A note on this column: This article is general medical information, not a description of a service offered at this practice. Dr. Ishiguro's surgical practice is focused on hip and knee conditions — he does not treat plantar fasciitis or other foot and ankle disorders. This column is written to help readers understand a common condition and know when and how to seek the right specialist, typically a foot and ankle orthopaedic surgeon, podiatrist, or physiotherapist.
What plantar fasciitis actually is
The plantar fascia is a thick band of connective tissue that runs along the sole of the foot, from the heel bone (calcaneus) to the base of the toes. It acts like a bowstring, supporting the arch and absorbing load with every step. When this tissue is subjected to repetitive strain beyond what it can comfortably tolerate, it develops small areas of structural breakdown near its attachment at the heel — a process now understood to be primarily degenerative rather than acutely inflammatory, which is why many specialists now prefer the term plantar fasciopathy over the older "fasciitis."
The result is pain concentrated at the inside/bottom of the heel, classically worst with the first steps in the morning or after any period of sitting, and easing somewhat with continued gentle movement — only to return after prolonged standing or at the end of the day. It is one of the most common causes of heel pain seen in general practice and sports medicine clinics, accounting for a substantial share of all foot-related visits.
Who gets it, and why
Plantar fasciitis is estimated to affect around 10% of people at some point in their lives, with peak incidence between the ages of 40 and 60. It occurs in both sedentary and highly active populations — it's a well-known overuse injury in runners, but it is at least as common in people whose work involves long hours of standing or walking on hard surfaces.
Recognised risk factors
- Age 40–60 — and more common in women than men in most studies
- Obesity / higher body mass index — increases mechanical load on the fascia with every step
- Prolonged standing or walking — occupations requiring long hours on hard flooring
- Tightness of the calf muscles and Achilles tendon — restricted ankle dorsiflexion increases fascia strain
- Foot shape — both flat feet (pes planus) and high arches (pes cavus) alter load distribution
- Sudden increases in running volume or a change in footwear/training surface
What the evidence shows: A cross-sectional survey of 480 adults in the Jazan region of Saudi Arabia found that the odds of plantar fasciitis were significantly higher in people aged 40–55 (odds ratio 2.15) and 56–65 (odds ratio 3.58) compared with younger adults, in people with obesity (odds ratio 2.16), in those with weakness of the calf and intrinsic foot muscles (odds ratio 7.39), and in those whose jobs required substantial time standing or walking (odds ratios 3.17 and 1.83). Being male was associated with lower odds (odds ratio 0.52) (Khired et al., Cureus, 2022).
How the diagnosis is made
Plantar fasciitis is primarily a clinical diagnosis, made from a typical history combined with focal tenderness at the inner heel where the fascia attaches to the calcaneus, and pain reproduced by passively bending the toes upward (dorsiflexion), which stretches the fascia. Imaging is not required to make the diagnosis in most cases and is generally reserved for atypical presentations, symptoms that fail to improve with a reasonable trial of treatment, or when another diagnosis — such as a calcaneal stress fracture, nerve entrapment, or a systemic inflammatory condition affecting the heel — needs to be excluded.
When imaging is used, ultrasound has become a practical first choice: it is quick, inexpensive, and directly visualises the fascia at the point of care. The key finding is a thickened, often hypoechoic (darker-appearing) fascia near its heel attachment — studies have reported average thickness around 5–6 mm in symptomatic feet compared to roughly 2–3 mm in unaffected feet. MRI offers similar and sometimes more detailed information and is generally reserved for cases where the clinical picture remains unclear or surgery is being considered. Plain X-rays are often obtained early in the work-up, not because they show the fascia itself, but to rule out other bony causes of heel pain such as stress fracture; the "heel spur" sometimes seen on X-ray is a common incidental finding, present in many pain-free feet, and is not itself the cause of the pain.
What the evidence says about treatment
The reassuring news is that the great majority of people with plantar fasciitis improve with non-surgical care, though it can take several months of consistent effort — this is a condition that typically requires patience rather than one dramatic intervention. The 2023 revision of the American Physical Therapy Association's clinical practice guideline on heel pain remains a useful roadmap for what has the strongest supporting evidence.
