Plantar Fasciitis That Won’t Go Away: Why It Persists and What the Evidence Says Works

Jonathan Hall
Aug 5
9 min read

Short answer: if heel pain has persisted beyond three to six months despite stretching, orthotics and rest, the plantar fascia has usually shifted from an irritable but reactive state into a degenerative one thickened, disorganised tissue with a stalled healing response. Rest doesn’t reverse that, because rest also reduces the tissue’s capacity. What the randomised evidence supports for this stage is a regenerative stimulus (shockwave therapy) combined with progressive loading, with high-power laser used where pain sensitivity limits what the foot will tolerate.

Roughly 90% of plantar fasciitis resolves with straightforward conservative care within a year. This article isn’t for those people. It’s for the 10% the ones limping through the first steps out of bed eighteen months later, who’ve done everything they were told and are quietly wondering whether this is just their life now.

It isn’t. But it does require treating the condition you have now, not the one you had in month one.

Chronic plantar heel pain is a different condition

Plantar fasciitis is the most common cause of plantar heel pain, accounting for roughly 11–15% of foot symptoms presenting to healthcare providers. In the early weeks, there genuinely is an irritative, reactive process, and it often settles with load management, calf work and sensible footwear.

When symptoms persist, histological and imaging studies show something different: fascial thickening (typically >4 mm on ultrasound), collagen disorganisation, mucoid degeneration, microtears, and neovascularisation with relatively little classic inflammatory cell infiltrate. This is why many clinicians now prefer the term plantar fasciopathyor plantar heel pain: it describes a failed healing response rather than an active inflammatory one.

The clinical consequence is direct. Anti-inflammatory strategies NSAIDs, ice, rest target a process that has largely finished. That’s why they stop working, and why patients so often report the same frustrating cycle: settle, resume normal life, flare, settle, flare.

Why rest actively works against you

This is the part that most surprises patients. Rest reduces symptoms because it reduces load but it also reduces the fascia’s capacity to handle load. Connective tissue adapts to the demands placed on it; remove the demand and the tissue down-regulates. So the fascia you return to walking on is less capable than the one that got sore in the first place, and the threshold for the next flare is lower.

This is the founding observation behind our clinic and our brand line, Movement Matters™ the absence of movement leads to the presence of pathology. The plantar fascia is a load-transmitting structure. It exists to absorb and return energy during walking and running. Protect it indefinitely and it becomes less able to do the one job it has.

The goal of treatment is therefore not to unload the fascia permanently. It’s to restore its healing biology and then rebuild its tolerance movement restores biology; biology restores movement.

Seven reasons your heel pain keeps coming back

In clinic, persistent cases nearly always involve factors beyond the painful spot itself:

Reduced ankle dorsiflexion and calf stiffness. Restricted ankle motion increases load through the fascia at push-off. Calf capacity is consistently one of the strongest modifiable factors we find.
Load spikes. A new job on hard floors, a training block, a walking holiday, a change in footwear. The fascia rarely fails from a single event it fails from a rate of change it wasn’t prepared for.
Occupational standing. Nurses, teachers, hospitality workers, tradies, retail staff. Hours of static loading with no recovery window is a distinct and under-recognised driver.
Foot and lower-limb weakness. Weak intrinsic foot musculature and calf complex means the fascia absorbs what muscle should.
Hip and pelvic mechanics. How force arrives at the foot is determined further up the chain which is why our assessment is never confined to the foot. This is core osteopathic reasoning.
A stalled healing environment. The degenerative state described above, which no amount of stretching reverses on its own.
It isn’t plantar fasciitis. Fat pad atrophy or contusion, Baxter’s nerve (inferior calcaneal nerve) entrapment, calcaneal stress reaction, tarsal tunnel syndrome, and inflammatory arthropathies all masquerade as “plantar fasciitis” and all need different treatment. Persistent non-response is itself a reason to revisit the diagnosis.

Point seven deserves emphasis. If you’ve had genuine, well-delivered treatment for twelve months without change, the most valuable thing a clinician can do is question the label including with imaging referral where indicated.

What the evidence supports for chronic cases

Shockwave therapy: the strongest non-invasive evidence base

Chronic plantar fasciitis is one of the most extensively researched indications in all of musculoskeletal medicine for extracorporeal shockwave therapy (ESWT).

The most directly relevant trial to our clinic is Gerdesmeyer et al., American Journal of Sports Medicine, 2008 a multicentre, double-blind, placebo-controlled randomised trial in 245 patients with chronic recalcitrant plantar fasciitis (symptoms ≥6 months, failed conservative care). Radial shockwave produced significantly greater improvement in heel pain, function and quality of life than sham at 12 weeks, sustained at 12 months, with a favourable safety profile. It was conducted with the Swiss DolorClast® and supported that device’s FDA approval for chronic proximal plantar fasciitis.

