Introduction

Plantar fasciitis is the most common cause of chronic heel pain and is a degenerative disorder of the plantar fascia resulting from repetitive mechanical overload and microtears at its origin on the medial calcaneal tubercle. Although previously considered an inflammatory condition, current evidence indicates that chronic plantar fasciitis is primarily a degenerative fasciopathy characterized by collagen disorganization, fibroblast proliferation, and failed tissue healing with minimal inflammation.

Based on symptom duration, plantar fasciitis may be classified as:

• Acute: 4–6 weeks

• Subacute: 6–12 weeks

• Chronic: >12 weeks

• Chronic refractory: Persistent symptoms despite appropriate conservative treatment.

Epidemiology

• Most common cause of inferior heel pain.

• Commonly affects adults between 40 and 60 years of age.

• Frequently occurs in runners and individuals whose occupations require prolonged standing.

• More common in overweight and obese individuals.

• Usually unilateral but may be bilateral.

Etiology

Plantar fasciitis results from repetitive tensile loading of the plantar fascia exceeding its capacity for repair.

Common causes include:

• Repetitive overuse

• Running and jumping activities

• Prolonged standing

• Sudden increase in physical activity

• Poor footwear

• Tight Achilles tendon

• Abnormal foot biomechanics

Risk factors

• Obesity

• Pes planus (flat foot)

• Pes cavus (high arch)

• Tight Achilles tendon

• Limited ankle dorsiflexion

• Prolonged standing

• Running on hard surfaces

• Increasing age

• Diabetes mellitus

• Inappropriate footwear

Pathophysiology

The plantar fascia functions as a major stabilizer of the longitudinal arch of the foot and plays an essential role during walking and running. Repetitive mechanical loading causes microscopic tears, particularly at the fascial insertion on the medial calcaneal tubercle. Instead of complete healing, repeated injury leads to collagen degeneration, fibroblast proliferation, disorganized extracellular matrix, and thickening of the fascia. These degenerative changes reduce the fascia's mechanical strength and produce pain, especially after periods of rest when the fascia shortens. During the first few steps after inactivity, sudden stretching of the shortened fascia reproduces the characteristic heel pain. Chronic disease may also involve surrounding nerves and adjacent soft tissues, contributing to persistent symptoms.

Classification

According to duration

Acute plantar fasciitis

Symptoms lasting 4–6 weeks.

Subacute plantar fasciitis

Symptoms lasting 6–12 weeks.

Chronic plantar fasciitis

Symptoms persisting for more than 12 weeks.

Chronic refractory plantar fasciitis

Persistent symptoms despite prolonged comprehensive conservative treatment.

Clinical presentation

Typical symptoms include:

• Sharp pain on the medial aspect of the heel

• Pain during the first steps after getting out of bed

• Pain after prolonged sitting or inactivity

• Pain improving after a few minutes of walking but worsening with prolonged activity

• Tenderness over the medial calcaneal tubercle

• Pain on passive dorsiflexion of the toes (positive Windlass test)

• Tight Achilles tendon

• Reduced ankle dorsiflexion

• Difficulty walking

• Limping in severe cases

Some patients may also report:

• Paresthesia

• Burning heel pain when associated with nerve irritation

Diagnostic criteria

Diagnosis is primarily clinical.

Diagnosis is supported by:

• Characteristic medial plantar heel pain

• Pain with the first steps after rest

• Tenderness at the medial calcaneal tubercle

• Pain reproduced by passive dorsiflexion of the toes (Windlass test)

• Tight Achilles tendon or limited ankle dorsiflexion

• Exclusion of alternative causes of heel pain

Investigations

Imaging is usually reserved for atypical presentations or persistent symptoms.

Plain X-ray

Useful to exclude:

• Calcaneal stress fracture

• Bone tumour

• Arthritis

A plantar calcaneal spur may be present but is not diagnostic of plantar fasciitis.

Ultrasound

First-line imaging when required.

Typical findings include:

• Plantar fascia thickness greater than 4 mm

• Hypoechoic degeneration

• Loss of normal fibrillar architecture

MRI

Recommended in:

• Chronic refractory plantar fasciitis

• Suspected plantar fascia rupture

• Suspected stress fracture

• Suspected tumour

• Persistent unexplained heel pain

MRI demonstrates:

• Thickened plantar fascia

• Increased signal intensity

• Bone marrow oedema when present

Nerve conduction studies and electromyography

May be considered when:

• Tarsal tunnel syndrome

• Peripheral neuropathy

• Entrapment neuropathy

are suspected.

