Managing Plantar Fasciitis: Different Sex, Different Protocol

The plantar fascia is a broad sheath of connective tissue that stabilizes the medial arch during the gait cycle. As the foot contacts the ground, it stretches to store and return energy, offloading nearby muscles. During propulsion, it transfers force from the Achilles tendon into the ground, stabilizing the midfoot by preventing the arch from collapsing. The plantar fascia is one of the strongest tissues in the body, capable of withstanding tensile forces exceeding 3.7 times body weight with each running stride.¹

The plantar fascia’s inherent strength comes from parallel type I collagen fibers organized into three bands. (Fig. 1) Of these components, the central band is by far the thickest and strongest; however, its lack of elasticity makes it susceptible to injury and microtearing, particularly at its proximal attachment to the calcaneus.² Despite this resilience, plantar fascial disorders affect over 10% of the population, resulting in more than 2 million doctors’ visits annually.³

A Sex-Based Injury Gap

Though rarely discussed, plantar fascial injuries are significantly more common in women, as a six-year study of over 130,000 people showed that females are nearly twice as likely to develop this frustrating injury.⁴ Even worse, a 15-year study by Hansen, et al.,⁵ found that women are more likely to develop chronic plantar fascial pain as they respond less favorably to conventional plantar fascial treatment programs.

The authors offered no clear explanation for the sex-based differences in injury frequency and chronicity, attributing them vaguely to “hormonal, physical, shoe wear, or some other factor.”

To better understand women’s greater susceptibility, Shiotani, et al.,⁶ used shear wave ultrasound to assess sex differences in plantar fascial mechanical properties and found that women have notably stiffer plantar fascias throughout the entire structure, not just at the proximal attachment.

The authors speculate that because women have weaker arch muscles, which normally offload the plantar fascia during propulsion, they place greater stress on the plantar fascia due to inadequate muscular stabilization, leading to chronic injury, adhesions and reduced flexibility.

In a follow-up study evaluating plantar fascial and Achilles tension in males and females, Shiotani, et al.,⁷ performed MRIs on 20 men and 20 women in a device specifically designed to measure tension in the Achilles and plantar fascia as the foot and ankle were moved into a dorsiflexed position. Using this detailed analysis, the authors found that men have significantly stiffer Achilles tendons with more compliant plantar fascias, while women have stiffer plantar fascias with more flexible Achilles tendons.

Since stiffer tissue fails more easily under load, this helps explain why women are more prone to plantar fascia injury while men are more prone to Achilles injury.

Why Calf Stretches Aren’t Enough for Women

The clinical significance of Shiotani’s research is huge, as the most commonly applied intervention for managing plantar fasciitis is to restore ankle mobility with calf stretches. These stretches will not alter plantar fascial tension in women because their overly flexible Achilles tendons will absorb force that would otherwise have gone into stretching the plantar fascia.⁷ As a result, conventional calf stretches will increase Achilles flexibility in women (which is not necessary) but will not alter tension in their chronically tight plantar fascias.

While men respond favorably to calf stretches, women need alternate stretches that specifically focus on lengthening their plantar fascia in isolation.

DiGiovanni, et al., ⁸ demonstrated this in 2003: A plantar fascia-specific stretch outperformed standard calf stretching across 101 chronic plantar fasciitis patients; greater pain reduction (83% vs. 58%), better functional improvement (50% vs. 11%), and higher satisfaction (91% vs. 61%). (Fig. 2) Despite DiGiovanni’s impressive outcomes, no studies have been done to determine if there are alternate stretches that might more effectively improve plantar fascia flexibility.

In 2026, researchers from Boston⁹ embedded strain gauges into 12 cadaveric plantar fascias and evaluated a series of alternate plantar fascial stretches. (Fig. 3) The DiGiovanni stretch produced modest lengthening of the plantar fascia by adding 20-30 pounds of axial load through a small ball positioned beneath the midfoot nearly doubled plantar fascial elongation. The results of this study suggest that the best way for women to reduce stiffness in their plantar fascias is with the stretch illustrated in figure 4.

What Men Need Instead

While targeted plantar fascial stretches are crucial when treating women with plantar fasciitis, men should prioritize improving medial gastrocnemius and Achilles tendon flexibility without overloading the plantar fascia.

Calf tightness, specifically tightness of the medial gastrocnemius, is a proven predictor of plantar fasciitis because it forces the heel to leave the ground prematurely, which greatly stresses the central band of the plantar fascia.^10-11

As demonstrated in a cadaveric study by Ballal, et al.,¹² tightness of the medial gastrocnemius increases the potential for plantar fasciitis because there is a continuation of medial gastrocnemius fibers through the Achilles tendon directly into the plantar fascia. As a result, tightness of the medial gastrocnemius is transferred almost immediately into the plantar fascia following heel lift.

When calf tightness is present, long-duration calf/Achilles stretches are the most effective remedy. Panidi, et al.,¹³ found that performing long-duration calf stretches five days a week for 12 weeks improves ankle dorsiflexion by a remarkable 22%. This dramatic increase in ankle motion appreciably offloads the plantar fascia, as the heel no longer leaves the ground prematurely.

Strengthening for Both Sexes

Because arch muscles reduce fascial tension during gait,¹⁴ strengthening them benefits both sexes: helping prevent chronicity in women (by offloading the fascia post-stretching) and reducing injury risk in men (by stabilizing the fascial origin at heel lift). Sullivan, et al.,¹⁵ suggest that people with plantar fasciitis are more likely to present with significant weakness of the peroneals and flexor digitorum brevis, so it is important to design an exercise program that targets these important muscles.

Toward Individualized Care

By creating an individualized treatment protocol that addresses the male-female differences between Achilles tendon and plantar fascia tension, it may be possible to improve clinical outcomes associated with this frustrating and difficult-to-treat condition.

Of course, alternate interventions should also be considered, as a 2026 systematic review found that soft-tissue massage improved clinical outcomes in people with chronic plantar fasciitis.¹⁶ Although not addressed in that study, it is likely that women are more likely to respond to soft-tissue manual therapy applied to the plantar fascia, while men are more likely to respond to aggressive massage of the medial gastrocnemius.

Interestingly, the authors state that in all of the studies included in their systematic review, manual therapy was most effective when coupled with stretching and strengthening exercises.

References

1. Shiotani H, Mizokuchi T, Yamashita R, et al. Acute effects of long-distance running on mechanical and morphological properties of the human plantar fascia. Scand J Med Sci Sports, 2020 Aug;30(8):1360-8.
2. Draghi F, Gitto S, Bortolotto C, et al. Imaging of plantar fascia disorders: findings on plain radiography, ultrasound and magnetic resonance imaging. Insights Imaging, 2017 Feb;8(1):69-78.
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4. Scher CD, Belmont Jr LC, Bear MR, et al. The incidence of plantar fasciitis in the United States military. JBJS, 2009 Dec 1;91(12):2867-72.
5. Hansen L, Krogh TP, Ellingsen T, et al. Long-term prognosis of plantar fasciitis: a 5-to 15-year follow-up study of 174 patients with ultrasound examination. Orthopaedic J Sports Med, 2018 Mar 1;6(3).
6. Shiotani H, Yamashita R, Mizokuchi T, et al. Site-and sex-differences in morphological and mechanical properties of the plantar fascia: a supersonic shear imaging study. J Biomechanics, 2019 Mar 6;85:198-203.
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14. Fessel G, Jacob HA, Wyss CH, et al. Changes in length of the plantar aponeurosis during the stance phase of gait–an in vivo dynamic fluoroscopic study. Ann Anat, 2014 Dec 1;196(6):471-8.
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