Plantar fasciitis: why your heel hurts, and how to fix it

Plantar fasciitis is one of the most common causes of heel pain we see, and one of the most misunderstood. The pain sits under the heel, is at its worst on your first steps in the morning or after long periods of sitting, and eases as you move. It is not a tear, it is not gout, and it is very rarely a spur. It is an overload problem in the thick band of tissue that runs along the sole of your foot, and it responds well to a proper loading programme, sensible footwear and time. Most people are meaningfully better within 3 months of well-guided treatment.

What is plantar fasciitis?

The plantar fascia is a strong band of connective tissue that runs from the heel to the base of the toes, supporting the arch of your foot. In plantar fasciitis, this tissue has been overloaded and has become painful, thickened and irritated where it attaches to the heel. Like most tendon and fascia problems, the label ending in "itis" is a bit misleading. Inflammation is a small part of the picture. The main problem is structural change under load.

Why does it happen?

Plantar fasciitis is a load story. It typically appears when the fascia has been asked to handle more than it was ready for, whether that is a sudden jump in running volume, long days on your feet in unsupportive footwear, a change in surface, a spell of standing work, or weight gain over a period of months. Tight or weak calves, limited ankle range, and weakness in the small muscles of the foot all make it more likely.

How is it diagnosed?

Plantar fasciitis is a clinical diagnosis. A physiotherapist will take a careful history, palpate the fascia in specific places, look at how it responds to load, and rule out the conditions that can mimic it, including fat pad problems, tarsal tunnel syndrome, stress reaction in the heel bone, and referred pain from the low back. Imaging is not needed in most cases. A diagnostic ultrasound scan is helpful when the picture is unclear or when symptoms have failed to move with rehab.

How is it treated?

The most effective treatment is progressive loading of the fascia and calf, combined with sensible load management. High-load strength work, typically slow, heavy calf raises performed with the toes elevated on a rolled towel to load the fascia, has been shown in a randomised trial to speed recovery compared with stretching alone. Supportive footwear or an off-the-shelf insole helps by reducing peak load, and a night splint or heel wedge can settle first-step-of-the-day pain. Shockwave therapy has a role in stubborn cases and works best combined with loading, not as a replacement for it. Steroid injections are used selectively.

Alongside this, we look at the rest of the picture: hip and calf strength, ankle range, running mechanics, work standing posture, and simple things like weight management and sleep. Small changes add up.

What does recovery look like?

Most people notice a real change within 8 to 12 weeks of a well-structured programme. A full return to running, long-distance walking or standing sport can take 3 to 6 months. Around 80 to 90% of people recover fully within a year. Flare-ups during the process are common and usually mean load has crept up too quickly, not that the programme has failed.

When should you see a physiotherapist?

The best time to see a physiotherapist is early. Pain that has lasted more than a couple of weeks, or that is worst on your first steps in the morning, deserves a proper assessment before you start compensating elsewhere. Our physiotherapy team in Milton Keynes will diagnose what is going on, build the right loading programme for you, and adjust it as you progress. If your pain is higher in the heel or ankle and worse with activity, read our companion piece on Achilles tendinopathy.