Plantar fasciitis

Heel Pain: Plantar fasciitis

Plantar fasciitis (PF) is by far the most common heel pain disorder. According to research there is either no inflammation or very, very low grade inflammation found in patients with plantar fasciitis. Therefore the proper name of this condition is plantar fasciopathy. This name truly reflects the degenerative nature of this condition.

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Most common symptom of PF is a heel pain. Pain on the inside of the heel pain is more common than pain in the middle of the heel. The classic symptom of PF is a strong heel pain upon standing on to the feet first time in the morning. As the day goes by the pain usually improves somewhat. Then it becomes worst again in the evening.


Most common cause of PF is excessive tensile load applied to plantar fascia. This excessive tensile loads are either due to excessive physical activities such as the case with runners and athletes which jump. Another type of overloading is excessive chronic tensile load which is a result of poor biomechanics or foot deformities.


  • Excessive foot pronation
  • To rapid foot pronation
  • Decreased ankle dorsiflexion
  • Tight cuff muscles
  • Limited dorsiflexion of the big toe (hallux limitus, hallux rigidus)
heel pain treatment at NYDNRehab


  • Plantar fascia rupture
  • Achilles tendinitis
  • Fat pad syndrome (rare)
  • Heel bursitis (rare)
  • Calcaneal stress fracture
  • Tarsal tunnel syndrome
  • Double crash syndrome of nerve irritation below the spine such as SI nerve loot syndrome
  • Sacrotuberous ligament irritation due to pelvis misalignment

Diagnosis of Plantar Fasciitis


Diagnosis begins with a patient interview and health history review, followed by a physical exam. Because plantar fasciitis is relatively common, it is easy to overlook other less common potential causes of heel pain. Misdiagnosis is a primary cause of plantar fasciitis becoming a chronic condition. Compression of the small tibial nerve branch is a common mimicker of plantar fasciitis. About 25% of patients with chronic plantar fasciitis have a secondary tibial nerve involvement. Accurate diagnosis is key to treatment and recovery.

At NYDNR, we use the highest resolution diagnostic ultrasonography with SMI ( superior microvascular imaging) and elastography to diagnose plantar fasciitis, and rule out other possible causes of heel pain.

Musculoskeletal diagnostic ultrasound is the only radiological modality that can:

  • image the small nerves in the foot.
  • examine the plantar fascia in motion.
  • measure the elasticity of the plantar fascia.

Ultrasound also gives us the ability monitor the progress of treatment pre and post intervention with SMI.

Please explore more advanced diagnostic option unavailable anywhere else:



Asymmetrical weight bearing
Asymmetrical weight bearing
Short leg syndrome
Short leg syndrome
Ankle dorsiflexion
Ankle dorsiflexion
Excessive lateral tibial torsion
Excessive lateral tibial torsion
Sexcessive pronation
Excessive pronation
Pes cavus (high arch)
Pes cavus (high arch)
PHip anteversion
PHip anteversion
Pes planus (flat foot)
Pes planus (flat foot)


Stretching the plantar fascia has not been shown by research to be beneficial. Our clinical experience over 10 years of treating patients with PF shows that stretching actually increases symptoms of PF in acute stage and can even increase symptoms in chronic stage if it exceeds tissue tolerance. Orthotics. Research has shown that custom made orthotics are not superior to prefabricated ones and both have limited value in treatment of plantar fasciitis Steroid injections may help to reduce inflammation in the initial stage of PF however downside of it is:
  • 1)it does not address cause of PF.
  • 2)may cause fat pad atrophy. Studies have not shown any benefit for patients with chronic PF.
Strapping – strapping has been shown to have good therapeutic effect on decreasing tensile forces to PF therefore allowing healing to occur. Downside of strapping is that it needs to be properly and very frequently done by qualified specialist. Physical therapy – A recent review of thirty-two studies have concluded that functional physical therapy has moderate effectiveness for people suffering from chronic plantar fasciitis. ESWT (extracorporeal shockwave therapy)- research has shown that shockwave therapy is the most effective treatment for PF.


We have developed a very comprehensive treatment approach for plantar fasciitis and different heel pain disorders. We use diagnostic ultrasonography imaging for foot and ankle disorders. We use gait and pressure analysis to look at step by step analysis of forces acting on the foot as well as joint mechanics and motor control. We use Computer Assisted Rehabilitation Environment (C.A.R.E.N) dual force plate analysis and feedback treatment for heel pain which is caused by weight bearing asymmetry and pelvic/hip misalignment dysfunction. Most importantly we combine our functional foot physical therapy with Extracorporeal Shockwave therapy. Over the past 10 years we have successfully treated over a thousand patients with various forms of heel pain.