Differential diagnosis

• Calcaneal stress fracture

• Tarsal tunnel syndrome

• Baxter nerve entrapment

• Achilles tendinopathy

• Fat pad atrophy

• Heel pad syndrome

• Calcaneal osteomyelitis

• Inflammatory arthritis

• Lumbar radiculopathy

Management

Treatment aims to:

• Relieve pain

• Restore function

• Improve flexibility

• Correct biomechanical abnormalities

• Prevent recurrence

• Avoid surgery whenever possible

Non-pharmacological management

Conservative treatment is the cornerstone of management.

Recommended interventions include:

• Weight reduction in overweight patients

• Activity modification

• Relative rest

• Stretching exercises for the plantar fascia and Achilles tendon

• Plantar fascia massage

• Ice application after activity

• Night splints

• Custom orthoses for patients with pes cavus or pes planus

• Appropriate footwear with adequate heel support

• Physiotherapy focusing on stretching and strengthening

• Extracorporeal shock wave therapy (ESWT) for subacute and chronic plantar fasciitis

Pharmacological treatment

Pain management (acute phase)

Ibuprofen

• 400 mg orally immediately, then 200 mg orally every 8 hours.

OR

Diclofenac sodium

• 50 mg orally every 8 hours for 7–14 days.

OR

Meloxicam

• 7.5–15 mg orally every 12–24 hours for 7–14 days.

OR

Tramadol + paracetamol (fixed-dose combination)

• 550 mg orally every 8 hours for 14 days.

OR

Ibuprofen + paracetamol (fixed-dose combination)

• 900 mg orally every 8 hours for 14 days.

Topical analgesics

For severe localized pain:

Diclofenac gel

• Apply every 12 hours.

OR

Ketoprofen gel

• Apply every 12 hours.

Gastroprotection

Patients with a previous history of peptic ulcer disease or those receiving NSAIDs for two weeks or longer should receive proton pump inhibitor therapy.

Options include:

Omeprazole

• 20 mg orally once daily for two weeks or longer.

OR

Pantoprazole

• 40 mg orally once daily for two weeks or longer.

Corticosteroid therapy

Prednisolone

• 40 mg orally once daily for 3 days followed by gradual tapering over 2–4 weeks.

OR

Triamcinolone (local injection)

• 40 mg per injection site.

• Repeat every 2–12 weeks if necessary.

• Maximum of four injections per year for up to two years.

OR

Betamethasone (intralesional)

• 12 mg per injection.

• Repeat every 2–12 weeks if necessary.

• Maximum of four injections annually for up to two years.

Surgical management

Surgery is reserved for patients with persistent symptoms despite prolonged comprehensive conservative treatment, usually after at least 6–12 months.

Procedures include:

• Open partial plantar fascia release with simultaneous release of the first branch of the lateral plantar nerve

OR

• Endoscopic partial plantar fascia release

Rehabilitation

Rehabilitation should continue throughout recovery and includes:

• Progressive plantar fascia stretching

• Achilles tendon stretching

• Strengthening of intrinsic foot muscles

• Calf strengthening exercises

• Gait retraining

• Balance and proprioception exercises

• Gradual return to work and sporting activities

Monitoring and follow-up

Patients should be reviewed regularly to assess:

• Pain severity

• Functional improvement

• Walking tolerance

• Response to physiotherapy

• Compliance with stretching programme

• Need for orthotic modification

• Medication adverse effects

Patients with persistent symptoms despite 6–12 months of appropriate conservative treatment should be referred for specialist assessment.

Complications

• Chronic heel pain

• Functional limitation

• Reduced walking tolerance

• Altered gait

• Plantar fascia rupture

• Heel fat pad atrophy following repeated steroid injections

• Reduced quality of life

Prognosis

The prognosis is generally excellent, with approximately 80–90% of patients improving with conservative treatment within 6–12 months. Early intervention using stretching exercises, activity modification, appropriate footwear, weight reduction, and physiotherapy significantly improves outcomes. Chronic refractory cases may require extracorporeal shock wave therapy or surgical intervention, although surgery is necessary in only a small proportion of patients.