Case Study: Chronic Plantar Fasciitis in a Manhattan Runner — When Massage and Exercise-Based Rehab Weren’t Enough

Patient: Ms. A, 34, recreational runner.
Diagnosis: Chronic right-sided plantar fasciitis (fasciopathy), symptomatic for approximately 14 months
Prior treatment: Massage therapy and exercise-based physical therapy elsewhere, over approximately 8 months, with only partial and temporary improvement
Intervention at FuncPhysio: Functional Manual Therapy (FMT), a whole-body manual therapy approach, combined with radial extracorporeal shockwave therapy (ESWT), once weekly
Duration: 5 sessions over 5 weeks
Outcome: Full resolution of pain, full return to running

Background

Plantar fasciitis is one of the most common running injuries we see in our Manhattan clinic — and also one of the most frequently mismanaged, particularly once it becomes chronic. The plantar fascia, a thick band of connective tissue running from the calcaneus (heel bone) along the sole of the foot, absorbs and releases load with every step through the windlass mechanism, engaged as the big toe extends during push-off. When it’s loaded faster than it can adapt, it begins to break down at its origin on the medial calcaneal tubercle.

Beyond a few months, this is rarely true inflammation — it’s fasciopathy, a degenerative tissue response, and by that stage the presentation is usually more complicated than the fascia alone. This case is a useful illustration of a pattern we see often: a runner who received reasonable, well-intentioned care for over half a year — massage therapy and a structured exercise program — that eased symptoms somewhat but never fully resolved them, because it addressed the painful tissue locally without addressing the mechanical restrictions elsewhere in the leg and hip that were continuing to overload it.

Patient History

Ms. A is a 34-year-old marketing manager working near Grand Central who had run recreationally for about five years, averaging 15–20 miles per week along the East River Esplanade and through Central Park.

Onset. Approximately 14 months before presenting to FuncPhysio, Ms. A noticed a mild ache at the inside of her right heel following a period of increased mileage while training for a 10K. She initially rested for a week and the ache subsided, but it returned within days of resuming running and gradually became a sharp, localized pain with her first steps each morning.

Prior care. About four months after onset, when the pain had not resolved on its own, Ms. A sought treatment:

• Massage therapy, approximately every two weeks for roughly five months, focused on the calf and plantar fascia. She reported this provided noticeable short-term relief — often 1–2 days of reduced pain — but symptoms consistently returned to baseline within about a week.
• Exercise-based physical therapy at another clinic, over an eight-week course, consisting primarily of standard calf and plantar fascia stretching, generic hip and glute strengthening exercises, and a prefabricated arch-support insole. She was also advised to rest from running for approximately three months. Her pain improved by what she estimated as “maybe 40%” during that period, but plateaued, and her first-step morning pain never fully resolved. When she attempted to resume running at the end of the rest period, the sharp heel pain returned within her first two runs.
• She had also tried a night splint intermittently and over-the-counter NSAIDs, both with minimal effect.

By the time she presented to FuncPhysio, roughly 14 months after her initial symptoms, Ms. A described herself as discouraged and somewhat skeptical that further treatment would help, having “already done the stretches and the massages.” She was walking with a mild limp most mornings, avoided stairs when possible due to pain with push-off, and had not completed a pain-free run in over a year. She was hoping to resume training for a fall half marathon.

At intake, she rated her pain 6/10 on the Numeric Pain Rating Scale (NPRS) with first steps in the morning, and described the sensation as “like a rubber band snapping right under my heel bone.”

Examination Findings

Measure	Right	Left
Point tenderness, medial calcaneal tubercle	Positive	Negative
Windlass test	Positive (reproduced pain)	Negative
Ankle dorsiflexion, knee extended	3°	9°
Ankle dorsiflexion, knee flexed	8°	15°
Gastroc-soleus / plantar fascia palpation	Marked tightness and fibrotic thickening, active trigger points	Mild tightness
Talocrural joint mobility (posterior glide)	Moderately restricted	Normal
Subtalar joint mobility	Moderately restricted	Normal
Single-leg balance (eyes open)	12 sec	27 sec
Hip abductor strength (manual muscle test)	4-/5, poor control during single-leg squat	4+/5
Gait analysis	Moderate overpronation with compensatory shortened stance phase on the right	Mild overpronation

No findings were consistent with calcaneal stress fracture, tarsal tunnel syndrome, or Baxter’s nerve entrapment.

Clinical impression. Two things stood out relative to her treatment history. First, her prior care had addressed the plantar fascia and calf soft tissue directly (via massage and stretching) but had never assessed or treated joint mobility at the talocrural and subtalar joints — both of which were moderately restricted on exam, and which stretching alone does not reliably resolve, since a joint capsule and surrounding ligamentous restriction generally requires manual joint mobilization rather than muscle-tendon stretching. Second, while her prior exercise program included generic hip and glute strengthening, it had not identified or specifically retrained the hip control deficit visible on single-leg squat testing, nor integrated it into a functional, weight-bearing task resembling running mechanics — it had been trained as an isolated strength exercise rather than as motor control during a movement pattern that mattered to her actual complaint. After more than a year of loading through a stiff ankle and an unstable hip, the plantar fascia had also developed palpable fibrotic thickening consistent with chronic fasciopathy rather than the more reactive tissue seen in earlier-stage cases.

