Why does an illness that heals on its own last so long? We've summarized the evidence.

Key points in 30 seconds

Heel pain that is worst with the first step after getting out of bed is the hallmark of plantar fasciitis. That's because the spot that healed slightly overnight gets pulled again under your morning body weight.
Most cases get better within 10 months, but 1 in 10 lasts a long time. You need care that shortens that time.
The treatment with the strongest evidence isn't an injection or a machine. It's a stretch that pulls the toes back to lengthen the plantar fascia itself. The key is doing it before you take your first step in the morning, and the effect held up at a 2-year follow-up.
Some studies suggest acupuncture improves pain in the short term, so we use it alongside, in the role of controlling pain so that stretching and load management can do their work.
If it hurts even at rest at night, if both heels hurt at once, or if you also have a stiff lower back, other causes besides plantar fasciitis need to be checked first.

What we often hear

"When I take my first step after getting up, my heel feels like it's tearing."
"It loosens up after a few steps, but it happens again when I get up after sitting for a while."
"I was told it heals on its own, so I waited. It's been more than six months."
"I've had shockwave therapy several times, and nothing has changed."

What people with heel pain tell us is remarkably the same.

Here's what happens on your first day

Whether it's really plantar fasciitis. We check whether the pain is on the inner side or the center of the heel, and whether it's the first-step type or the constant type. If another cause is suspected, we look into it together with the radiology clinic on the 2nd floor of the same building.
How many points your first morning step scores right now. It's the scale we use to measure recovery, so we record it that day.
What to do starting today. We show you in person, right there, how and when to do the stretch. It costs nothing, has no side effects, and is the treatment with the strongest evidence.

Why the first step in the morning hurts the most

There's a reason for this pattern.

The plantar fascia is a thick band of fibrous tissue that runs across the sole from the heel bone to the toes, acting like a bowstring that takes your body weight with every step. Overnight, while the foot is relaxed, the damaged fascia heals slightly. Then, with your first step in the morning, your body weight comes down and pulls that healed spot again.

In effect, the same spot is torn again every morning.

One point about the name. Despite the "-itis" (inflammation) in its name, the literature points out that the tissue findings of chronic plantar fasciitis are closer to degenerative changes from repeated injury than to acute inflammation. That's why the response to anti-inflammatory drugs is often disappointing, and it's also why the focus of treatment is less on putting out inflammation than on creating the conditions for the tissue to heal.

Doesn't it heal on its own?

Most cases do. Symptoms are generally reported to improve within 10 months.

But about 10% go on to persistent symptoms that sometimes disrupt daily life. It's the same structure we saw with frozen shoulder. "It usually gets better" and "some cases last a long time" are both true at once, and the problem is that those 10 months are by no means short.

Ten months of painful first steps every morning is a stretch of time that the words "it heals on its own" don't make any easier.

So the question changes: what should you do to shorten that time and keep from ending up in that 10%?

The treatment with the strongest evidence is also the cheapest

In this field, the star of the best-designed trial isn't an injection or a machine. It's stretching. But not just any stretching.

In a trial that divided patients with chronic plantar fasciitis lasting more than 10 months into a plantar fascia-specific stretching group and an Achilles tendon stretching group, both groups improved after 8 weeks, but the plantar fascia stretching group had clearly greater improvement in first-step pain and activity function.

The method has two key points. Without putting weight on the foot, pull the toes back toward you to stretch the plantar fascia itself. And of the three times a day, do the first one before you take your first step in the morning. It's a design aimed precisely at how the condition works: stretching it ahead of time, before it gets torn again every morning.

This result wasn't temporary. In a 2-year follow-up study, the clear reductions in pain and activity limits were maintained, and satisfaction was high.

It's a treatment that costs nothing, has no side effects, and has 2 years of evidence. That's why it should be the default in any plantar fasciitis treatment plan.

How far has the evidence for other treatments come?

Extracorporeal shockwave therapy. In a meta-analysis combining 6 randomized trials with 897 people, the weighted mean difference in improvement of morning pain was 0.42 cm on a 10 cm scale. It was statistically significant, but the effect size was very small, and in an analysis of only high-quality trials, the significance disappeared. Research has continued since, but what this data implies is that it's not as certain a treatment as first hoped. What to look at if you've had shockwave therapy several times and nothing has changed is covered separately.

