Plantar Fasciitis

History:

First-step pain is the cardinal symptom - sharp, stabbing medial heel pain with the first steps in the morning or after prolonged sitting, easing with movement and worsening with prolonged weight-bearing. Insidious onset. Bilateral in around 30%.

Examination:

• •Focal tenderness at the medial calcaneal tuberosity is the most important sign

• •Windlass test: passive great-toe dorsiflexion reproduces pain at the insertion

• •Reduced ankle dorsiflexion: weight-bearing lunge or Silfverskiold test

• •Calcaneal squeeze test: positive in calcaneal stress fracture, NOT in plantar fasciitis

• •Footwear and foot-posture assessment

Red flags:

Bilateral pain with morning stiffness over 30 minutes (spondyloarthropathy enthesitis), severe rest or night pain (stress fracture, bone tumour, osteomyelitis), neuropathic symptoms (tarsal tunnel, Baxter nerve), acute pain with palpable defect (fascia rupture).

Plantar fasciitis is a clinical diagnosis. Imaging is usually not required for a typical presentation.

• •Plain radiographs: not first-line. Consider with red flags (e.g. suspected stress fracture) or atypical/refractory presentations. May show an incidental calcaneal spur.

• •USS: supports the diagnosis when uncertain. Shows fascial thickening (>4 mm), hypoechogenicity, neovascularisation. Also assesses fat pad and excludes rupture. Operator-dependent.

• •MRI: not first-line. Reserve for diagnostic uncertainty, refractory symptoms, or pre-operative planning.

• •Bloods: not routine. Consider ESR, CRP, HLA-B27 if spondyloarthropathy suspected.

Conservative care is the mainstay - around 80-90% resolve within 12 months. NICE CKS provides UK guidance.

First-line:

• •Education on the degenerative nature and self-limiting course. Explain the heel spur is not the cause of pain.

• •Load modification: reduce provocative activities. Avoid walking barefoot on hard surfaces - keep supportive shoes by the bed.

• •Plantar fascia-specific stretching (windlass stretch, with the toes pulled into dorsiflexion): 10 reps of 10-second holds, three times daily, particularly before first steps.

• •Calf stretching: gastrocnemius and soleus, 30-second holds, 3 reps, twice daily.

• •Cushioned and supportive footwear; silicone gel heel pads.

Adjuncts:

Low-Dye taping early - if it relieves pain, orthoses are likely to help. Trial prefabricated arch-support insoles. Short courses of oral or topical NSAIDs for symptomatic flares.

Progressive loading:

Rathleff high-load protocol - heel raises with a towel rolled under the toes, every other day, progressing from double-leg to single-leg with weight.

Refractory (>6 months):

Corticosteroid injection provides only short-term relief, with risks of fascia rupture and irreversible fat pad atrophy. UK practice limits to 1-2 lifetime injections. ESWT is supported by NICE IPG311.

Surgery is rarely needed; do not excise the heel spur.

Phase 1 - Symptom management (0-4 weeks):

• •Footwear review; avoid barefoot on hard surfaces; trial silicone gel heel pads.

• •Plantar fascia-specific stretching (windlass): 10 reps of 10-second holds, three times daily - especially before first steps.

• •Calf stretching: 30-second holds, 3 reps, twice daily.

• •Trial Low-Dye taping; consider a night splint if morning pain is prominent.

• •Ice after activity if acutely painful (frozen water bottle roll under the foot).

Phase 2 - Progressive loading (4-12 weeks):

• •Continue stretching.

• •Begin the Rathleff high-load protocol: heel raises with a towel rolled under the toes, every other day. Progress seated to standing double-leg to single-leg to weighted.

• •Add intrinsic foot strengthening (short-foot exercise, towel scrunches).

• •Continue orthoses if useful.

• •Refer to physiotherapy or podiatry if not progressing.

Phase 3 - Functional return (12+ weeks):

• •Build walking duration, stair tolerance, and single-leg balance.

• •For runners: a graduated walk-run programme once symptoms allow comfortable walking.

• •Maintenance strengthening alongside continued stretching.

Return to activity:

Criteria-based - comfortable walking without significant morning pain or post-activity flare, adequate calf endurance, and tolerable running where applicable.

Prevention:

Ongoing calf stretching, supportive footwear, gradual training progression, weight management.

• •NICE CKS: Heel pain (plantar) - Recommends conservative measures (education, footwear, stretching, analgesia) first-line. Refer if symptoms persist beyond 3-6 months.

• •NICE IPG311: Extracorporeal shockwave therapy - Supported for refractory plantar fasciitis after >6 months of failed conservative management.

• •DiGiovanni et al. (2003, JBJS) - Plantar fascia-specific stretching produced superior outcomes to standard Achilles stretching alone in chronic plantar fasciitis.

• •Rathleff et al. (Scand J Med Sci Sports 2015) - High-load strength training (heel raises with towel under toes) outperformed stretching alone at 3 months.

• •Aqil et al. (BMC MSK Disorders 2013) - Meta-analysis: ESWT produced clinically meaningful pain reduction in chronic plantar fasciitis at 12 weeks.

• •The cardinal symptom is first-step pain. Focal tenderness at the medial calcaneal tuberosity is the key sign; the windlass test reproduces pain at the insertion.

• •Heel spurs are incidental (50% of cases, 20% of controls). Do not excise them. This is one of the most commonly tested misconceptions.

• •Reduced ankle dorsiflexion (calf tightness) is the most important modifiable biomechanical factor. Use the Silfverskiold test.

• •Plantar fascia-specific stretching and calf stretching are the best-supported first-line treatments. Steroid injection is short-term only and risks fascia rupture and irreversible fat pad atrophy.

• •ESWT (NICE IPG311) is supported for refractory plantar heel pain >6 months.

• •Bilateral heel pain with morning stiffness over 30 minutes suggests spondyloarthropathy.