidance for plantar fasciitis management. They represent the consolidated evidence from systematic reviews and RCTs across the full range of treatment options and carry A-level (strong) and B-level (moderate) recommendations.

A-level (strong) recommendations:

• Manual therapy directed at the joints and soft tissue structures of the lower extremity to address relevant joint and flexibility restrictions, decrease pain, and improve function. This includes joint mobilisation of the ankle and midfoot, and soft tissue work to the plantar fascia and calf.
• Stretching of the plantar fascia and calf musculature — specifically, a non-weight-bearing plantar fascia stretch (pulling the toes into extension to stretch the fascia before the first steps of the morning) and calf stretching to address dorsiflexion restriction.
• Foot orthoses — custom or prefabricated — to reduce symptoms and improve function. Prefabricated orthoses are supported by the evidence and are not inferior to custom devices in most cases.

B-level (moderate) recommendations:

• Night splints for patients with symptoms lasting longer than 6 months, to maintain passive dorsiflexion stretch overnight and reduce morning first-step pain.
• Therapeutic taping (low-dye taping or calcaneal taping) for short-term pain relief and facilitation of activity.
• Progressive loading and strengthening exercise — calf strengthening, intrinsic foot muscle exercises, and lower extremity strengthening to address contributing weakness.

The 2023 CPG does not support early corticosteroid injection as a first-line treatment. Cortisone may provide short-term benefit but does not produce superior medium-term outcomes compared to other treatments, and carries a small risk of plantar fascia rupture. It is most appropriate for cases refractory to initial conservative management at 6 to 12 weeks.

The runner-specific approach: loading the plantar fascia

For runners specifically, the management approach needs to account for the fact that running itself loads the plantar fascia significantly with every step. The goal is not to avoid loading the plantar fascia — which would mean not running at all — but to manage that load within the tissue’s current tolerance while building its capacity.

The non-weight-bearing plantar fascia stretch: do this before your first step

The single most accessible and consistently evidence-supported self-management strategy for plantar fasciitis is the non-weight-bearing plantar fascia stretch performed before the first morning steps. Sitting on the edge of the bed, cross the affected foot over the opposite knee, grasp the toes and pull them into extension, and hold for 30 seconds. Perform 3 repetitions before standing. This pre-stretches the plantar fascia and significantly reduces the first-step pain that is characteristic of the condition.

A 2006 RCT (DiGiovanni et al.) found this specific plantar fascia stretch superior to Achilles tendon stretching alone for plantar fasciitis outcomes. It remains one of the most effective and low-cost interventions available.

Calf stretching and ankle dorsiflexion

Limited ankle dorsiflexion is one of the most consistently identified risk factors for plantar fasciitis. A tight calf complex forces the foot into compensatory pronation during running and increases the tensile load on the plantar fascia. Addressing calf tightness and restoring ankle dorsiflexion is a fundamental component of plantar fasciitis management.

Both gastrocnemius stretching (knee straight, foot flat against a wall) and soleus stretching (knee bent) should be performed, as the two muscles have different insertion points and are both commonly limited in runners with plantar fasciitis.

Intrinsic foot muscle strengthening

Weak intrinsic foot muscles — the small muscles within the foot that control arch height and dynamic foot stability — contribute to plantar fascia overload by reducing the active stabilisation of the arch during running. Short foot exercises (the “foot dome”: drawing the metatarsal heads toward the heel without curling the toes) progressively strengthen the intrinsic foot muscles and have shown benefits for plantar fasciitis when combined with hip and knee exercises (Kamel et al., 2024).

Load management and return to running

Runners with plantar fasciitis should not stop running entirely unless symptoms are severe. Instead:

• Reduce overall running volume temporarily — to the level at which symptoms during and after running are manageable (no worse than 3 to 4/10)
• Avoid speed work and hill running in the early management phase — both significantly increase plantar fascia loading
• Run on softer surfaces where possible
• Avoid barefoot running during the symptomatic phase
• Consider temporary heel lift or cushioned heel insole to offload the plantar fascia insertion
• Progress running volume gradually as symptoms improve — applying the same “no single-run spike beyond 10%” principle that applies to all running injuries

Footwear

Running shoes with adequate heel cushioning and appropriate arch support for the runner’s foot type significantly reduce plantar fascia stress. Runners with plantar fasciitis should not be running in worn-out shoes. Walking barefoot on hard floors — which many people do at home — significantly loads the plantar fascia and should be temporarily avoided, with supportive footwear worn from the moment of getting out of bed.