That matters because it’s the same device family we use at Movement Mechanics, in the same patient group: people for whom the standard advice has already failed.

Multiple subsequent meta-analyses have supported ESWT for chronic plantar heel pain, and a meta-analysis comparing shockwave against corticosteroid injection found corticosteroid better early but shockwave superior at longer follow-up the same pattern we describe in shockwave therapy vs cortisone injections.

Mechanistically, shockwave stimulates mechanotransduction, neovascularisation and collagen remodelling, while modulating neurogenic inflammation (substance P, CGRP) that maintains pain sensitivity. In plain terms: it restarts a healing process that has stalled, and reduces pain without blocking repair.

High-power laser therapy: useful, with honest caveats

High-intensity laser therapy (HILT) works through photobiomodulation light energy absorbed by mitochondrial chromophores, increasing ATP production, influencing inflammatory signalling and microcirculation, and reducing nerve sensitivity.

The evidence in plantar fasciitis is promising but more mixed than for shockwave, and we’d rather tell you that than oversell it. A randomised clinical trial comparing high-intensity to low-level laser therapy found greater improvements with high-intensity, and a double-blind randomised trial comparing HILT with ESWT found both effective with differing time courses. However, a small sham-controlled trial published in 2026 found no significant advantage of HILT over sham in a 34-patient sample a useful reminder that effect sizes vary with dose, device and protocol.

Our clinical position: laser is not our primary treatment for chronic plantar fasciitis. It is a valuable adjunct, particularly where the heel is too irritable to tolerate mechanical loading, in earlier or acutely flared phases, and in combination with shockwave which is the specific rationale explored in our article on the therapeutic synergy of laser and shockwave therapy.

Loading: the part nobody can skip

No passive treatment resolves plantar fasciopathy on its own. Randomised evidence supports high-load strength training for plantar heel pain, and the consistent theme across the tendinopathy literature including the Achilles trials by Rompe and colleagues, where shockwave plus eccentric loading outperformed loading alone is that shockwave makes loading work better, rather than replacing it.

If a clinic offers you a course of shockwave with no loading programme attached, you are being sold half a treatment.

Where injections and surgery sit

Corticosteroid injection can help short-term but carries risks specific to this region, including fat pad atrophy and (rarely) plantar fascia rupture, and its benefits fade. Surgical fasciotomy is genuinely rare and reserved for the small minority who fail comprehensive conservative care which is precisely why exhausting good non-invasive options first matters so much. Helping people avoid unnecessary surgery and injections is the reason we invested in this technology.

Still limping through your mornings?

Book an assessment with Jonathan Hall (M.Ost) ACC-registered osteopath, EMS DolorClast® Key Opinion Leader for Aotearoa. Diagnosis first, then a plan with a defined endpoint. Book an appointment → · Browns Bay · Same-week appointments · No referral needed

How we treat chronic plantar heel pain at Movement Mechanics

Our approach runs in three overlapping phases. Full detail on the condition is on our plantar fasciitis treatment page.

Phase 1 - Confirm the diagnosis, reduce irritability

Clinical assessment plus orthopaedic testing, with ultrasound or X-ray referral where the presentation is atypical or non-responsive. Where the heel is highly irritable, high-power laser therapy and hands-on treatment reduce sensitivity enough to begin. Short-term unloading strategies (taping, footwear adjustment) are used as a bridge never as the plan.

Phase 2 - Restart the biology and address the drivers

EMS DolorClast® radial shockwave to the fascial origin and, where depth or presentation warrants it, focused shockwave we’re currently the only clinic in Aotearoa running both alongside high-power laser (as at 2026). Alongside this: calf and plantar soft-tissue work, ankle and first-MTP joint mobilisation, and treatment of hip and pelvic contributors. Electro-acupuncture is used for some pain-dominant presentations.

Typical course: 4–8 sessions at weekly intervals. Some patients feel change within one or two; the literature’s consistent finding is that outcomes continue improving for around 12 weeks after treatment, because remodelling is a biological process, not a switch.

Phase 3 - Rebuild capacity so it doesn’t return

Progressive loading for the calf complex, plantar intrinsics and whole lower limb, matched to your actual demands whether that’s a 12-hour nursing shift or a half marathon. Movement analysis is used where objective measurement helps. For runners, this integrates with our running injury clinic.

We work to defined review points. If you aren’t tracking, we change the plan or refer on we’re based inside Bays Health alongside GP and imaging pathways, which makes that straightforward.

Is your heel pain past the “just keep stretching” stage?

