Plantar Fasciitis
Degenerative (not purely inflammatory, despite the "-itis" suffix: now understood as fasciopathy with microtears/collagen degeneration) condition of the plantar fascia at its calcaneal origin, from repetitive microtrauma/overload.
Most common cause of heel pain.
Classic history: sharp, stabbing heel pain, worst with first steps in the morning or after periods of rest ("post-static dyskinesia"), improving somewhat with initial activity then worsening again with prolonged standing/walking by day's end.
Pain localized to medial plantar heel/calcaneal origin of fascia.
Risk factors: obesity, prolonged standing occupation, sudden increase in activity/running, tight Achilles/calf muscles, pes planus or pes cavus, inappropriate footwear.
Clinical: history and point tenderness over medial calcaneal tuberosity typically sufficient.
Imaging not routinely needed for typical presentation.
X-ray: if diagnostic uncertainty, atypical features, or considering alternative diagnosis (calcaneal stress fracture, bony pathology), plantar calcaneal spur may be seen but is an incidental finding present in many asymptomatic people, not causative or diagnostic.
Ultrasound/MRI: reserved for atypical/refractory cases before considering more invasive intervention.
Differentials: calcaneal stress fracture (more diffuse pain, activity-related without the classic first-step pattern), tarsal tunnel syndrome (nerve distribution, paresthesia), fat pad atrophy, systemic inflammatory arthropathy (bilateral, other joint involvement, consider spondyloarthropathy if young/bilateral), nerve entrapment (Baxter's nerve).
- Activity modification: reduce aggravating high-impact activity temporarily, not complete rest
- Stretching: plantar fascia-specific and Achilles/calf stretching, strong evidence, mainstay of treatment, several times daily
- Appropriate footwear: cushioned, supportive shoes; avoid barefoot walking on hard surfaces
- Over-the-counter or custom orthotics/heel cups: arch support, cushioning
- NSAIDs: short-term symptomatic relief
- Night splints: maintain dorsiflexion overnight, particularly for morning pain
- Ice massage/rolling (frozen water bottle under foot): symptomatic relief
- Most cases resolve within 6-12 months with conservative measures: set realistic expectations regarding timeframe
- Refractory (>6 months conservative management): corticosteroid injection (short-term relief, some risk of fascia rupture/fat pad atrophy with repeated use), extracorporeal shockwave therapy, platelet-rich plasma injection (emerging evidence)
- Surgical fasciotomy: rare, last resort for true refractory cases after exhausting conservative/minimally invasive options
Referral: podiatry/physiotherapy for structured stretching/orthotic program; orthopedics for refractory cases considering injection/surgical options.
