Plantar fasciitis develops when the band of tissue that connects the heel bone to the toes (the plantar fascia) is strained, and it causes pain under the heel, especially with the first steps in the morning [1][2]. The heel spur seen on an X-ray is not the cause of plantar fasciitis pain [2]. More than 90% of patients improve within 10 months with simple measures such as stretching exercises, suitable shoes and insoles; surgery is rarely needed [1][2].
What are plantar fasciitis and a heel spur?
The plantar fascia is a long, thin band of ligament tissue that lies just beneath the skin on the sole of the foot, connects the heel bone to the front of the foot and supports the arch [2]. Plantar fasciitis is the condition that arises when this tissue is strained, causing pain on the bottom of the foot around the heel and arch [1]. It is one of the commonest causes of pain under the heel [2].
In everyday language this pain is often called a "heel spur". A heel spur is a bony outgrowth on the heel bone that can be seen on an X-ray [2]. However, most people who have a bony spur on the heel have no heel pain, and the spur is not the cause of plantar fasciitis pain; the pain can therefore be treated without removing the spur [2].
What symptoms does it cause?
Pain usually comes on gradually and is generally linked to a change in the time spent on your feet or in your level of activity [3]. The following features suggest plantar fasciitis [1][2]:
- Pain that is much worse when you start walking after sleeping or resting; the first steps after getting out of bed in the morning are typical
- Pain that eases with movement but increases again with long periods of standing, walking or running
- Pain when the sole of the foot is stretched, for example when raising your toes off the floor or climbing stairs
- Pain that increases after exercise or activity rather than during it
Who gets it?
It is most common between the ages of 40 and 60 [1][2][3]. The main factors that increase the risk are [1][2][3]:
- Activity that is new or has been increased over a short time, especially exercise on hard surfaces
- Repetitive high-impact activities such as running and dancing
- Standing or walking for long periods on hard surfaces at work
- Tight calf muscles and limited upward movement of the ankle
- Excess weight
- Flat feet or a high arch
- Shoes with poor cushioning and support
How is it diagnosed?
The diagnosis is usually made from your history and examination; this checks for tenderness on the sole just in front of the heel bone and for limitation in bending the ankle upwards, and looks for other conditions that can cause similar pain [2][3].
If the examination findings are typical, imaging is usually not needed; it is considered when non-surgical treatment has not worked [3]. X-rays show the bones and help rule out other causes of heel pain such as a fracture or arthritis; MRI and ultrasound are not used routinely for diagnosis and are rarely requested [2].
First-line treatment: stretching, footwear and reducing load
More than 90% of patients with plantar fasciitis improve within 10 months of starting simple treatment methods [2].
The American Physical Therapy Association (APTA) guideline reports, on strong evidence, that stretching of the sole of the foot and the calf muscles reduces pain and improves function in the short and long term [3]. The stretch for the sole of the foot is best done in the morning, before standing or walking [2].
The evidence for insoles is more limited: the same guideline does not recommend ready-made or custom-made insoles on their own for short-term pain relief, and states that they may be used together with other treatments [3]. If a painkiller is needed, a pharmacist or doctor can be asked which one is suitable [1].
The main measures that can be applied at home are [1][2]:
- Reducing, or stopping for a while, the activities that make the pain worse; avoiding long periods of standing and walking
- Regular exercises to stretch the calf muscles and the sole of the foot
- Shoes that cushion the heel and support the arch well; avoiding high heels, tight pointed shoes and backless slippers; not walking barefoot on hard surfaces
- Insoles or heel pads inside the shoes
- An ice pack wrapped in a towel on the painful area for up to 20 minutes every 2 to 3 hours
- Exercise that does not put weight on the foot, such as swimming
- Losing weight if you are overweight
Other treatments: night splints, physiotherapy, injections and shock-wave therapy
A night splint keeps the sole of the foot stretched during sleep [2]. The APTA guideline recommends its use for 1 to 3 months in people who consistently have pain with the first step in the morning [3].
A physiotherapist shows you exercises that ease the symptoms [1]; in addition to stretching, the guideline also recommends hands-on treatment (manual therapy) and strengthening exercises [3].