Symptoms persisting beyond 3–6 months despite genuine conservative care
Sharp first-step pain each morning, easing then returning later in the day
Cycles of temporary improvement followed by predictable flare-ups
Orthotics, night splints, rolling and new shoes each helped briefly
You’ve stopped running, walking or training because of your heel
It’s now affecting work, sleep or daily life not just sport

Three or more of these, and the tissue has almost certainly moved beyond what stretching alone can address.

Frequently asked questions

How do I know if my plantar fasciitis is chronic?

As a working rule, symptoms persisting beyond three to six months despite appropriate conservative treatment are considered chronic or recalcitrant. At that point the tissue state and the treatment approach both change which is exactly the population studied in the major shockwave trials.

Does shockwave therapy work for plantar fasciitis?

Yes it has one of the strongest evidence bases of any non-invasive treatment for chronic plantar heel pain. A multicentre double-blind randomised trial of 245 patients (Gerdesmeyer et al., 2008), conducted with the Swiss DolorClast® device, found significant improvements in pain and function versus sham at 12 weeks, sustained at 12 months.

How many shockwave sessions will I need for plantar fasciitis?

Most patients are treated over 4–8 sessions at weekly intervals. Improvement typically continues for around 12 weeks after the course, so we assess final outcomes at that point rather than immediately.

Should I stop walking or running completely?

Almost never. Complete rest reduces pain temporarily but also reduces tissue capacity, which is why symptoms return on resuming activity. We modify load rather than remove it most patients keep walking, and many runners keep running in adjusted form.

Do orthotics fix plantar fasciitis?

Orthotics can reduce symptoms by changing load distribution, and are useful for some people but they modify the environment rather than the tissue. They’re a legitimate part of a plan, not a plan.

Is my heel spur causing the pain?

Usually not. Heel spurs are common incidental findings in pain-free feet and are generally a consequence of altered loading rather than the pain source. Treatment targets the fascia and its loading environment regardless.

Is laser or shockwave better for plantar fasciitis?

For chronic, degenerative plantar heel pain, shockwave has the stronger and more consistent evidence. Laser is valuable where pain sensitivity or irritability limits tolerance to loading, and the two are frequently combined see our article on combining laser and shockwave.

Will ACC or Southern Cross cover treatment?

Where heel pain relates to a specific injury, we can lodge an ACC claim (ACC-subsidised osteopathy consultations from $70, subject to approval). We’re Southern Cross Easy-claim providers. Current pricing is on our fees page.

What if treatment doesn’t work?

Then the diagnosis or the plan is wrong, and we’ll say so. Non-response is clinical information: it triggers reassessment, imaging, or referral not another ten sessions of the same thing.

The bottom line

Chronic plantar fasciitis isn’t stubborn inflammation and it isn’t a failure of willpower. It’s a tissue that has stopped healing and lost capacity at the same time. Restart the biology with a treatment that has randomised evidence behind it, rebuild the capacity with loading matched to your life, and address the ankle, calf and hip factors that created the overload in the first place that’s the combination that ends the cycle.

Let’s find out what’s actually driving your heel pain

Book with Jonathan Hall → Browns Bay, Auckland. Monday to Saturday. Or call 09 884 0935.

Jonathan Hall M.Ost, BAppSci (Human Biology), PGCertHSc (Acupuncture), GradDipHeal, FIFA Diploma in Football Medicine

References

Gerdesmeyer L, Frey C, Vester J, et al. Radial extracorporeal shock wave therapy is safe and effective in the treatment of chronic recalcitrant plantar fasciitis: results of a confirmatory randomized placebo-controlled multicenter study. Am J Sports Med. 2008;36(11):2100–2109.
Xu D, Jiang W, Huang D, et al. Comparison of efficacy of shock wave therapy versus corticosteroids in plantar fasciitis: a meta-analysis of randomized controlled trials. Med Sci Monit. 2019.
Rompe JD, Furia J, Maffulli N. Eccentric loading versus eccentric loading plus shock-wave treatment for midportion Achilles tendinopathy: a randomized controlled trial. Am J Sports Med. 2009;37(3):463–470.
Ordahan B, Karahan AY, Kaydok E. The effect of high-intensity versus low-level laser therapy in the management of plantar fasciitis: a randomized clinical trial. Lasers Med Sci. 2018;33(6):1363–1369.
Comparison of high-intensity laser therapy with extracorporeal shockwave therapy in the treatment of patients with plantar fasciitis: a double-blind randomized clinical trial. (2024).
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 Sports. 2015;25(3):e292–300.

Disclaimer: This article is general information, not individual clinical advice. Treatment recommendations require assessment.