Plantar Fasciitis

Introduction

Plantar fasciitis—now more accurately referred to as Plantar Heel Pain—is like the wear and tear of a tension cable that runs beneath the foot. This cable, the plantar fascia, connects your heel to your toes and acts as a support beam for your arch. Over time, especially with repeated stress, the point where this band attaches to your heel bone (the calcaneal tuberosity) can start to break down. This leads to pain and stiffness in the base of your heel.

The condition was originally called fasciitis, with the -itis suffix suggesting inflammation. But newer research shows there's often no inflammation present—just degeneration of the tissue, like a rope fraying with age and overuse. That’s why more accurate terms like fasciosis or fasciopathy are now used. Plantar heel pain is the most common type of foot pain seen in clinics.

The plantar fascia plays a crucial role in foot mechanics. Think of it as the bowstring to the arch’s bow, helping hold everything together and absorb shocks when you walk or run.

This condition usually develops gradually, with sharp pain in the inner part of the heel, particularly where the fascia connects to the heel bone. It’s often worse first thing in the morning or after sitting for a while. Many people describe it as stepping on a pebble or a nail. It frequently becomes a long-standing issue, sometimes lasting more than a year.

Because several structures can contribute to pain in the bottom of the heel, Plantar Heel Pain is a better umbrella term to describe the various possible causes beyond just the fascia.

Clinically Relevant Anatomy

The plantar fascia is a thick, fibrous band that starts at the inner bump of the heel (medial tubercle of the calcaneus) and stretches forward to the toes. It splits into five bands, each supporting a toe, like five suspension cables that stabilize the foot.

This central part of the fascia wraps around the flexor tendons near the ball of the foot. Pain can happen at the point of insertion or along any of these bands. The fascia is interconnected with other important foot and lower leg structures, including the Achilles tendon and small intrinsic foot muscles.

Below the fascia is a soft, fatty cushion—a kind of built-in mattress—which absorbs as much as 110% of your body weight when walking and up to 250% when running. Interestingly, this pad deforms more when walking barefoot than in shoes.

When you walk or stand, a mechanism known as the windlass effect kicks in. Imagine winding a rope around a winch: when your toes extend, tension builds in the fascia, which helps support the arch and stabilize your foot with minimal effort from muscles.

Etiology (Causes)

Plantar heel pain often shows up as an overuse injury, like a rope that’s been tugged too hard, too often. Micro-tears form in the fascia, usually from repeated stress. Sometimes, it also results from trauma or other contributing factors.

Risk factors include:

• Limited ankle dorsiflexion or big toe flexibility
• Increased plantarflexion range
• Foot shape: Flat feet (pes planus) can overstretch the fascia; high arches (pes cavus) don’t absorb impact well, stressing the heel
• Dynamic overpronation or supination
• High-impact activities: running, jumping, standing long hours
• Poorly fitting shoes
• High BMI: In non-athletes, higher weight correlates with greater risk
• Heel spurs (though they’re not necessarily the cause)
• Diabetes or metabolic conditions
• Leg length differences
• Tight or weak calf muscles, Achilles tendon, or intrinsic foot muscles
• Active trigger points in muscles, which can amplify pain and disability

A 2016 systematic review confirmed three strong associations with plantar fasciitis: a thickened fascia, the presence of heel spurs, and high BMI (especially in non-athletes).

About 50% of those with this condition have heel spurs, but these are more of a side effect than a root cause. This condition often affects runners and older adults, but anyone who puts repetitive stress on their feet is at risk. In about 85% of cases, no specific systemic cause is found.

Epidemiology

Plantar fasciitis is the leading cause of heel pain in outpatient clinics.

• Affects 4% to 7% of the population
• Peak age: 40 to 60 years
• Accounts for 15% of foot injuries in the general population
• Responsible for 8% of running injuries
• 83% of patients are working adults (25 to 65 years old)
• A third of patients have bilateral symptoms
• Average symptom duration: 6+ months
• 90% recover with conservative care

Women are slightly more affected than men, especially those aged 45 to 64 and those with a BMI over 25. In the U.S., this condition leads to an estimated 2 million clinic visits annually and represents 1% of orthopedic consultations. It is the most common foot issue treated in physical therapy and podiatry clinics.

