Tendinopathy of the plantar fascia origin at the medial calcaneal tubercle causing first-step morning heel pain.
Also known as: plantar fasciitis, plantar fasciopathy, heel pain, plantar fasciosis
Overview
Degenerative tendinopathy of the plantar fascia at its origin on the medial calcaneal tubercle. Despite its name, the histopathology shows myxoid degeneration and fibroblastic disarray rather than acute inflammation ('fasciosis').
Epidemiology
Most common cause of heel pain in adults. Lifetime prevalence ~10%. Peak age 40-60; common in runners and people with prolonged standing occupations. Bilateral in ~30%.
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Repetitive microtrauma at the medial calcaneal tubercle from tensile loading of the plantar fascia during gait. Histologically, the lesion is degenerative with collagen disorganization, fibroblast proliferation, and neovascularization — analogous to other tendinopathies.
Clinical presentation
Symptoms
Sharp medial heel pain with the first steps in the morning or after prolonged sitting (post-static dyskinesia)
Pain improves after the first few minutes of walking but worsens with prolonged standing or activity
Insidious onset, often weeks to months
Worse on hard surfaces or in unsupportive footwear
Signs / physical exam
Point tenderness at the medial calcaneal tubercle (origin of plantar fascia)
Pain reproduced with passive dorsiflexion of the toes (windlass test)
Tight Achilles / limited ankle dorsiflexion common
Examine for pes planus or pes cavus
Calcaneal squeeze test typically negative (helps exclude calcaneal stress fracture)
Differential diagnosis
Calcaneal stress fracture — Pain with calcaneal squeeze, more diffuse heel pain; MRI bone edema; common in runners and military recruits
Tarsal tunnel syndrome — Numbness/burning of medial heel and sole; positive Tinel over posterior tibial nerve
Baxter nerve (first branch of lateral plantar nerve) entrapment — Sharp medial heel pain with weakness of fifth toe abduction; common in runners
Plantar fascia rupture — Sudden popping followed by bruising; usually after steroid injection or athletic injury
Sero-negative spondyloarthropathy (enthesitis) — Bilateral heel pain in a young patient, inflammatory features, HLA-B27
Fat pad atrophy — Diffuse heel pain in older adults, tenderness directly under the calcaneus
Achilles tendinopathy / insertional — Posterior heel pain, tender Achilles insertion or 2-6 cm proximal
Sever disease (calcaneal apophysitis) — Adolescent athletes; tenderness at posterior calcaneus
Diagnostic workup
Labs
Generally NOT indicated
Consider HLA-B27, ESR, CRP if young patient with bilateral disease and inflammatory features (suggesting enthesitis)
Imaging
Diagnosis is CLINICAL — imaging not routinely needed
Plain radiographs — heel spurs (incidental and unrelated to symptoms), exclude stress fracture
Ultrasound — thickened plantar fascia >4 mm with hypoechoic origin; useful when diagnosis uncertain
MRI — reserved for refractory cases, atypical presentations, suspected rupture, or alternative diagnoses
Diagnostic algorithm
Intervention
Evidence
Notes
Plantar fascia / calf stretching
Strong
First-line; eccentric calf protocol
Supportive footwear / orthotics
Moderate
Cushioned arch support
Night splints
Moderate
Helpful for refractory morning pain
NSAIDs (oral or topical)
Limited
Symptomatic only
Corticosteroid injection
Short-term benefit
Risk of rupture and fat pad atrophy — use sparingly
Patient education — natural history is favorable; most resolve within 6-12 months
Activity modification — reduce high-impact activity, alternate with cycling/swimming
Plantar fascia and Achilles stretching exercises (most evidence-based; eccentric calf stretching)
Supportive footwear with cushioning and arch support
Over-the-counter or custom orthotics
Night splints — hold ankle in dorsiflexion overnight; effective for refractory cases
NSAIDs — ibuprofen, naproxen, meloxicam — short course for pain (limited evidence for long-term benefit)
Ice massage, weight loss
Second-line / adjunct
Corticosteroid injection — short-term pain relief; carries risk of plantar fascia rupture and fat pad atrophy; ultrasound-guided injections reduce these risks
Extracorporeal shockwave therapy — modest evidence for chronic refractory cases
Platelet-rich plasma — emerging evidence for refractory tendinopathy
Physical therapy with manual treatment and gastrocnemius stretching
Walking boot for severe symptoms unresponsive to other measures
Gastrocnemius recession or plantar fascia release surgery — last resort after 6-12 months of failed conservative care
Complications
Persistent or recurrent pain
Plantar fascia rupture (sometimes after corticosteroid injection)
Fat pad atrophy from repeated steroid injections
Compensatory gait abnormalities, knee or back pain
Postoperative complications: persistent pain, nerve injury, arch collapse with overly aggressive plantar fascia release
PANCE pearls
First-step morning heel pain that improves with walking is essentially diagnostic.
Avoid repeated corticosteroid injections — they accelerate fat pad atrophy and risk fascia rupture.
Bilateral plantar fasciitis in a young patient warrants screening for spondyloarthropathy (enthesitis).
Heel spurs on X-ray are incidental — present in many asymptomatic adults and not a treatment target.
The single most effective intervention is consistent plantar fascia and gastrocnemius stretching; counsel patients on adherence over weeks to months.
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