Heel pain treatment Treatment at NYDNRehab

Research at NYDNRehab

Plantar Fasciopathy
Previously called plantar fasciitis, PF is by far the most common heel pain disorder. The suffix “itis” refers to tissue inflammation, which is not characteristic of PF. Plantar fasciopathy is degenerative in nature, and does not respond to traditional treatment approaches for inflammation.

Symptoms of PF

The most common symptom of PF is heel pain, most often along the inside of the heel. Pain is most pronounced upon waking in the morning, and may subside during the day, flaring up again toward evening.

Causes of PF

PF is an overuse syndrome resulting from overloading of the plantar fascia, the tough band of connective tissue that spans the bottom of the foot, connecting the heel to the toes. Overload can arise from sports and physical activity, or it can result from long bouts of standing or walking. PF overload is also associated with faulty gait mechanics and muscle imbalances. Poor fitting or non-supportive footwear can increase the risk of PF.

Diagnosis of PF

A medical history and physical exam are often the primary diagnostic tools in cases of PF, but heel pain can arise from other sources, including fractures, Achilles tendinitis, tarsal tunnel syndrome and other less common conditions. Real-time dynamic diagnostic ultrasound can help rule out other causes of heel pain and confirm a diagnosis of PF.

Treatment Options for PF

Traditional treatments for PF often fail to relieve symptoms, and many are deemed ineffective, yet they continue to be used in many clinical settings:

  • Stretching has been a long-standing approach to treating PF, but recent research shows that stretching of the plantar fascia is not beneficial, and can actually cause increased pain.
  • Orthotics are often prescribed for PF, but research reveals that custom-made orthotics are no better than prefabricated ones, and that orthotics in general have limited value in treating PF.
  • Steroid injections are geared to reducing inflammation, which we noted is not a characteristic of PF. Steroids do not address the cause of PF, and may even contribute to atrophy of the fat pad that protects the heel, creating more pain.

More effective treatment options are available:

  • Strapping or taping can relieve tensile forces on the plantar fascia, allowing healing to occur. However, it must be done properly and frequently by a qualified specialist.
  • Functional physical therapy has been shown by research to be moderately effective in treating PF.
  • ESWT (extracorporeal shock wave therapy) is currently the most effective approach available for treating PF. ESWT promotes blood flow to the affected area and stimulates the genesis of new tissue, accelerating the healing process.

Plantar Fasciopathy Treatment at NYDNR

At NYDNR, we have developed a very comprehensive treatment approach to plantar fasciopathy and other heel pain disorders. Some of our treatment methods include:

  • Real time dynamic ultrasound for diagnosis and treatment.
  • Gait and pressure analysis to analyze forces acting on the foot, and to identify deficiencies in gait mechanics and motor control.
  • C.A.R.E.N (computer assisted rehabilitation environment), a system featuring dual force plate analysis and feedback treatment for heel pain caused by asymmetrical weight bearing or hip/pelvic dysfunction.
  • ESWT to speed up healing and alleviate pain.

For more than a decade, the foot pain specialists at NYDNR have treated more than a thousand patients suffering from various forms of heel pain.


In this instance, an athlete was originally diagnosed with minor quadriceps muscle strain and was treated for four weeks, with unsatisfactory results. When he came to our clinic, the muscle was not healing, and the patients’ muscle tissue had already begun to atrophy.

Upon examination using MSUS, we discovered that he had a full muscle thickness tear that had been overlooked by his previous provider. To mitigate damage and promote healing, surgery should have been performed immediately after the injury occurred. Because of misdiagnosis and inappropriate treatment, the patient now has permanent damage that cannot be corrected.

The most important advantage of Ultrasound over MRI imaging is its ability to zero in on the symptomatic region and obtain imaging, with active participation and feedback from the patient. Using dynamic MSUS, we can see what happens when patients contract their muscles, something that cannot be done with MRI. From a diagnostic perspective, this interaction is invaluable.

Dynamic ultrasonography examination demonstrating
the full thickness tear and already occurring muscle atrophy
due to misdiagnosis and not referring the patient
to proper diagnostic workup

Demonstration of how very small muscle defect is made and revealed
to be a complete tear with muscle contraction
under diagnostic sonography (not possible with MRI)


Complete tear of rectus femoris
with large hematoma (blood)


Separation of muscle ends due to tear elicited
on dynamic sonography examination

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