Why does plantar fasciitis cause heel pain?

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Last reviewed on: 6/8/2022

Reviewed by: C. Benjamin Ma, MD, Professor, Chief, Sports Medicine and Shoulder Service, UCSF Department of Orthopaedic Surgery, San Francisco, CA. Also reviewed by David C. Dugdale, MD, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.

Treatment for heel pain usually involves using a combination of techniques, such as stretches and painkillers, to relieve pain and speed up recovery.

See your GP or another suitably qualified healthcare professional, such as a podiatrist, if you’ve had persistent heel pain for a number of weeks and it hasn't cleared up. They'll be able to diagnose the problem and give you specific advice about a suitable exercise programme.

Most cases of heel pain get better within 12 months. Surgery may be recommended as a last resort if your symptoms don't improve after this time. Only one in 20 people with heel pain will need surgery.

Rest

Rest the affected foot whenever possible. Avoid walking long distances and standing for long periods. However, you should regularly stretch your feet and calves using exercises such as those described below.

Pain relief

Non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, can be used to help relieve pain.

Some people also find applying an ice pack to the affected heel for five to 10 minutes can help relieve pain and inflammation.

However, don't apply the ice pack directly to your skin. Instead, wrap it in a towel. If you don't have an ice pack, you can use a packet of frozen vegetables.

Exercise

Exercises designed to stretch both your calf muscles and your plantar fascia (the band of tissue that runs under the sole of your foot) should help relieve pain and improve flexibility in the affected foot.

A number of stretching exercises are described below. It's usually recommended that you do the exercises on both legs, even if only one of your heels is affected by pain. This will improve your balance and stability as well as relieving your heel pain.

Towel stretches

Keep a long towel beside your bed. Before you get out of bed in the morning, loop the towel around your foot and use it to pull your toes towards your body, while keeping your knee straight. Repeat three times on each foot.

Wall stretches

Place both hands on a wall at shoulder height, with one of your feet in front of the other. The front foot should be about 30cm (12 inches) away from the wall.

With your front knee bent and your back leg straight, lean towards the wall until you feel a tightening in the calf muscles of your back leg. Then relax.

Repeat this exercise 10 times before switching legs and repeating the cycle. You should practise wall stretches twice a day.

Stair stretches

Stand on a step of your stairs facing upstairs, using the banister for support. Your feet should be slightly apart, with your heels hanging off the back of the step.

Lower your heels until you feel a tightening in your calves. Hold this position for about 40 seconds, before raising your heels back to the starting position. Repeat this procedure six times, at least twice a day.

Chair stretches

Sit on a chair, with your knees bent at right angles. Turn your feet sideways so your heels are touching and your toes are pointing in opposite directions. Lift the toes of the affected foot upwards, while keeping your heel firmly on the floor.

You should feel your calf muscles and Achilles tendon (the band of tissue that connects your heel bone to your calf muscle) tighten. Hold this position for several seconds and then relax. Repeat this procedure 10 times, five or six times a day.

Dynamic stretches

While seated, roll the arch of your foot (the curved bottom part of the foot between your toes and heel) over a round object, such as a rolling pin, tennis ball or drinks can. Some people find that using a chilled can from their fridge has the added benefit of helping to relieve pain.

Move your foot and ankle in all directions over the object for several minutes. Repeat the exercise twice a day.

Footwear

Your GP or podiatrist may advise you to change your footwear.

You should avoid wearing flat-soled shoes because they won't provide your heel with support and could make your heel pain worse.

Ideally, you should wear shoes that cushion your heels and provide a good level of support to the arches of your feet.

For women, wearing high heels, and for men wearing heeled boots or brogues, can provide short- to medium-term pain relief. This is because they help reduce pressure on the heels.

However, these types of shoes may not be suitable in the long-term because they can lead to further episodes of heel pain. Your GP or podiatrist will be able to advise you about suitable footwear.

Orthoses

Orthoses are insoles that fit inside your shoe to support your foot and help your heel recover. You can buy orthoses off-the-shelf from sports shops and larger pharmacies. Alternatively, your podiatrist should be able to recommend a supplier.