Acupuncture. A systematic review of randomized trials of acupuncture for plantar heel pain found evidence suggesting short-term (4–8 weeks) pain improvement, but also pointed out limits in the number and quality of the included studies. Research is ongoing, including a later randomized trial directly comparing electroacupuncture with manual acupuncture.

Invasive stimulation such as dry needling. There is a 2021 updated meta-analysis of treatments that directly stimulate tender points in the fascia. It reports pain improvement, but again notes limits in study quality.

This is the landscape of the field. There's no single sure fix. The basics, stretching, have the strongest evidence, and the treatments layered on top are in the state of "suggesting pain improvement, but with limited quality of evidence." Knowing this landscape or not makes a big difference in choosing treatment.

The limits of this evidence

No blinding. Most trials in this field, including the stretching trials, can't keep patients from knowing what they're getting. Pain is a subjective measure, and it's influenced by expectations.

Mixed with natural improvement. Since most cases get better within 10 months, any treatment given during that time will show improvement. In studies with weak control designs, the improvement includes the natural course of the condition.

Data centered on chronic patients. The subjects of the stretching trials were chronic patients whose condition had lasted more than 10 months. The size of the effect in patients early in the condition hasn't been confirmed separately. That said, it's hard to find a reason why the results would be worse earlier on.

Variation among acupuncture studies. Point selection, stimulation method and number of treatments differ from study to study, which makes combined interpretation difficult, and which method works best hasn't been established.

What we make clear

Since most cases get better within 10 months, even research can't neatly separate how much of the improvement comes from treatment and how much from time passing.

So we record your first-morning-step score. If it's going down, we continue. If it isn't, we don't repeat the same treatment; we go back to the step of sorting out the diagnosis.

So these are the standards we use

First, we sort out whether it really is plantar fasciitis. Not all heel pain is plantar fasciitis. It can be a thinned heel fat pad, a pinched nerve, a stress fracture, and, though rarely, heel pain on both sides at a young age together with lower back stiffness can be a sign of inflammatory spinal disease. Pain that hurts even at rest at night, both sides hurting at once, and symptoms throughout the body are signs that call for a second look.

Second, we put stretching at the center of the prescription. Treating the treatment with the strongest evidence like an add-on gets the order wrong. We show you exactly how and when, and check at follow-up visits that you're actually doing it.

Third, we work out the load equation together. The load on the plantar fascia is a function of body weight, tight calf muscles, time spent standing, and shoes. If you've gained weight, your calves are stiff, you stand all day at work, or your exercise has recently jumped up, treating only the sole without dealing with those factors is like pouring water into a bottomless jar. That's usually also why the same spot keeps coming back (on recurrence).

Fourth, we add treatments only as much as their evidence supports. Acupuncture and pharmacopuncture, on the basis of evidence for short-term pain improvement, play the role of controlling pain and creating the conditions for tissue to recover, and for stubborn adhesions we decide whether acupotomy (needle-knife therapy) is appropriate. The position that fits the evidence is not a treatment that promises big results but a treatment that buys time for stretching and load management to work.

Fifth, we use first-step pain as the measure. Recovery from this condition shows up most honestly in the pain score of your first step in the morning.

How we work

We sort out the diagnosis first. We check whether the pain is on the inner side or the center of the heel, and whether it's the first-step type or the constant type, and if a stress fracture or another cause is suspected, we check together with the radiology clinic on the 2nd floor of the same building. If both sides hurt at once, it hurts at night too, or there are symptoms throughout the body, we point you to the right care.

We prescribe stretching. At your first visit we show you in person how and when to do the plantar fascia-specific stretch (three times a day, including before your first step in the morning), and at follow-up visits we see how you're doing it and correct it. If your calves have tightened, we have you do Achilles tendon stretches as well.

We deal with load factors together. We check body weight factors with a body composition test, look at ankle and leg alignment with a posture analysis, and ask about time spent standing and your shoes to decide together what can be adjusted. If needed, we use Chuna (Korean manual therapy) to work on the alignment and movement of the ankle and leg.