When to escalate: treatments for persistent plantar fasciitis

The majority of plantar fasciitis cases — approximately 80 to 90% — resolve with conservative management within 12 months. For the persistent cases that do not respond to first-line treatment:

• Night splints: Recommended by the 2023 CPG for cases lasting more than 6 months. The night splint maintains the foot and ankle in dorsiflexion overnight, keeping the plantar fascia in a lengthened position and preventing the tightening that occurs during sleep (which is responsible for the first-step morning pain).
• Extracorporeal shockwave therapy (ESWT): Supported by the 2023 CPG as an option for chronic plantar fasciitis refractory to initial conservative treatment. Multiple RCTs support ESWT for pain reduction in persistent cases. At Upwell we can discuss referral for ESWT where indicated.
• Corticosteroid injection: Appropriate for refractory cases at 6 to 12 weeks where conservative management has not produced adequate improvement. Short-term pain relief is well-documented. Not a first-line treatment and should always be combined with ongoing physiotherapy and the strengthening programme.
• PRP (platelet-rich plasma) injection: Emerging evidence for PRP in plantar fasciitis, with some RCTs showing longer-lasting benefit than cortisone at 3 to 6 months. The 2025 comprehensive review (Nweke, PMC12294660) includes PRP as a specialised therapy within the management framework.
• Surgical management: Reserved for cases that have failed a minimum of 6 to 12 months of structured conservative care. Endoscopic plantar fascia release is the most common procedure. Surgery is the last resort, not an early option.

The Upwell approach to plantar fasciitis

At Upwell, plantar fasciitis management for runners is built around the CPG recommendations with runner-specific modifications:

• Diagnosis first: Differentiating plantar fasciitis from Baxter’s neuropathy, calcaneal stress fracture, and tarsal tunnel syndrome is the first clinical step. The management differs significantly between these conditions.
• Manual therapy: Ankle joint mobilisation to restore dorsiflexion, soft tissue work to the plantar fascia and calf, and calf stretching instruction — from the first appointment.
• Exercise prescription: Non-weight-bearing plantar fascia stretch, gastrocnemius and soleus calf stretching, short foot intrinsic exercises, and progressive calf strengthening via exercise physiology.
• Footwear review: Assessment of current running shoes and recommendation for replacement or modification where indicated.
• Orthoses: Prefabricated orthoses prescribed and trialled where foot pronation is identified. Our physiotherapy team works alongside podiatry where custom orthoses are indicated.
• Load management: Training modification to reduce symptoms while maintaining running volume as much as possible. Runners are rarely asked to stop running entirely — they are asked to manage their running within current tissue tolerance while capacity is built.

If heel pain is affecting your running — particularly that brutal first-step morning pain — contact our team or book an assessment. Most plantar fasciitis resolves well with the right programme. The key is starting the right programme, not just hoping rest will fix it.

References

1. Heel Pain – Plantar Fasciitis: Revision 2023. AOPT Clinical Practice Guidelines. J Orthop Sports Phys Ther. 2023;53(12):CPG1–CPG39. (manual therapy A-level; stretching A-level; orthoses A-level; night splints B-level; plantar fasciitis 15% of foot pathology; most common in runners aged 40-60)
2. Comprehensive Review and Evidence-Based Treatment Framework for Plantar Fasciitis Diagnosis and Management. Nweke TC. Cureus. 2025. PMC12294660. (degenerative rather than inflammatory pathology; four-phase treatment framework; PRP as specialised therapy)
3. Kamel FM, et al. Adding short foot exercise to hip and knee exercises improved pain, function, and side-to-side stability in patients with PFPS. 2024. (intrinsic foot muscle strengthening benefits)
4. DiGiovanni BF, et al. Plantar fascia-specific stretching exercise improves outcomes in patients with chronic plantar fasciitis: RCT. J Bone Joint Surg Am. 2006. (non-weight-bearing plantar fascia stretch superior to Achilles stretching alone)
5. Single run spike >10% of monthly maximum associated with significantly higher injury risk. Br J Sports Med. 2025.
6. 2025 Best Practices for Managing Plantar Heel Pain. Formthotics consensus summary. (biomechanical support, stretching, cortisone, and ESWT all safe and effective; prefabricated orthoses not inferior to custom)

This article is for educational purposes only. Information last reviewed May 2026.