Heel pain is one of the most common foot problems experienced by adults. It can affect people of all ages and activity levels—from athletes and people who exercise regularly to those who spend long hours standing at work.

One of the most common causes of pain underneath the heel is plantar fasciitis, a condition involving the strong band of tissue that runs along the bottom of the foot.

Although plantar fasciitis is common, an important point should be remembered:

Not all heel pain is plantar fasciitis.

Heel pain can arise from several different structures in and around the foot and ankle. Correctly identifying the cause is therefore important, particularly when pain is severe, persistent, recurrent or associated with other symptoms.

What Is the Plantar Fascia?

The plantar fascia is a thick band of connective tissue that runs from the heel bone, known as the calcaneus, towards the toes.

It has several important functions. It helps:

• support the arch of the foot;

• absorb and distribute forces as we walk;

• stabilise the foot during standing and movement; and

• assist the foot as it pushes off the ground during walking and running.

Every time we stand, walk or run, considerable forces pass through the feet. The plantar fascia forms part of the system that helps the foot cope with these stresses.

When the amount of stress placed on the plantar fascia exceeds what the tissue can comfortably tolerate, pain can develop.

What Is Plantar Fasciitis?

Plantar fasciitis is the commonly used term for pain arising from the plantar fascia, usually near the point where it attaches to the heel bone.

Despite the name, the problem is not always simply one of "inflammation". In persistent cases, changes within the tissue may be more degenerative or related to repeated overloading rather than ongoing inflammation alone. For this reason, health professionals may sometimes use terms such as plantar fasciopathy or plantar heel pain.

For the general public, however, plantar fasciitis remains the term most commonly used.

What Does Plantar Fasciitis Feel Like?

One of the most characteristic symptoms is pain underneath the heel.

Many patients describe a very distinctive pattern:

The first few steps after getting out of bed in the morning are extremely painful.

The pain may begin to ease after walking for a short period, only to return later after prolonged standing, walking or exercise. Pain may also occur when standing after sitting for a long time. This "first-step pain" is a classic feature of plantar fasciitis.

Other symptoms can include:

• tenderness underneath or towards the inside of the heel;

• aching or sharp pain when weight is placed on the foot;

• discomfort extending slightly forward into the arch;

• pain following prolonged walking or standing;

• pain after exercise rather than necessarily during exercise;

• discomfort when the toes are pulled upwards and the plantar fascia is stretched.

Some people describe the pain as feeling like they are stepping onto a stone or nail, even though nothing is actually inside the heel.

Why Does Plantar Fasciitis Develop?

There is rarely one single cause.

In many cases, plantar fasciitis develops when the forces placed on the plantar fascia repeatedly exceed the tissue's ability to recover.

Several factors may contribute.

A Sudden Increase in Activity

Beginning a new exercise programme, significantly increasing walking, running more frequently or suddenly becoming much more active can overload the plantar fascia.

The body needs time to adapt to increased physical demands.

This can also occur when someone who has been relatively inactive suddenly spends several days walking extensively—for example, while travelling, participating in an event or returning to exercise.

Long Periods of Standing

People whose occupations require prolonged standing or walking can be more susceptible to heel pain, particularly when working on hard surfaces.

Teachers, nurses, healthcare workers, hospitality workers, retail staff, factory workers, construction workers and others who spend much of the day on their feet may experience this problem.

Tight Calf Muscles

Tightness in the calf muscles and reduced ankle flexibility can affect the way forces pass through the foot.

This is one reason calf stretching is commonly included as part of plantar fasciitis treatment. Stretching of the plantar fascia itself is also supported as part of conservative management.

Foot Structure and Function

Both high-arched and lower-arched feet can experience plantar heel pain.

The important issue is not simply whether someone has a "flat foot" or a "high arch", but how the entire foot and lower limb function when standing, walking and running.

A podiatrist may therefore examine:

• foot posture;

• ankle movement;

• calf flexibility;

• walking pattern;

• footwear;

• muscle strength;

• areas of excessive pressure;

• occupational demands; and

• sporting or exercise activity.

Footwear

Shoes affect how forces are transmitted between the ground and the foot.

Footwear with very thin soles, poor cushioning or inadequate support may aggravate symptoms in some individuals.

This can be particularly relevant in Caribbean environments where people may spend considerable time in flip-flops, slippers, sandals or barefoot on hard tiled or concrete floors.