In short: the tissue itself had been treated repeatedly. The mechanical drivers feeding it had not.

Why a Whole-Body Approach, Not Another Local Treatment

It would have been reasonable to try another local approach, a different massage technique, a course of shockwave therapy alone, a different insole. But Ms. A had already spent eight months on a program that treated the symptomatic area competently and still plateaued at partial improvement. That pattern, meaningful short-term relief from soft tissue work that doesn’t hold, plus a strengthening program that doesn’t change the underlying pain pattern, is a common signature of a case where the problem isn’t confined to the tissue that hurts.

Functional Manual Therapy (FMT) is built specifically around that distinction. Rather than treating the plantar fascia as an isolated problem, FMT treats the body as an interconnected mechanical and neuromuscular chain, and systematically assesses and addresses restrictions anywhere along it, joints, soft tissue, nerve mobility, and motor control, that are contributing to load at the symptomatic site. In Ms. A’s case, that meant treatment was never only about her heel. It addressed:

• Talocrural and subtalar joint mobility, using manual joint mobilization — a category of treatment her prior stretching-based program had not included, and which is mechanically distinct from muscle stretching
• Soft tissue and myofascial work to the calf and fascia, similar in category to the massage she’d already received, but integrated with the joint and motor control work rather than delivered in isolation
• Tibial nerve mobility, screened and addressed with neurodynamic mobilization
• Hip motor control, retrained specifically during single-leg stance and step-down tasks — functional, weight-bearing positions — using a CoreFirst® approach, rather than as a generic isolated strengthening exercise
• Functional Mobilization™, performing mobilization techniques in weight-bearing, movement-based positions (such as a loaded lunge) so that gained mobility was immediately trained into a pattern resembling gait and running, rather than left as passive range of motion on a treatment table

Radial extracorporeal shockwave therapy was added alongside FMT to address the fibrotic, chronically-loaded fascia tissue itself — appropriate given her tissue had been symptomatic long enough to develop the thickening and reduced healing responsiveness typical of chronic fasciopathy, and consistent with how ESWT is generally used clinically: as an option for cases that have not resolved with several months of more conservative care. Shockwave delivered on its own, however, would have been another local intervention layered onto tissue that was still being mechanically overloaded from above. The combination, a tissue-level intervention plus a systematic whole-chain mechanical correction, was the specific difference from what she’d already tried, not the addition of any single new technique in isolation.

Treatment Course

Ms. A was seen once weekly for five consecutive weeks.

Session 1

• Subjective history and physical exam as above; findings explained to the patient, including how her prior treatment had addressed the tissue without addressing the joint mobility and hip control deficits now identified
• Shockwave therapy: ~1,500 pulses at a low starting energy level over the medial calcaneal tubercle and proximal plantar fascia
• Grade I–II joint mobilization to the talocrural and subtalar joints — the first manual joint mobilization she had received for this condition, distinct from the stretching and massage she’d previously done
• Soft tissue mobilization to gastrocnemius and soleus, addressing the fibrotic density found on palpation
• Home program: sustained calf stretching (straight-knee and bent-knee variations) and towel scrunches for intrinsic foot muscle activation
• NPRS at end of session: 5/10 (first-step pain)

Session 2

• NPRS at start of session: 5/10
• Shockwave therapy: pulses increased to ~2,000 as tolerated
• Functional Mobilization™ in a weight-bearing lunge position, addressing the talocrural restriction in a loaded position rather than passively
• Myofascial release to the plantar fascia and deep posterior calf compartment
• Trigger point release through soleus
• Tibial nerve neurodynamic mobilization (sliders)
• First hip motor control session: single-leg stance retraining with real-time feedback on pelvic control, distinct from the isolated hip-strengthening exercises in her prior program
• Exercise: pain-free isometric calf raise holds introduced
• NPRS at end of session: 4/10

Session 3

• NPRS at start of session: 3/10; Ms. A reported this was the first time in over a year that morning pain had felt meaningfully different rather than “the same, a little better”
• Shockwave therapy, energy progressed further
• Joint mobilization progressed to Grade III–IV at talocrural and subtalar joints, working toward end-range
• Cross-friction massage at the plantar fascia insertion on the calcaneus
• CoreFirst® hip integration: single-leg stance and step-down tasks with active pronation control cueing
• Eccentric calf raises introduced
• Return-to-run trial: 1-minute easy jog / 2-minute walk intervals on a soft surface, guided by a strict no-more-than-mild-pain rule — her first running, of any duration, in over a year without a subsequent flare
• NPRS at end of session: 2/10