Commonly used treatment options
- Plantar-fascia-specific and calf/Achilles stretching — recommended as a first-line measure with good evidence for short- and long-term pain relief
- Manual therapy — joint mobilisation and soft-tissue work directed at the foot and ankle, used to address stiffness and improve function
- Foot orthoses — prefabricated or custom insoles to redistribute load away from the painful area, particularly useful early in treatment
- Night splints — maintain the ankle in dorsiflexion overnight to reduce the classic first-step morning pain
- Corticosteroid injection — used for short-term pain relief when other measures haven't been sufficient, generally not repeated frequently given effects on fascia integrity with overuse
- Extracorporeal shockwave therapy (ESWT) — considered for persistent symptoms not responding to initial conservative measures
- Surgery (plantar fascia release) — reserved for the small minority whose symptoms persist despite 6–12 months of genuine conservative treatment
What the evidence shows: The 2023 Heel Pain – Plantar Fasciitis clinical practice guideline from the Academy of Orthopaedic Physical Therapy and American Academy of Sports Physical Therapy recommends manual therapy directed at the joints and soft tissues of the lower extremity to reduce pain and improve function, and plantar-fascia-specific plus gastrocnemius/soleus stretching for short- and long-term pain reduction. The guideline also notes that conventional weight-bearing radiography is the appropriate first imaging study for chronic heel pain, primarily to exclude other causes rather than to confirm plantar fasciitis itself (Koc et al., Journal of Orthopaedic & Sports Physical Therapy, 2023).
For patients who don't respond adequately to the basic measures above, two further options are commonly discussed: shockwave therapy and injections. Both have a reasonable evidence base, though neither is universally superior.
What the evidence shows: A systematic review with meta-analysis and meta-regression of 11 randomised controlled trials found that both focal and radial ESWT significantly reduced pain intensity on the Visual Analogue Scale compared with control (focal-ESWT: mean reduction of 2.82 points, 95% CI 1.24–4.39; radial-ESWT: mean reduction of 3.04 points, 95% CI 2.20–3.88; both P<0.001), and treatment was generally well tolerated, with the number and intensity of pulses influencing both pain outcomes and dropout rates (Lippi et al., European Journal of Physical and Rehabilitation Medicine, 2024).
What the evidence shows: A 2025 systematic review and meta-analysis comparing ultrasound-guided with landmark-guided ("blind") corticosteroid injection for plantar fasciitis found that ultrasound guidance produced significantly greater improvement in local tenderness threshold at both short- and long-term follow-up, along with a greater reduction in plantar fascia thickness on repeat imaging — but no significant difference between the two techniques in overall pain scores (VAS) or heel tenderness index. In practice, this suggests image guidance may improve the precision and some objective measures of the injection without necessarily changing how much pain relief the patient ultimately feels (Doan, Choo & Chang, Life, 2025).
| Approach | Typical timing | Notes |
|---|---|---|
| Stretching / orthoses | Weeks 0–6+ | First-line; low risk; requires consistency to work |
| Night splint | Weeks 2–8 | Targets morning "first-step" pain specifically |
| Corticosteroid injection | If unresponsive at 6–8 weeks | Short-term relief; limited repeat use |
| ESWT | If unresponsive at 8–12 weeks | Several sessions typically needed; evidence supports pain reduction |
| Surgical release | After 6–12 months of failed conservative care | Reserved for a small minority; specialist decision |
Surgical plantar fascia release — open or endoscopic partial release of the fascia — is considered only after a genuine, sustained trial of conservative treatment has failed, typically over 6 to 12 months. Because the fascia plays a real structural role in supporting the arch, surgery is approached cautiously and is not a routine first step even for stubborn cases; the overwhelming majority of patients never need it.
When to see a specialist
Heel pain that is severe, follows an injury, is accompanied by numbness or tingling, or occurs in both heels simultaneously without an obvious mechanical cause deserves a proper clinical evaluation rather than self-treatment, since these features can point toward a stress fracture, nerve entrapment (such as tarsal tunnel syndrome), or an underlying inflammatory arthritis rather than ordinary plantar fasciitis. For typical, gradually developing first-step heel pain, a period of self-directed stretching and supportive footwear is a reasonable starting point, but persistent symptoms beyond several weeks are worth discussing with a foot and ankle specialist or physiotherapist to confirm the diagnosis and build a structured treatment plan.
References (PubMed / Journal)
Koc TA Jr, Bise CG, Neville C, Carreira D, Martin RL, McDonough CM. Heel Pain – Plantar Fasciitis: Revision 2023. J Orthop Sports Phys Ther. 2023;53(12):CPG1–CPG39. DOI: 10.2519/jospt.2023.0303
Lippi L, Folli A, Moalli S, Turco A, Ammendolia A, de Sire A, Invernizzi M. Efficacy and tolerability of extracorporeal shock wave therapy in patients with plantar fasciopathy: a systematic review with meta-analysis and meta-regression. Eur J Phys Rehabil Med. 2024;60(5):832–845. DOI: 10.23736/S1973-9087.24.08136-X
Doan HN, Choo YJ, Chang MC. Comparison of Effectiveness Between Ultrasound-Guided and Blind Corticosteroid Injections in Plantar Fasciitis: A Systematic Review and Meta-Analysis. Life (Basel). 2025;15(7):1107. DOI: 10.3390/life15071107
Khired Z, et al. The Prevalence and Risk Factors of Plantar Fasciitis Amongst the Population of Jazan. Cureus. 2022;14(9):e29434. DOI: 10.7759/cureus.29434