This does not mean everyone with plantar fasciitis requires rigid or specialised footwear. Rather, footwear should be appropriate for the individual's symptoms, activity and foot mechanics.

Body Weight

Carrying additional body weight can increase the forces passing through the feet during standing and walking.

For some individuals, weight management may therefore form part of a broader treatment approach. Both the NHS and clinical guidance recognise increased body weight as one of several factors associated with plantar heel pain.

Age

Plantar fasciitis is particularly common in middle-aged adults, although it can occur at almost any age.

Heel pain in children and adolescents has different considerations and should not automatically be assumed to be plantar fasciitis.

For example, an active growing child with heel pain may have calcaneal apophysitis, commonly called Sever's disease, rather than adult-type plantar fasciitis.

What About Heel Spurs?

Heel pain is frequently blamed on a heel spur seen on an X-ray.

A heel spur is an area of bony growth on the heel bone. However, finding a heel spur does not automatically mean that it is causing the patient's pain.

Some people have prominent heel spurs without experiencing heel pain, while people with significant plantar fasciitis may have little or no spur formation.

For this reason, treatment should generally be based on the patient's symptoms and clinical findings rather than simply trying to "treat the spur".

The painful structure is often the surrounding soft tissue rather than the presence of the bony spur itself.

Not Every Painful Heel Is Plantar Fasciitis

This is particularly important.

Heel pain is a symptom, not a diagnosis.

Several conditions can produce pain around the heel.

Achilles Tendinopathy

This usually causes pain towards the back of the heel or above the heel, rather than underneath it.

It may be associated with stiffness, swelling and pain during walking, running or climbing stairs.

Heel Pad Pain

The natural fatty tissue underneath the heel acts as a shock absorber.

Irritation, thinning or injury of this heel pad can cause pain directly beneath the centre of the heel. Patients sometimes describe this as a deep, bruised feeling.

Calcaneal Stress Fracture

Repeated loading can occasionally produce a stress injury within the heel bone.

This may cause progressively worsening pain with weight-bearing and can sometimes be mistaken for plantar fasciitis.

Nerve-Related Pain

Nerves around the ankle and heel can become irritated or compressed.

Burning, shooting, tingling, electric-type pain or numbness may suggest a nerve problem rather than typical plantar fasciitis.

Arthritis and Inflammatory Conditions

Certain forms of arthritis can cause heel pain.

Pain affecting several joints, prolonged morning stiffness, recurrent swelling or heel pain affecting both feet may require investigation for a broader inflammatory condition.

Gout

Although gout more commonly affects the big-toe joint, it can affect other parts of the foot and ankle.

Sudden severe pain accompanied by marked redness, heat and swelling is not the usual presentation of uncomplicated plantar fasciitis and should be medically assessed.

Bursitis

Small fluid-filled sacs called bursae reduce friction around joints and tendons. Irritation of these structures can cause pain around the heel.

Injury or Foreign Body

Stepping on an object, sustaining a puncture injury or experiencing trauma may cause heel pain.

A foreign body is not always remembered by the patient and may not necessarily be immediately obvious.

Infection

Infection is not a typical cause of ordinary plantar fasciitis but must be considered when heel pain occurs with symptoms such as increasing redness, heat, swelling, a wound, discharge or fever.

Particular caution is necessary in people with diabetes or impaired circulation.

The NHS similarly advises that heel pain may have several causes, including plantar fasciitis, Achilles problems, bursitis and fractures, and that severe or unusual presentations should be assessed.

How Is Plantar Fasciitis Diagnosed?

In many cases, plantar fasciitis can be diagnosed from a person's history and a clinical examination.

A podiatrist may ask:

• Where exactly is the pain?

• When did it begin?

• Is it worse with the first few steps in the morning?

• Does it improve after moving?

• Does it return after prolonged standing?

• Has there been a recent increase in activity?

• Has there been an injury?

• What footwear is normally worn?

• What type of work does the person do?

• What sports or exercise are involved?

• Are there any medical conditions that could be relevant?

The foot and ankle can then be examined to determine the location of tenderness, joint movement, foot mechanics, calf flexibility, muscle strength and other possible causes.

Imaging is not required for every case of plantar fasciitis. Clinical examination is often sufficient. Imaging may be considered when symptoms are unusual, severe, persistent or when another condition such as a stress fracture is suspected.

