Plantar Fasciitis
Common cause of heel pain due to degeneration and inflammation of the plantar fascia at its calcaneal insertion. Characterised by 'first-step' pain that improves with walking.
Key Facts
Most common cause of heel pain: affects ~10% of population at some point First-step pain: worst pain on first steps in morning or after prolonged sitting; improves with walking initially Risk factors: obesity (BMI >30), prolonged standing, flat feet (pes planus), high arch, tight calf muscles, runners Diagnosis: clinical; imaging NOT usually required Treatment: stretching exercises (calf and plantar fascia), supportive footwear, insoles, weight loss Corticosteroid injection: effective short-term but risk of fat pad atrophy and plantar fascia rupture Self-limiting: ~80% resolve within 12 months with conservative management Calcaneal spur: found in ~50% with plantar fasciitis; also in ~20% asymptomatic — poor correlation with symptoms
Overview
Key Facts
Plantar fasciitis (plantar heel pain, plantar fasciopathy) is the most common cause of inferior heel pain, resulting from degeneration of the plantar fascia at its attachment to the medial calcaneal tuberosity.
Epidemiology
- ~10% of population affected at some point
- Peak incidence: 40–60 years
- Equal sex distribution in general population; more common in female runners
- Accounts for ~80% of heel pain presentations
Aetiology
- Overuse/repetitive microtrauma
- Obesity (BMI >30)
- Prolonged standing (occupational)
- Biomechanical: pes planus (flat feet), pes cavus (high arch), tight Achilles/calf
- Running (especially increased mileage)
Pathophysiology
- Degenerative rather than inflammatory (similar to tendinopathy)
- Repetitive microtears at the enthesis (calcaneal insertion)
- Collagen degeneration, mucoid change, neovascularisation
- Calcaneal spur: reactive bony formation; poor correlation with symptoms
Clinical Presentation
Typical Presentation
- First-step pain: sharp/stabbing pain at inferior heel with first steps in morning
- Improves after a few minutes of walking ('warm-up' phenomenon)
- Worsens again after prolonged walking or standing
- Localised to medial calcaneal tuberosity
- Usually unilateral (bilateral in ~30%)
Examination
- Tenderness over medial calcaneal tuberosity (plantar surface)
- Pain on dorsiflexion of toes (windlass test)
- Tight calf muscles/Achilles
- May have pes planus
Red Flags
- Night pain at rest (consider stress fracture, tumour)
- Numbness/tingling (tarsal tunnel syndrome, neuropathy)
- Bilateral heel pain in young adult (enthesitis — spondyloarthropathy)
- Systemic features (reactive arthritis, AS)
Differential Diagnosis
| Diagnosis | Key Features | Investigation |
|---|---|---|
| Calcaneal stress fracture | Squeeze test positive, night pain, recent increased activity | MRI |
| Tarsal tunnel syndrome | Tingling/numbness in sole, Tinel positive behind medial malleolus | Nerve conduction |
| Spondyloarthropathy (enthesitis) | Young adult, bilateral, back pain, HLA-B27 | HLA-B27, MRI sacroiliacs |
| Fat pad atrophy | Central heel pain, loss of fat pad bulk | Clinical, USS |
| Achilles tendinopathy | Posterior heel pain, tenderness at Achilles insertion | USS |
Diagnosis / Investigation
Clinical Diagnosis (imaging rarely required)
- X-ray: if diagnostic uncertainty; may show calcaneal spur (non-specific)
- USS: thickened plantar fascia >4mm supports diagnosis; useful if persistent or atypical
- MRI: calcaneal stress fracture or other differential
Bloods
- Usually not needed
- If enthesitis suspected: HLA-B27, ESR/CRP
Management
Non-pharmacological (FIRST-LINE — ~80% effective)
- Stretching: plantar fascia stretch (pulling toes back) and calf stretches; 3× daily
- Supportive footwear: avoid flat shoes; cushioned heel
- Insoles/orthotics: prefabricated heel cups, arch supports
- Weight loss: if BMI >25
- Activity modification: reduce running/standing
- Ice: frozen water bottle rolling under foot
Pharmacological
- NSAIDs: ibuprofen 400mg TDS or naproxen 500mg BD (short course for pain)
- Corticosteroid injection: triamcinolone 40mg + lidocaine
- Short-term benefit (~50–70% relief at 4 weeks)
- Risks: fat pad atrophy, plantar fascia rupture (~2–6%)
- USS-guided preferred
Interventional
- Extracorporeal shockwave therapy (ESWT): if refractory to 6 months conservative; NICE IPG311
- PRP injection: emerging evidence; not routinely recommended
- Surgery: plantar fascia release (endoscopic or open) — very rarely needed (<5%)
Referral Criteria
- Podiatry: biomechanical assessment, orthotics
- MSK/sports medicine: persistent symptoms >3 months
- Orthopaedics: refractory to 6–12 months conservative
Prognosis
- ~80% resolve within 12 months with conservative treatment
- ~90–95% resolve within 18 months
- Surgery: ~75–85% satisfaction for refractory cases
- Recurrence: ~10–30%
- Bilateral: more common in spondyloarthropathy-associated
- Corticosteroid injection: short-term benefit; no long-term advantage over placebo
Other Relevant Information
Conservative Treatment Stepwise Approach
| Step | Intervention | Duration |
|---|---|---|
| 1 | Stretching, footwear, insoles, weight loss | 6 weeks |
| 2 | Add NSAIDs, continue stretching | 6 weeks |
| 3 | Corticosteroid injection | If 12 weeks conservative failed |
| 4 | ESWT or PRP | If 6 months failed |
| 5 | Surgical release | Very rarely needed |