Added treatments are used with a set role. We control pain with acupuncture and pharmacopuncture to make stretching and activity possible, and for stubborn adhesions we decide whether acupotomy is appropriate. We tell you the size of the evidence for each treatment as it is.

We check with your first-step score. We record your first-morning-step pain score before treatment and compare it at every follow-up visit. If you're not on a good track within the set period, we don't repeat the same treatment; we go back to the step of sorting out the diagnosis.

How long recovery takes varies from person to person, depending on how long you've had it, body weight, the load from your work, and how flexible your calves are.

What changes

Not having to brace yourself when you get out of bed in the morning. That's the first change.

Next is the score. Since we wrote down your first-step pain before treatment, you can see with your own eyes how much it has come down. You won't have to spend months thinking "maybe it's getting better, maybe not."

Please come see us if

Your first steps in the morning have hurt for several months
You were told it heals on its own and you're waiting
You've had shockwave therapy or injections and nothing has changed
You stand all day at work

When you come in, we'll measure your first-step score that day, and you'll go home having learned the stretch to start today. We begin with what costs nothing.

Sources used in this post

Source	What the study looked at	Result
DiGiovanni et al., 2003	Randomized assignment of chronic patients (10+ months) (82 completed)	Plantar fascia-specific stretching improved first-step pain and activity function more than Achilles tendon stretching
DiGiovanni et al., 2006	2-year follow-up of the trial participants above	Clear reductions in pain and activity limits maintained; high satisfaction
Thomson et al., 2005	Pooled analysis of 6 shockwave trials, 897 people	Morning pain improved by 0.42 cm (10 cm scale), a very small effect size. Significance disappeared when only high-quality trials were included
Clark & Tighe, 2012	Review of pooled acupuncture trials	Suggested short-term (4–8 weeks) pain improvement. Limits in number and quality of studies also noted
Wang et al., 2021	Randomized trial in plantar heel pain	Directly compared electroacupuncture and manual acupuncture
Llurda-Almuzara et al., 2021	Updated analysis of dry needling trials	Pain improvement reported. Limits in quality of evidence also noted

References

DiGiovanni BF, Nawoczenski DA, Lintal ME, Moore EA, Murray JC, Wilding GE, Baumhauer JF. Tissue-specific plantar fascia-stretching exercise enhances outcomes in patients with chronic heel pain: a prospective, randomized study. Journal of Bone and Joint Surgery (American). 2003;85(7):1270-1277. doi:10.2106/00004623-200307000-00013. PMID: 12851352
DiGiovanni BF, Nawoczenski DA, Malay DP, Graci PA, Williams TT, Wilding GE, Baumhauer JF. Plantar fascia-specific stretching exercise improves outcomes in patients with chronic plantar fasciitis: a prospective clinical trial with two-year follow-up. Journal of Bone and Joint Surgery (American). 2006;88(8):1775-1781. doi:10.2106/JBJS.E.01281. PMID: 16882901
Thomson CE, Crawford F, Murray GD. The effectiveness of extra corporeal shock wave therapy for plantar heel pain: a systematic review and meta-analysis. BMC Musculoskeletal Disorders. 2005;6:19
Clark RJ, Tighe M. The effectiveness of acupuncture for plantar heel pain: a systematic review. Acupuncture in Medicine. 2012;30(4):298-306. doi:10.1136/acupmed-2012-010183
Wang W, Liu Y, Jiao R, et al. Comparison of electroacupuncture and manual acupuncture for patients with plantar heel pain syndrome: a randomized controlled trial. Acupuncture in Medicine. 2021;39(4):272-282
Llurda-Almuzara L, et al. Is dry needling effective for the management of plantar heel pain or plantar fasciitis? An updated systematic review and meta-analysis. Pain Medicine. 2021;22(7):1630-1641

If your first steps in the morning have hurt for months, please come see us. We'll measure your score that day, and you'll go home having learned what to start doing today.

For questions or appointments, message us in English through the messenger at the bottom right of the page, or call +82-53-716-1175.

If your first steps in the morning hurt the most

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