Plantar heel pain

What it is

How a guideline and reviews describe it

A 2023 clinical practice guideline restates a case description for plantar fasciitis¹. It centres on pain under the inner side of the heel, most noticeable with the first steps after inactivity¹. The pain is also worse after long spells of weight-bearing¹. The guideline describes pain that comes on gradually, usually tied to a change in how much weight-bearing activity a person does¹.

A 2022 systematic review (a study that searches for all the research on a question in a set way) covered 214 articles⁵. It found that the criteria studies use to decide who takes part vary widely⁵. This page keeps the name each study used: plantar heel pain, plantar fasciitis or plantar fasciopathy^1,6,7.

The tissue behind the name

The plantar fascia is a band of tough tissue along the sole of the foot, from the heel toward the toes. In dissections of 12 feet, its thick central part arose on the calcaneus (heel bone) and split into five slips⁸.

Two views of the bones of the right foot with the plantar fascia coloured orange. From the inner side, with the lower shin bones above the ankle, it is a thin band under the arch, running from the underside of the heel bone to the ball of the foot. From below, it starts as a narrow band on the heel bone, widens as it runs forward along the sole, and splits into five slips, joined by cross bands, that reach the bases of the toes. — The plantar fascia of the right foot, from the inner side and from belowRendered by Your Basic Trainer from the Open 3D Model by AnatomyTOOL, which builds on Z-Anatomy and BodyParts3D (Database Center for Life Science). (source, CC BY-SA 4.0). Rendered from the 3D model with only the bones and the plantar fascia shown, the plantar fascia coloured orange, and the shin bones cut short

The 2023 guideline notes that the name plantar fasciitis implies a mainly inflammatory condition¹. It adds that the tissue changes may sit along a spectrum with both inflammatory and degenerative features¹. A meta-analysis (a study pooling earlier studies) of 21 ultrasound studies found the fascia 2.00 mm thicker in people with plantar heel pain⁹.

Who it affects

How common it is

Prevalence is the share of people in a group who have a condition at a given time. Incidence is how many new cases appear in a group over a set time. Studies report both for this pain^2,11.

Group studied	What was found
About 1.9 million patients in Dutch general-practice records	3.83 new cases per 1,000 patient-years: 4.64 in females and 2.98 in males²
About 75,000 people in a 2013 internet panel survey built to match US adults	An estimated 0.85% reported plantar fasciitis identified by a clinician, with pain in the past month¹²
5,109 adults aged 50 and over, from four general practices, answering a survey	Estimated prevalence in the last month of 9.6%, and 7.9% for disabling plantar heel pain¹¹
Runners, in a 2012 systematic review of running-related injuries	Incidence from 4.5% to 10.0% and prevalence from 5.2% to 17.5%¹³

In the US survey, it was more prevalent in women (1.19%) than men (0.47%)¹². The 2023 guideline states that it is most common between ages 40 and 60, without a sex bias¹.

A 2021 best practice guide says the pain mostly affects sedentary middle-aged and older adults⁶. It puts the pain at an estimated 8% of injuries related to running⁶.

Factors studied

Several findings come from one case-control study, which compares people who have a condition with similar people who do not. It had 50 patients with plantar fasciitis in one foot¹⁴.

Body weight: in that study, a body mass index (weight for height) above 30 had 5.6 times the odds of 25 or less¹⁴. A 2016 systematic review of 51 studies found an index above 27 was the one clinical factor significantly associated¹⁵. The effect was strongest in non-athletic people¹⁵.
Body weight in active people: a 2021 review of reviews reports one review of 12 studies that found no link in athletic populations¹⁶. A 2021 meta-analysis of 16 studies in physically active people did report higher body mass index as a risk factor¹⁷.
Ankle range: dorsiflexion is pulling the foot up toward the shin. In the case-control study, 0 degrees or less carried 23.3 times the odds of more than 10 degrees¹⁴. The confidence interval, a range showing how precise a result is, was wide: 4.3 to 124.4¹⁴. The 2023 guideline restates limited dorsiflexion as a risk factor¹. A 2024 case-control study of 108 patients with plantar fasciitis found it was not a risk factor: patients had more dorsiflexion than matched controls¹⁸.
Time on the feet: in the 50-patient study, spending most of the workday standing carried 3.6 times the odds¹⁴. A 2015 systematic review of four studies in workers found low-quality evidence of a link with weight-bearing tasks¹⁹.
Heel spurs: a heel spur is a bony outgrowth from the heel bone²⁰. A 2006 systematic review of 16 articles found a spur associated with chronic plantar heel pain²¹.

What studies found

How it changes over time

A 2023 systematic review describes plantar heel pain as not self-limiting, meaning not tending to settle on its own²². It notes that some studies report many people recovering on their own within a year²². It also cites evidence that up to 50% still have the pain at 10 years²².

One follow-up study covered 174 patients seen for plantar fasciitis between 2001 and 2011³. It estimated the risk of still having it at set times after symptoms began:

Estimated risk of still having it (%). Bars start at zero; the table below gives each value with its source.

