Overview
The plantar fascia is a thick band that runs from the underside of the heel bone to the base of the toes and supports the arch under tension. Every step tightens it, and when the calf is tight or load rises faster than the tissue can adapt, it thickens and hurts where it attaches to the heel. The name says inflammation, but the tissue is degenerate rather than inflamed, which is why rest alone does little. It is the commonest cause of adult heel pain.
Treatment is decided by duration. Pain of under 3 months responds to a home program of stretching, footwear and load management in the large majority. Pain persisting at 6 months despite that program moves to shockwave or an ultrasound-guided injection, and only pain that has failed a year of proper care raises the question of surgery, which is rarely needed.
Common Symptoms
- Sharp pain under the heel with the first steps out of bed, easing after 5 to 10 minutes of walking
- The same pain after sitting through a meal or a drive, and at the end of a day on your feet
- Tenderness at one spot on the inner front edge of the heel pad, where the fascia attaches
- Pain that worsens with barefoot walking on tile, flat shoes, hills or speed work
Pain at the back of the heel rather than underneath it is insertional Achilles tendinopathy. Burning or numbness in the sole points to a pinched nerve (tarsal tunnel syndrome), a runner's heel that hurts when squeezed from both sides may be a stress fracture, and deep ankle joint pain is a different problem.
Causes & Risk Factors
A tight gastrocnemius is the most consistent finding: with the calf short, the ankle cannot bend enough during walking and the fascia is stretched to compensate. A jump in mileage, a new job standing on concrete, a return to training after time off, a summer in flat sandals and weight gain, including pregnancy, are the usual triggers. Runners in their 20s and 30s get it from training errors; between 40 and 60 it is most often the tight-calf, standing-occupation, extra-weight pattern.
How It Is Diagnosed
The diagnosis is made on exam. Dr. O'Donnell reproduces the pain by pressing on the medial calcaneal tubercle, the inner front edge of the heel, and performs the windlass test, pulling the big toe up to tension the fascia. Calf tightness is measured with the Silfverskiöld test, comparing ankle dorsiflexion with the knee straight and bent. The heel is squeezed to screen for a stress fracture and the tarsal tunnel is tapped for nerve symptoms.
Imaging is not needed to start treatment. A weight-bearing X-ray is taken if the history is atypical, the heel squeeze is painful, or pain has not improved after 3 months; it may show a heel spur, a consequence of the tension rather than the cause of the pain. Office ultrasound measures fascia thickness (over 4 mm supports the diagnosis) and guides any injection. Prior imaging can be shared through mymedicalimages.com.
Treatment Options
Non-operative care
The program has four parts, and it works when all four are done daily for 6 weeks or more. First, stretching: the plantar fascia stretch (pulling the toes back with the hand for 10 seconds, ten repetitions, before the first step in the morning and several times a day) and a straight-knee calf stretch on a step. Second, footwear: a supportive shoe with a firm heel counter and a slight heel, worn from the moment you get up, with a cushioned heel cup. Third, load: keep running but cut volume and hills, and swap some sessions for cycling. Fourth, a night splint that holds the ankle up while you sleep so the fascia does not shorten overnight, which is what stops the first-step pain.
Heel pain still present at 3 to 6 months is treated with shockwave therapy, a series of office treatments that stimulates healing in the degenerate tissue, or an ultrasound-guided injection. Dr. O'Donnell uses corticosteroid sparingly and not repeatedly, because repeated steroid can rupture the fascia and thin the heel fat pad; platelet-rich plasma is an alternative.
Surgery for refractory cases
Fewer than 5 in 100 need an operation. For those who have failed 12 months of care including shockwave, Dr. O'Donnell prefers a gastrocnemius recession, lengthening the tight calf through a small incision behind the knee, because it treats the cause and preserves the fascia. A partial release of the medial fascia is reserved for cases without calf tightness.
Recovery & What to Expect
Improvement is measured in months, the first-step pain is the last symptom to resolve, and progression is individualized.
| Phase | Timing | What happens |
|---|---|---|
| Settle | Weeks 0–2 | Daily fascia and calf stretching; supportive shoes at all times; heel cups; night splint; running volume cut; ice massage after activity |
| Build | Weeks 2–6 | Stretching continued; calf strengthening and foot intrinsic exercises; cross-training; morning pain shortening |
| Reload | Weeks 6–12 | Gradual return of running volume and hills; most patients substantially better by 12 weeks |
| Escalate if needed | Months 3–6 | Shockwave series or ultrasound-guided injection for persistent pain; program continued |
| Surgery considered | After 12 months | Gastrocnemius recession or partial fascia release; boot for 2 weeks; running at about 3 months |
Work and driving are not interrupted; running continues at reduced volume and returns to normal over months 2 to 3 in most patients. About 9 in 10 are better within a year without an injection or operation.
Frequently Asked Questions
Will plantar fasciitis go away on its own?
Most cases eventually settle, but left alone that can take a year or more, and rest prolongs it because the fascia and calf stiffen. With daily stretching, supportive shoes, a night splint and sensible load, most patients are substantially better within 3 months.
Is a heel spur causing my pain?
Almost certainly not. A spur is bone laid down where the fascia pulls on the heel; many people with spurs have no pain, and most with plantar fasciitis have no spur. The pain comes from the degenerate fascia, and the spur is left alone even in the rare case that goes to surgery.
What are the best exercises for plantar fasciitis?
Two stretches, done consistently. Before you stand up each morning, pull your toes back with your hand until the arch tightens and hold for 10 seconds, ten times; repeat several times a day. Then a straight-knee calf stretch on a step, 30 seconds, three times, twice a day. Add calf raises and towel curls from week 2.
Should I get a cortisone shot for plantar fasciitis?
Not as a first step. A single ultrasound-guided steroid injection gives good short-term relief for pain that has resisted 3 months of stretching, but repeated injections can rupture the fascia and thin the heel pad, so Dr. O'Donnell limits them. Shockwave and platelet-rich plasma are the alternatives, always alongside stretching.
Can I keep running with plantar fasciitis?
Usually yes, at reduced volume, on flat ground, in supportive shoes, with cycling replacing some sessions. Pain that stays mild during the run and settles by morning is acceptable; pain that is worse the next morning means the load is too high.
This page is for general education and is not a substitute for a medical evaluation. Treatment recommendations depend on your individual diagnosis and goals. Kevin O'Donnell, MD sees patients from Coral Gables, Miami, Brickell, Pinecrest and Coconut Grove at 475 Biltmore Way, and out-of-town patients by telemedicine.