Session 4

• NPRS at start of session: 1/10, tolerating run-walk intervals without flare-up
• Shockwave therapy
• Video gait analysis of running mechanics: foot strike, cadence, pronation control
• Continued hip and core control retraining integrated into single-leg and step-down tasks
• Continued soft tissue work to calf and fascia (maintenance)
• Low-level plyometric progression (pogo hops)
• Discussion of footwear rotation and surface selection during return to volume
• NPRS at end of session: 0–1/10

Session 5

• NPRS at start of session: 0/10 with activities of daily living
• Shockwave therapy, completing the course
• Reassessment (see Outcomes)
• Single-leg hop testing and higher-load plyometric work to confirm tissue tolerance for return to full training
• Discharge home program: ongoing talocrural/subtalar mobility maintenance, hip and core control work, staged mileage progression
• Training load guidance for resuming a half marathon training block without repeating the load pattern that contributed to the original injury

Outcomes

Measure	Baseline (14 months symptomatic)	Discharge (Session 5)
NPRS, first-step morning pain	6/10	0/10
Windlass test	Positive	Negative
Ankle dorsiflexion, knee extended	3°	8° (near-symmetrical to left)
Talocrural / subtalar joint mobility	Moderately restricted	Within normal limits
Single-leg balance	12 sec	25 sec
Hip abductor manual muscle test	4-/5	4+/5
Running tolerance	No pain-free run in 12+ months	Full training runs, including hills

Ms. A resumed half marathon training without pain. She noted that this was the first course of treatment in over a year that had resolved her morning pain completely, rather than reducing it temporarily.

Clinical Discussion

The detail worth emphasizing in this case is not any single technique — it’s the shift from a locally-focused treatment model to a whole-chain one. Ms. A had already received competent, appropriate local treatment: massage to reduce tissue tension, and exercises to build strength. Both are reasonable first-line interventions, and both produced some benefit. Neither, on their own, addressed a stiff talocrural and subtalar joint that was limiting how well her ankle could absorb load, or a hip control deficit that was allowing repeated pronation overload with every stride — findings that a soft-tissue-and-stretching model isn’t designed to catch or resolve, since joint mobility restrictions typically require manual joint mobilization rather than muscle stretching, and motor control deficits typically require task-specific retraining rather than isolated strengthening.

This is also why shockwave therapy alone would likely have been an incomplete answer here, despite being well-supported for chronic, fibrotic plantar fascia tissue like hers. Shockwave addresses the tissue; it does not correct ankle joint mobility or hip motor control. Pairing it with Functional Manual Therapy’s systematic, whole-body assessment and treatment gave the tissue a chance to heal while removing the ongoing mechanical overload that had been driving the problem for over a year.

The pain trajectory across sessions (6 → 5 → 3 → 1 → 0) was gradual rather than immediate, consistent with treating chronic, fibrotic tissue rather than an acute reactive one — but notably faster than the plateaued, partial improvement she experienced over her prior eight-month course of care, which is the more clinically relevant comparison in a chronic case like this.

Frequently Asked Questions

I’ve had massage therapy for plantar fasciitis and it helps temporarily but the pain always comes back — why? Massage and soft tissue work can meaningfully reduce muscle and fascial tension, but if the underlying driver includes a joint mobility restriction or a motor control deficit further up the chain (as in this case), the tissue will typically return to its prior state once the treatment effect wears off, because the mechanical cause of the overload hasn’t changed. This is a common pattern in cases that plateau with soft-tissue-only treatment.

I did physical therapy, stretching, & strengthening, and it only partially helped. Is there something else to try? Possibly. A program built around general stretching and strengthening can miss joint-specific mobility restrictions (which usually need manual joint mobilization, not stretching) and motor control deficits that need to be retrained during a functional, weight-bearing task rather than as an isolated exercise. A more comprehensive assessment can identify whether either of those is still present.

How long does chronic plantar fasciitis take to resolve once it’s been present for a year or more? It depends on the specific findings and how the tissue has changed over time (fibrotic thickening, joint restrictions, compensatory movement patterns), but a whole-chain approach combining manual therapy with shockwave therapy has, in cases like this one, produced full resolution within about 5 weekly sessions — even after many months of partial-response treatment elsewhere.

Is shockwave therapy painful? Most patients describe an intense thumping, tapping sensation, or sometimes sharp pain, typically decreasing in intensity across sessions. Sessions run 5–15 minutes.

What’s the difference between Functional Manual Therapy and general physical therapy techniques? FMT is a specific manual therapy framework that treats joint, soft tissue, and neuromuscular systems as interconnected, using joint mobilization and soft tissue techniques performed in functional, weight-bearing positions combined with motor control retraining — rather than treating an isolated symptomatic area with stretching, generic exercise, or modalities alone.