Depending on the circumstances, investigations could include X-rays, ultrasound, MRI or other tests.

How Is Plantar Fasciitis Treated?

Most cases are treated without surgery.

Successful treatment usually involves addressing several contributing factors rather than looking for one "miracle cure".

1. Reduce the Irritating Load

Complete inactivity is not usually necessary, but repeatedly performing the activity that aggravates the heel can delay recovery.

Running, jumping, prolonged walking or extended standing may need to be temporarily reduced.

Lower-impact activities can sometimes be substituted while symptoms settle.

The aim is often load modification rather than complete rest.

2. Wear Appropriate Footwear

A comfortable shoe with suitable cushioning and support can reduce stress on the painful heel.

During a painful episode, repeatedly walking barefoot on hard floors may aggravate symptoms. Very flat, thin or unsupportive footwear may also be uncomfortable.

For many people, something as simple as changing what they wear around the house can make a noticeable difference.

3. Stretch the Plantar Fascia

Specific plantar fascia stretching can be helpful.

A simple technique is to sit down, cross the painful foot over the opposite leg, hold the toes and gently pull them backwards towards the shin until a stretch is felt along the arch.

The stretch should be controlled rather than forceful.

4. Stretch the Calf Muscles

Calf stretching may improve ankle flexibility and reduce excessive loading through the foot.

Different stretches can target the gastrocnemius and soleus muscles, which together form much of the calf complex.

Stretching exercises are among the interventions supported in contemporary clinical guidance for plantar heel pain.

5. Strengthening

Modern management of persistent musculoskeletal problems increasingly recognises the importance of improving the body's capacity to tolerate load.

Depending on the individual, strengthening may include exercises for the calf, intrinsic muscles of the foot and other muscles controlling the lower limb.

Exercise should ideally be progressed according to symptoms rather than applying the same programme to everyone.

6. Insoles or Foot Orthoses

Some patients benefit from temporary inserts, heel cushioning or foot orthoses.

Orthoses should not be viewed as a universal cure for plantar fasciitis.

Current clinical guidance suggests that orthoses may be useful as part of a broader treatment programme, rather than as the sole treatment.

A podiatrist can determine whether an off-the-shelf device is sufficient or whether a more individual approach is appropriate.

7. Taping

Foot taping can sometimes provide short-term symptom relief.

It may also help the clinician determine whether changing the mechanical load on the foot is likely to be useful before considering longer-term devices.

8. Ice and Pain Relief

Cold therapy may temporarily ease discomfort for some people.

An ice pack should normally be wrapped rather than placed directly against the skin.

Pain-relieving or anti-inflammatory medication may also be appropriate for some people, but medication is not suitable for everyone.

People with other medical conditions or those taking regular medication should seek advice from a doctor or pharmacist before taking anti-inflammatory medicines.

9. Night Splints

A night splint keeps the ankle and plantar fascia gently stretched while the person sleeps.

It may be particularly useful for people whose major complaint is severe pain during the first few steps in the morning.

The 2023 clinical practice guideline recommends a one- to three-month programme of night splints for patients who consistently experience first-step morning pain.

10. Shockwave Therapy

Extracorporeal shockwave therapy may be considered for persistent plantar heel pain that has not responded adequately to simpler conservative treatment.

It delivers mechanical energy to the affected tissue and does not involve surgery.

It is usually considered for more persistent cases rather than as the first treatment for someone who has only recently developed heel pain.

11. Injection Therapy

Corticosteroid injections may reduce pain in selected patients, but they are not automatically required for plantar fasciitis.

Repeated or inappropriate steroid injections around the plantar fascia carry potential complications, including weakening or rupture of the plantar fascia and changes to the heel's protective fat pad.

The potential benefits and risks should therefore be carefully considered.

12. Surgery

Surgery is rarely the first answer to plantar fasciitis.

Most people can be managed conservatively. Surgery is generally reserved for a relatively small group with persistent symptoms despite an extended period of appropriate non-surgical treatment.

How Long Does Plantar Fasciitis Take to Get Better?

Recovery varies considerably.

Some mild cases improve relatively quickly once the aggravating activity or footwear is changed. Others may take several months.

Long-standing plantar fasciitis can be frustrating because improvement is not always linear. A patient may feel considerably better for several days and then experience another painful episode after increased activity.

This does not necessarily mean that treatment has failed.

