Plantar heel

Plantar Fasciitis/Fasciopathy

Significant History/Physical symptoms

Plantar heel pain is a common problem in the foot, said to affect around 10% of adults during their lifetime (Babatunde et al, 2019) and there are a variety of mechanical factors that can contribute to the onset of pain around this area. Plantar fasciopathy (fasciitis, fasciosis) is likely the most common diagnosis, however the etiology of plantar heel pain is still not fully understood. Evidence suggests that it is associated with a high BMI, reduced ankle joint dorsiflexion and reduced strength in specific muscle groups, however, there is insufficient evidence that foot alignment is an important factor to consider (Sullivan et al, 2020).

It is crucial that the clinicians exclude red flags and serious pathology before settling on a diagnosis. Plantar fasciitis is usually diagnosed by clinical findings alone; if characteristic signs and symptoms are present the diagnosis is likely to be accurate. It is usually worse on initial weight bearing in the morning, better throughout the day and increasing in the evening, and often there is tenderness at the medial tubercle where it attaches to the calcaneum.

Fat Pad Atrophy

Significant History/Physical symptoms

Fat pad atrophy is where the layer of fat that lies under the heel bone, begins to waste away due to too much strain being placed on the pad. People who wear high heels for a period of many years have an increased risk of developing fat pad atrophy.

Pain is usually felt in the central heel as a dull deep ache that feels like a bruise. Direct pressure with thumb to plate centre often recreates pain. This is a non–radiating pain, medial calcaneal tuberosity and planter fascia NOT affected. Pain is aggravated by walking barefoot on hard surfaces.

It is more common in elderly / overweight females, in occupations involving standing on concrete floors for long periods, or in patients with diabetes mellitus.

• Centralised or diffuse heel pain
• Dorsiflexion of toe does not increase pain
• Flattened, atrophied surface
• Often elderly or obese patients

Less Common Differential Diagnoses not included in this pathway:

Video on calcaneal squeeze test

• Tarsal Tunnel Syndrome
• Nerve entrapment
• Traumatic (fracture / heel bruise)
• Bursitis
• Infection
• Tumour
• Plantar calcaneal bursitis
• Stress fracture of calcaneum
• Calcaneal apophysitis
• Skin lesion e.g. verrucae, corn

The first line intervention should focus on educating the patient about the condition, and prescribing therapies that can be self-administered by the patient.

Leaflets should be given to patients to reinforce verbal advice and links to NHS website resources where available.

Plantar Heel Pain (2025)

Plantar Heel Pain - ARABIC

Plantar Heel Pain - UKRAINIAN

Plantar Heel Pain - PASHTO

Plantar Heel pain leaflet - FARSI

Plantar Heel Pain - URDU

Reasons that may require escalation to 2nd line intervention immediately:

• Significant biomechanical deficit
• Bilateral presentation, if through a thorough history, systemic factors as well as mechanical factors are suspected.

Initial Patient Directed Treatment Options

• Advise weight loss if appropriate
  • Signposting to activities which may promote weight loss link exit/parallel pathways
  • Referral to Weight Management Service if BMI greater than 30.
  • NHS Choices - Lose weight
  • Leisure Pathway
• Activity modification and management advice
• Analgesia & Non-Steroidal Anti Inflammatory Drugs as appropriate.
  • See guidance on good practice for Analgesia Advice
• PEACE and LOVE (Protect, Elevate, Avoid anti-inflammatory modalities, Compress, Educate, Load, Optimisation, Vascularisation and Exercise)
• Footwear Advice
  • Give leaflet to reinforce verbal advice
    • NHSGGC Footwear Advice
  • Alternative Shoe Lacing Options

Plantar Fasciitis only

• Exercise Prescription
  • Both specific plantar fascia and achilles tendon stretches should be used. See Plantar Heel Pain Booklet.
• Heel Raise
  • These should be given bilaterally so as to avoid Leg Length Discrepancy
• Anti Pronation Strapping or Taping
  • Can be useful for a short period for pain relief and to aid in the differential diagnosis of heel pain and future treatment options. Remember to ask the patient about potential skin allergies before use.
  • Low Dye Taping

Fat Pad Atrophy only

• Heel pad
  • This may be supplied if available or patient can be directed to buy these

Non evidenced treatments

The following treatments are not supported by high quality evidence therefore they should not be considered as a treatment option for patients unless all other evidenced treatments have been tried unsuccessfully and there is clear clinical justification as to why these treatments are being used.