If your pain doesn't respond to treatment and keeps recurring, or if you have an abnormal foot shape or structure, custom-made orthoses are available. These are specifically made to fit the shape of your feet.

However, there's currently no evidence to suggest that custom-made orthoses are more effective than those bought off-the-shelf.

Strapping and splinting

An alternative to using orthoses is to have your heel strapped with sports strapping (zinc oxide) tape, which helps relieve pressure on your heel. Your GP or podiatrist can teach you how to apply the tape yourself.

In some cases, night splints can also be useful. Most people sleep with their toes pointing down, which means tissue inside the heel is squeezed together.

Night splints, which look like boots, are designed to keep your toes and feet pointing up while you're asleep. This will stretch both your Achilles tendon and your plantar fascia, which should help speed up your recovery time.

Night splints are usually only available from specialist shops and online retailers. Again, your podiatrist should be able to recommend a supplier.

Corticosteroid injections

If treatment hasn't helped relieve your painful symptoms, your GP may recommend corticosteroid injections.

Corticosteroids are a type of medication that has a powerful anti-inflammatory effect. They have to be used sparingly because overuse can cause serious side effects, such as weight gain and high blood pressure (hypertension).

As a result, it's usually recommended that no more than three corticosteroid injections are given within a year in any part of the body.

Before having a corticosteroid injection, a local anaesthetic may be used to numb your foot so you don't feel any pain.

Surgery

If treatment hasn't worked and you still have painful symptoms after a year, your GP may refer you to either:

• an orthopaedic surgeon – a surgeon who specialises in surgery that involves bones, muscles and joints
• a podiatric surgeon – a podiatrist who specialises in foot surgery

Surgery is sometimes recommended for professional athletes and other sportspeople who have heel pain that's adversely affecting their career.

Plantar release surgery

Plantar release surgery is the most widely used type of surgery for heel pain. The surgeon will cut the fascia to release it from your heel bone and reduce the tension in your plantar fascia. This should reduce any inflammation and relieve your painful symptoms.

Surgery can be carried out either as:

• open surgery – where the section of the plantar fascia is released by making a cut into your heel
• endoscopic or minimal incision surgery – where a smaller incision is made and special instruments are inserted through it to gain access to the plantar fascia

Endoscopic or minimal incision surgery has a quicker recovery time, so you'll be able to walk normally much sooner (almost immediately), compared with two to three weeks for open surgery.

A disadvantage of endoscopic surgery is that it requires a specially trained surgical team and specialised equipment, so you may have to wait longer for treatment than if you were to choose open surgery.

Endoscopic surgery also carries a higher risk of damaging nearby nerves, which could result in symptoms such as numbness, tingling, or some loss of movement in your foot.

As with all surgery, plantar release carries the risk of causing complications such as infection, nerve damage and a worsening of your symptoms after surgery (although this is rare).

You should discuss the advantages and disadvantages of both techniques with your surgical team. 

Extracorporeal shockwave therapy (EST)

Extracorporeal shockwave therapy (EST) is a fairly new type of non-invasive treatment. Non-invasive means it doesn't involve making cuts into the body.

EST involves using a device to deliver high-energy soundwaves into your heel. The soundwaves can sometimes cause pain, so a local anaesthetic may be used to numb your heel.

It's claimed that EST works in two ways. It's thought to:

• have a "numbing" effect on the nerves that transmit pain signals to your brain
• help stimulate and speed up the healing process

However, these claims haven't been definitively proven.

The National Institute for Health and Care Excellence (NICE) has issued guidance about the use of EST for treating plantar fasciitis.

NICE states that there are no concerns over the safety of EST, but there are uncertainties about the effectiveness of the procedure for treating heel pain.

Some studies have reported that EST is more effective than surgery and other non-surgical treatments, while other studies found the procedure to be no better than a placebo (sham treatment).

For more information, you can read the NICE guidance about using EST for treating plantar fasciitis (PDF, 96.4kb).

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