Plantar Fasciitis – Heel Pain That Requires Patience

Those first steps out of bed in the morning are the classic hallmark. Plantar fasciitis is among the most common causes of heel pain, and among the conditions where expectations about the timeline most often break down – because the tissue involved needs months, not weeks, to adapt.

What the plantar fascia does – and what goes wrong

The plantar fascia is a strong sheet of connective tissue running from the heel bone forward to the toes, acting as a spring and shock absorber in the arch of the foot with every step you take. In plantar fasciitis, irritation and structural change occur where the fascia attaches to the heel bone.

As with tennis elbow, the '-itis' ending is misleading. Tissue samples rarely show active inflammation, but rather degenerative changes – which is why the term plantar fasciopathy is often preferred. This is why purely anti-inflammatory measures rarely solve the problem alone.

A commonly misunderstood finding is the heel spur. This bony outgrowth on the heel bone is present in a great many people with no pain at all, and is usually a sign of loading over time rather than the cause of your symptoms.

Heavy strength training beats stretching

In a randomised trial published in Scandinavian Journal of Medicine & Science in Sports in 2015, patients with ultrasound-verified plantar fasciitis were divided into two groups: one received insoles and daily stretching of the fascia, the other received insoles and heavy, progressive strength training every other day – single-leg heel raises with a towel rolled under the toes, so the fascia is tensioned during the lift.

After three months the strength group had clearly better results in foot function. After twelve months the groups were equal – both had improved. The practical message is therefore twofold: heavy loading appears to accelerate recovery considerably, but the condition takes time regardless.

That's an important message to receive early. Many people abandon a programme after four to six weeks because they aren't yet pain-free, when in reality they were on the right track.

Where injection therapy belongs

Corticosteroid injection often provides rapid pain relief in plantar fasciitis, but the effect is short-lived, and repeated injections carry a genuine risk of weakening the fascia – in the worst case leading to rupture. This means corticosteroid should be used cautiously and never as an ongoing solution.

A systematic review and meta-analysis published in the American Journal of Physical Medicine & Rehabilitation in 2025 compared PRP with corticosteroid. The finding was that PRP produced better pain relief in the medium term – at three and six months – while the difference was not statistically reliable at either one month or twelve months.

My clinical view: the evidence for PRP in plantar fasciitis is not as strong as in tennis elbow, and the picture is more mixed. Exercise is and remains the primary treatment. But for long-standing cases that don't respond to good loading programmes, PRP appears a safer alternative than repeated corticosteroid, precisely because it doesn't weaken the tissue.

Assessment: ruling out the look-alikes

Heel pain can come from more than the plantar fascia. Stress fracture in the heel bone, irritation of the nerve to the outer side of the foot (Baxter's nerve), fat pad atrophy under the heel, insertional Achilles problems, or referred pain from the lower back can all produce similar symptoms. The treatment differs for each of them.

Clinical examination with loading tests, palpation and neurological screening distinguishes most of these. Ultrasound supplements this by measuring the thickness of the fascia directly – a thickened fascia is an objective finding – and by revealing any tears, fluid accumulation or changes in the surrounding tissue.

A phase-adapted plan over time

Progression should follow the symptom picture rather than the calendar:

• Irritable phase: offload the peaks in loading, adjust footwear, and begin strength training at a level the foot actually tolerates
• Building phase: gradually increasing heavy, slow strength training for foot and calf, using morning pain as the marker
• Loading phase: systematically reintroducing walking and running volume, with jump loading where relevant
• Maintenance: keeping the strength work going after symptoms settle, to prevent recurrence

Sources

1. Rathleff MS, Mølgaard CM, Fredberg U, et al. "High-load strength training improves outcome in patients with plantar fasciitis: A randomized controlled trial with 12-month follow-up." Scandinavian Journal of Medicine & Science in Sports 2015;25(3):e292–e300.
2. "Platelet-Rich Plasma Versus Corticosteroids in the Treatment of Plantar Fasciitis: A Systematic Review and Meta-analysis." American Journal of Physical Medicine & Rehabilitation 2025.