Plantar fasciitis (heel pain)

What is plantar fasciitis?

The plantar fascia is a thick band of tissue running from the heel bone to the toes, supporting the arch. Plantar fasciitis develops when it is overloaded over time. Despite the name, it is usually not an inflammatory condition. It is a problem of repeated strain and slow tissue healing, sometimes called plantar fasciopathy.

What causes it?

It usually comes from several factors together:

1. A tight calf (gastrocnemius tightness). The most important and most treatable cause. Limited ankle movement strains the plantar fascia. In one study, people with the least ankle flexibility were about 23 times more likely to develop plantar fasciitis, and pain rose steadily with tightness.
2. Sleep position. Sleeping with the feet pointed down, particularly on your front, lets the calf and fascia tighten overnight, causing sharp pain with the first steps.
3. Mechanical overload. Long hours standing, especially at work, or a sudden increase in walking, running or exercise (the “weekend warrior” pattern).
4. Weight and metabolic health. Higher body weight increases load on the heel. Central body fat, raised cholesterol and diabetes reduce the healing ability of tendon and fascia.
5. Footwear and lifestyle. Unsupportive shoes, hard floors, walking barefoot and reduced overall fitness.

What are the symptoms?

• Pain under the heel, usually towards the inner side
• Worst with the first steps in the morning
• Pain when standing up after sitting
• Often eases after a few minutes of walking, then returns later in the day

First-line treatment: the most important part

• Calf stretching, every day. The key treatment. It improves ankle movement and reduces strain on the heel. It needs to continue long-term.
• Plantar fascia-specific stretching. Stretching the sole directly by pulling the toes back. Shown to reduce pain and improve function more than general stretching alone.
• Load management. Modify activity rather than stopping completely, and avoid sudden increases in walking, running or standing.
• Footwear and insoles. Cushioned, supportive shoes. Full-length contoured insoles work better than heel cups. Avoid walking barefoot on hard floors.
• Night splints or a foot positioning pillow. Hold the ankle gently stretched during sleep to reduce morning pain. Traditional splints can be hard to tolerate. The Foot-ZZ pillow is designed to be more comfortable.
• Physiotherapy to guide stretching, strengthening and a gradual return to activity.
• Weight management and general health improve the success of every treatment.

Second-line treatment

Used selectively when symptoms persist, alongside continued first-line treatment:

• Shockwave therapy. Sound waves applied to the heel stimulate healing. Relief is not immediate but builds over several weeks. It is a well-supported option and combines safely with stretching and physiotherapy.
• Steroid injection. Short-term relief only (see the questions below).
• PRP (platelet-rich plasma) or Botox injection. Short-term benefit similar to steroid, with better results at 12 months in some studies. Responses vary, so these are used when standard treatment has not worked.

Surgery

Surgery is uncommon. It is considered only when symptoms have lasted beyond 6 to 12 months, non-surgical treatment has been properly tried, and a tight calf is a major factor.

Gastrocnemius release (calf release)

A small operation behind the knee or upper calf lengthens the tight calf muscle and reduces strain on the plantar fascia, without cutting the fascia itself.

• More than 80% of patients have significant improvement in pain
• Some improve within weeks, but recovery continues for several months
• Recurrence is rare in long-term follow-up
• Usually a day-case procedure, with early walking and physiotherapy