The important goal is usually a gradual reduction in symptoms accompanied by an increasing ability to tolerate normal activity.

Should You Stop Exercising?

Not necessarily.

The answer depends on the severity of the condition and the activity involved.

Someone whose heel becomes increasingly painful every time they run may need to temporarily reduce running distance or frequency.

However, this does not necessarily mean all exercise must stop.

Cycling, swimming, resistance training or another lower-impact activity may sometimes allow a person to maintain fitness while reducing repetitive stress on the heel.

Returning to higher-impact exercise should generally be progressive.

Can Plantar Fasciitis Come Back?

Yes.

A person may recover completely and experience another episode months or years later if the combination of contributing factors returns.

For example:

• suddenly increasing running mileage;

• returning to activity too aggressively;

• prolonged standing;

• changes in footwear;

• reduced ankle flexibility;

• reduced conditioning; or

• a significant increase in body weight.

Understanding what contributed to the original problem can therefore be as important as reducing the immediate pain.

When Should You See a Podiatrist?

A podiatrist should be considered when:

• heel pain is severe;

• pain is affecting normal walking or daily activities;

• symptoms continue despite appropriate self-care;

• the pain repeatedly returns;

• there is uncertainty about the diagnosis;

• pain developed after an injury;

• there is numbness, tingling or burning;

• the heel is significantly swollen;

• symptoms are unusual for plantar fasciitis;

• both heels are persistently affected;

• footwear or foot mechanics may be contributing;

• the individual is an athlete or needs guidance returning to sport; or

• there is an underlying medical condition affecting the feet.

A podiatrist can look beyond the painful spot itself and assess the entire foot and lower limb to determine why the heel is being overloaded.

Heel Pain and Diabetes

People with diabetes should be particularly careful about new foot pain.

Heel pain in a person with diabetes may still be caused by plantar fasciitis, but diabetes can also be associated with neuropathy, circulation problems, infection and delayed healing.

People with diabetes are therefore advised to seek professional assessment for new or unexplained foot problems rather than repeatedly attempting to treat them themselves. The NHS specifically recommends medical assessment when a person with diabetes develops heel or foot pain because foot problems can potentially be more serious in this group.

Any wound, blister, discolouration, swelling, heat or unexplained break in the skin deserves particular attention.

When Is Heel Pain Urgent?

Seek prompt medical attention if heel pain is accompanied by:

• a significant injury;

• inability to bear weight;

• sudden severe pain after a jump, fall or accident;

• a snapping or popping sensation;

• significant swelling or bruising;

• obvious deformity;

• rapidly increasing redness or heat;

• an open wound or discharge;

• fever or feeling generally unwell;

• significant numbness or loss of sensation; or

• a foot that becomes unusually cold, pale, blue or otherwise discoloured.

Severe heel pain following injury can indicate problems such as a fracture or Achilles tendon rupture and should not simply be assumed to be plantar fasciitis.

Can Heel Pain Be Prevented?

Not every case can be prevented, but several sensible measures can reduce unnecessary stress on the feet:

• increase exercise gradually rather than suddenly;

• wear footwear suited to the activity;

• replace excessively worn-out shoes;

• avoid spending excessive periods barefoot on hard surfaces if this triggers symptoms;

• maintain calf and ankle flexibility;

• include appropriate strengthening in an exercise programme;

• allow adequate recovery between demanding activities;

• manage body weight where appropriate; and

• address minor symptoms before they become severe enough to alter the way you walk.

The Bottom Line

Plantar fasciitis is one of the most common causes of heel pain, but it is not the only one.

The classic pattern is pain underneath the heel that is particularly noticeable during the first few steps after getting out of bed or after sitting for a while. The discomfort may ease once the foot warms up but return after prolonged standing, walking or exercise.

For many people, treatment involves a combination of modifying activity, appropriate footwear, stretching, strengthening and, where indicated, taping, orthoses or other therapies.

Most importantly, persistent heel pain should not simply be ignored or automatically blamed on a heel spur.

Pain is the body's way of indicating that something requires attention.

If heel pain is severe, persistent, recurrent or interfering with normal activities, having the foot properly assessed can help identify the cause and allow an appropriate treatment plan to be developed.

This article is intended for general education and should not replace individual medical or podiatric assessment. Anyone concerned about persistent or unusual heel pain should seek advice from an appropriately qualified healthcare professional.