Plantar Fasciitis and Heel Spur

Sharp pain under the heel with the first steps after waking or after sitting, easing as you walk, returning after prolonged standing. The fascia shortens overnight and the first loading stretches it abruptly.

It is a load-related degenerative condition of the plantar fascia rather than an inflammation, which is why anti-inflammatory treatment alone helps symptoms and not the course.

Progressive high-load strengthening of the plantar fascia and calf, plantar fascia and calf stretching, and footwear or orthotic support that reduces the load. Load management — reducing the standing or running volume that provoked it — runs alongside.

Shockwave therapy has reasonable evidence for cases that have persisted beyond a few months, and it works with a loading programme rather than instead of one.

Most cases resolve, and slowly. Six to twelve months is common 1. Knowing this at the start prevents the common pattern of abandoning a programme at six weeks because it has not worked yet.

Corticosteroid injection gives short-term relief and carries a risk of fascia rupture and fat pad atrophy, so it is used cautiously and not repeatedly.

Heel pain with burning or tingling suggests nerve involvement. Sudden heel pain without a clear cause in an older adult or someone with osteoporosis can be a calcaneal stress fracture. Pain at the back of the heel is Achilles rather than fascia.

In children and adolescents during growth, heel pain is usually growth plate irritation and settles with load management.

The instinct with heel pain is to rest, and complete rest reliably produces short-term relief followed by return of the pain as soon as walking resumes. The tissue needs graded load to remodel.

The core of the programme is progressive calf and foot loading — slow, heavy, controlled — combined with calf stretching, because limited ankle dorsiflexion increases the strain the plantar fascia takes with every step. This is unglamorous and it is what changes the condition.

Supportive footwear with adequate cushioning reduces symptoms for many people, and going barefoot on hard floors at home is a common and easily fixed aggravator. Orthoses can help in the short term, particularly where foot mechanics are contributing.

What insoles do not do is treat the problem. They reduce the load while the tissue is sensitive, which is useful, but a plan consisting only of insoles leaves the underlying capacity untouched — and the pain returns when they come out.

Extracorporeal shockwave therapy is used for heel pain that has not responded to a genuine loading programme, and it is reasonable at that point rather than at the start.

Corticosteroid injection reduces pain for a period but carries a real risk of fascial rupture and fat pad atrophy with repetition, so it is used sparingly. Neither of these replaces the loading work; they create room for it.

Because the pain resolves before the tissue capacity is restored, and people stop. The heel starts to feel normal well before the tissue has fully adapted, the exercises stop, and the same load that caused the problem meets the same unprepared tissue.

The programme therefore ends with a maintenance plan and a clear statement of when it can be reduced — usually months rather than weeks after symptoms settle.

A heel spur is a small shelf of bone at the front of the heel where the plantar fascia attaches, and it appears on the X-rays of many people who have no heel pain at all. It is the result of years of traction on the fascia, not the cause of the pain, and removing it does not treat plantar fasciitis.

Patients who arrive with a diagnosis of heel spur are treated for the plantar fasciitis that produced it — loading, calf and fascia work, footwear and, where the tissue has not responded, shockwave. The spur stays where it is and stops mattering once the fascia settles.