Time since symptoms began	Estimated risk of still having it
1 year	80.5%³
5 years	50.0%³
10 years	45.6%³
15 years	44.0%³

In that study, 54% were symptom-free after a mean of 725 days of symptoms³. Of that group, 31.9% had at least one relapse first³. The risk of still having it was significantly greater for women and for patients with pain in both heels³. Fascia thickness and a heel spur at the start had no impact³.

The authors note that 75 of 269 invited patients did not respond, and probably had few or no symptoms³. They say the outlook would most likely have looked better had those patients taken part³.

Two 1994 follow-ups of patients managed without surgery reported^23,24:

100 patients, telephone follow-up at an average of 47 months: 82 had no symptoms, and 3 had symptoms that limited activity or changed their work²³.
105 patients on a standard non-surgical protocol: 89.5% had no heel pain within 10.9 months, and 4.8% chose surgery²⁴.

What a guideline and broad reviews concluded

The 2023 guideline gives¹:

Grade A to plantar fascia-specific and calf stretching, for short- and long-term pain and function¹.
Grade A to foot taping alongside other approaches, for short-term pain and function¹.
Grade A, kept from 2014, to 1 to 3 months of night splints (splints worn during sleep) for morning first-step pain¹. It notes that no new studies had tested them¹.
Grade B to exercise with resistance training for the muscles of the foot and ankle¹. It found too little evidence to identify a superior type¹.

A 2021 best practice guide drew on a systematic review, the views of experts and feedback from patients⁶. It concluded that the core approach should include taping, stretching and individualised education⁶.

The 2019 analysis of 31 trials was a network meta-analysis, which compares many options at once⁴. It found that the evidence does not suggest any commonly used option is better than any other⁴.

Stretching and exercise

A meta-analysis of eight randomised trials found moderate-quality evidence that plantar fascia-specific stretching reduced pain more than calf stretching²⁵. A 2026 meta-analysis of 12 randomised trials found no statistically significant difference in pain or foot function between stretching and comparators²⁶. Certainty was very low across its pooled outcomes, as the plantar fascia stretch page sets out²⁶.

A randomised trial of 48 patients compared high-load heel raises with daily plantar fascia-specific stretching²⁷. At 3 months the heel-raise group scored 29 points lower, a better result, on the Foot Function Index²⁷. The groups did not differ at 1, 6 or 12 months²⁷.

Foot orthoses and shockwave

Two 2018 meta-analyses of foot orthoses (shoe inserts) reached different conclusions^28,29:

19 trials, 1,660 participants: moderate-quality evidence that orthoses reduced pain more than sham (dummy) orthoses at 7 to 12 weeks²⁸. It was uncertain whether the change is clinically important²⁸.
20 randomised trials: no short-term difference in pain between prefabricated, custom and sham orthoses²⁹. It concluded that orthoses are not superior to sham or other conservative approaches²⁹.

The 2023 guideline says orthoses should not be used alone for short-term pain relief (grade B), but may be combined with other approaches (grade C)¹.

Shockwave therapy sends pulses of sound energy through the skin to a painful area. A 2023 meta-analysis of 236 randomised trials found it was the one approach that reduced pain against control in the medium and long term³⁰. A sham-controlled trial of 200 patients gave everyone advice and customised orthoses³¹. Adding radial shockwave gave no extra drop in heel pain during activity at 6 months³¹.

Injections and surgery

A 2017 Cochrane review, a systematic review done to the Cochrane Collaboration’s standards, covered 39 trials of corticosteroid injection³². A corticosteroid is a drug that copies a type of hormone the body makes. Against placebo (a dummy version) or nothing, it found low-quality evidence that an injection may slightly reduce pain for up to one month³². Among 699 injected participants in 21 trials, it counted two plantar fascia ruptures and three injection-site infections³². It said serious adverse events were rare but under-reported³².

A 2020 review covered 15 studies of endoscopic (keyhole) plantar fascia release for chronic plantar fasciitis³³. Scores improved after surgery in each study and the complication rate was 11.0%, on evidence the review judged weak³³.

In a 1986 report of 15 athletes who had surgical release of the plantar fascia, 14 returned to full athletic activity³⁴. In the 2017 Cochrane review, no trial of injection against placebo or nothing reported on return to previous activity³².

Connections

The central part of the plantar fascia arises on the calcaneus⁸. The tibial nerve page covers Baxter’s neuropathy.

A systematic review of seven studies found foot muscles generally smaller in volume in people with plantar heel pain, on very low-strength evidence³⁵.

Among injured runners seen at one sports medicine centre, plantar fasciitis was the third most common running injury³⁶. Heel raises, covered on the calf raise page, were added to advice and a heel cup in a randomised trial of 180 adults⁷. No between-group difference in pain reached the minimal important difference at any follow-up up to 52 weeks⁷.

A randomised study of 101 people with chronic plantar fasciitis compared a plantar fascia stretch programme with an Achilles tendon calf stretch programme³⁷. The first gave better scores for worst pain and first-step morning pain at eight weeks³⁷.