Physical Examination

Diagnosis is typically clinical, based on:

• Tenderness at the inner heel where the fascia inserts
• Pain with first steps in the morning or after resting
• Discomfort during toe dorsiflexion

The Windlass Test helps confirm diagnosis: dorsiflexing the big toe creates tension in the fascia and reproduces pain.

Secondary signs include:

• Tight calves or Achilles tendon
• Flat feet or high arches
• Gait changes
• Obesity
• Long periods of standing

Imaging (ultrasound or MRI) is only used in tough-to-diagnose cases. These can show thickened fascia or changes in tissue quality.

Clinical Presentation

• Sharp heel pain with first steps in the morning or after rest
• Tenderness in the front/inner part of the heel
• Limited ankle dorsiflexion
• Limp or toe-walking
• Pain walking barefoot or upstairs
• Often triggered by increased activity

Diagnostic Imaging

Ultrasound is the go-to imaging tool, showing thickened fascia (>4.0 mm) compared to controls. A newer technique, sonoelastography, may detect soft, damaged fascia even when traditional ultrasound looks normal.

Ultrasound is quick, cost-effective, and allows comparison with the other foot. MRI is more detailed but costly, making it a second-choice option. X-rays can show heel spurs but are rarely needed.

Medical Management

Start with conservative care:

• Relative rest
• Ice after activity
• NSAIDs (oral or topical)
• Massage and manual therapy
• Shoe inserts or orthotics
• Night splints
• Stretching (plantar fascia, calves, Achilles)

If symptoms persist:

• Corticosteroid injections: Short-term relief, but no long-term benefit
• Platelet-rich plasma (PRP): Promising, but results are mixed
• Surgery: Last resort (e.g. endoscopic plantar fasciotomy)

Physical Therapy Management

Key: patient education and setting expectations (it can take weeks to months to improve).

Recommended PT interventions:

• Manual therapy: joint mobilization, soft tissue release
• Stretching: especially plantar fascia and calf complex
• Active release techniques, fascial manipulation, and instrument-assisted mobilization
• Taping (e.g., low-dye technique) to control pronation
• Foot orthoses to support arch and cushion the heel
• Night splints to maintain gentle stretch overnight
• Dry needling of calf trigger points before invasive treatments

Other modalities:

• Cryotherapy
• Low-Level Laser Therapy (LLLT)
• High-Intensity Laser Therapy (HILT)
• Iontophoresis
• Extracorporeal Shockwave Therapy (ESWT)

ESWT has shown good results across several reviews, including faster pain relief and better return-to-work outcomes than other treatments.

Avoid routine use of ultrasound, electrotherapy, or dry needling per current guidelines. Instead, focus on:

• Proper footwear (e.g. rocker-bottom shoes)
• Weight management support if applicable
• Neuromuscular retraining to improve movement mechanics

High-load strength training (e.g. calf raises) may help speed up recovery and restore function. Foot muscle training alone has limited evidence.

Outcome Measures

• Foot and Ankle Ability Measure (FAAM)
• Visual Analog Scale (VAS)
• Patient-Specific Functional Scale

Differential Diagnosis

• Neurological: nerve entrapment, lumbar radiculopathy
• Soft tissue: Achilles tendinopathy, fat pad issues, fascia rupture
• Bone: stress fracture, arthritis, tumors (rare)
• Systemic/metabolic: RA, infections, Paget’s disease, vascular issues

Conclusion

Recovery from plantar heel pain requires patient understanding and consistent rehab. With proper care, most people recover within 12 months. In stubborn cases, more advanced techniques and interdisciplinary care may be needed, especially to correct walking patterns or biomechanical issues.

Short-term use of corticosteroid injections may help, but the long-term benefit is minimal. Newer treatments like PRP and shockwave therapy show promise but need more research.

A combination of conservative therapy, movement education, and strength work remains the gold standard for most patients dealing with this frustrating but manageable condition.