A cortisone (steroid) injection is among the other treatments that may be offered [1]. A Cochrane review found low-quality evidence that, compared with placebo or no treatment, a steroid injection may slightly reduce heel pain for up to one month but makes no difference after that; serious side effects were rare, but they were under-reported [4]. A steroid injection can weaken the plantar fascia and lead to its rupture, which can in turn cause flattening of the arch and chronic pain [2].
In extracorporeal shock-wave therapy (ESWT) a machine delivers sound waves to the painful area, with the aim of stimulating healing of the tissue [5]. NICE has stated that in plantar fasciitis that has not responded to other treatments there is no major concern about the safety of this method, but that the evidence on its efficacy is inconsistent, and has asked that patients be informed of this uncertainty [5]. The American Academy of Orthopaedic Surgeons (AAOS) also reports that results are mixed and that the method is therefore not commonly performed [2].
Platelet-rich plasma (PRP) is obtained from the person's own blood and injected into the plantar fascia [2]. It does not carry the same risk of rupture as a cortisone injection; however, it can be expensive and more research is needed to determine its effectiveness [2].
Surgery
Because the great majority of patients improve without an operation, surgery is rarely needed; it is generally reserved for people who have not improved despite 12 months of intensive non-surgical treatment [1][2].
There are two types of procedure: releasing the plantar fascia by partly cutting it where it attaches to the heel bone, and lengthening the calf muscle in patients who still have difficulty pulling the ankle upwards despite stretching exercises [2]. Because the bony spur is not the cause of the pain, it is usually not removed [2].
In most patients the result is good; however, because surgery can also end in chronic pain and dissatisfaction, it is recommended only after all non-surgical methods have been tried [2].
How long does it last and what should you expect?
In most people plantar fasciitis improves with non-surgical methods, but this can take months [2]. If, despite the measures taken at home, the pain does not ease within two weeks, is getting worse or keeps coming back, is severe or is stopping daily activities, it is appropriate to see a doctor [1].
When not to wait
Not every heel pain is plantar fasciitis. In the following situations seek care without waiting; the first four can be signs of an injury such as a fracture or a ruptured Achilles tendon [1][6]:
- Severe heel pain that started after an injury
- A snapping, grinding or popping noise heard at the time of the injury
- You cannot walk, cannot walk on tiptoe or cannot climb stairs
- The foot or ankle has changed shape, or there is swelling and bruising in the calf and ankle
- Tingling or loss of feeling in the foot
- You have diabetes and foot pain; foot problems can be more serious in diabetes
Frequently asked questions
- Does a heel spur need to be removed by surgery?
- Usually not. Most people with a bony spur on the heel have no pain, and the spur is not the cause of plantar fasciitis pain; the pain can be treated without removing the spur [2].
- How long does heel pain take to settle?
- More than 90% of patients improve within 10 months of starting simple treatment methods [2]. If there is no improvement within two weeks of home treatment, you are advised to see a doctor [1].
- Do I need an X-ray or an MRI?
- Often not; the diagnosis is made by examination, and imaging is usually requested when treatment has not worked [3]. An X-ray helps rule out other causes such as a fracture; MRI and ultrasound are not used routinely [2].
This article is a general summary; diagnosis and treatment decisions are made by the doctor who examines you.
Sources
- Plantar fasciitis. NHS (nhs.uk), 2025. nhs.uk
- Plantar Fasciitis and Bone Spurs. American Academy of Orthopaedic Surgeons (OrthoInfo), n.d.. orthoinfo.org
- Heel Pain - Plantar Fasciitis: Revision 2023. Journal of Orthopaedic & Sports Physical Therapy (Koc TA Jr, et al.), 2023. pubmed.ncbi.nlm.nih.gov
- Injected corticosteroids for treating plantar heel pain in adults. Cochrane Database of Systematic Reviews (David JA, et al.), 2017. pubmed.ncbi.nlm.nih.gov
- Extracorporeal shockwave therapy for refractory plantar fasciitis (IPG311). National Institute for Health and Care Excellence (NICE), 2009. nice.org.uk
- Heel pain. NHS (nhs.uk), 2025. nhs.uk
This article is general information and does not replace an examination or imaging. If you have symptoms, see a doctor.
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- Foot pain: what causes it, what helps and which specialist to see?
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