• Acupuncture/dry needling
  • Insufficient evidence to support use in this condition
• Low Level Laser Therapy LLLT
  • Some limited evidence but more research needed to determine optimum dosage to provide a significant effect
• Therapeutic Ultrasound
  • Minimal benefit and no conclusion on effective dosage parameters
  • Electrotherapy
• Night splints
  • No great evidence of therapeutic benefit with night splints

If patients are not improving as expected they should be referred on to another AHP who can deliver an escalated evidenced intervention or referred to orthopaedics as per the escalation guidance on the pathway.

• Biomechanical assessment and potential prescription of Foot Orthoses
  • Address biomechanical deficit if indicated by assessment.
  • Off the shelf or custom made insoles should be prescribed dependant on the severity of biomechanical deficit
  • The orthotic prescription should be decided by the clinician, who should describe the prescription in detail in the patient records
    
    
• Manual therapy
  • consisting of joint and soft tissue mobilisation

NOTE Corticosteroid Injections

Corticosteroid injection has historically been used as a first-tier intervention for heel pain/plantar fasciitis, however this treatment should not be used in either the first or second line intervention because there is limited evidence supporting the effectiveness and the benefits do not offset the risk of harms, including long-term disablement.

The results of 2 systematic reviews failed to yield evidence favouring any substantive clinical benefit of corticosteroid injection for patients with heel pain/plantar fasciitis. Potential harms associated with corticosteroid injection may include injection-site pain, infection, subcutaneous fat atrophy, skin pigmentation changes, plantar fascia rupture, peripheral nerve injury, and muscle damage.

Corticosteroid injection

• Ultrasound guided injection is not necessary in most cases and should only be considered in cases which are complex and a normal injection has failed or is assessed as having a high likelihood of failure.

One reason for referring to the orthopaedic department is for a surgical opinion. This is not a guarantee that surgery is the correct option for your patient so it’s important that this is not the expectation given to the patient by the referring clinician.

It is important that the patient has the option of a surgical opinion if this may be an appropriate treatment option for them so that they can discuss what is involved in surgery and make an informed decision.

Common conditions which are operated on include: hallux valgus, hallux rigidus, Morton’s neuroma, lesser toe issues, tendon pathology and degenerative changes of the joints of the foot and ankle.

The indications for surgery include persistent pain, worsening symptoms, significant limited mobility or failure of conservative therapy.

Foot and ankle surgery is generally successful with many of the common foot operations achieving 85% success rate, however complications can occur and will be considered as part of the decision making process for surgery.

Remember to exhaust all conservative means ie: orthotics, footwear advice , physiotherapy, pain relief medication , if appropriate steroid injections, before considering surgical opinion.

Further Investigation

The other reason for referral to Orthopaedics is for “Further Investigations”.

MRI and CT are helpful and can be arranged within orthopaedics as appropriate – if your patient does not have a clear diagnosis or there is a concern about a diagnosis and as above, struggling with symptoms, referral on to orthopaedics is appropriate.

Things to consider before referring for further investigation are the severity of the symptoms and whether there are odd/suspicious symptoms making it difficult to make a clear diagnosis.

Things to consider before referring to Orthopaedics:

Before referring to orthopaedics ensure the following:

• Vascular status – palpable pulses (for surgery)
• Patient is happy to attend for further review, possible further investigation and possible surgery as an outcome.
• Conservative means have been attempted.

This is a referral guide however please do not hesitate to contact your local ESP Orthopaedic clinician if you are unsure whether to refer.

The majority of the papers included here are level 1 or level 2 evidence, however other papers have been included to allow for further reading around the subject. Articles are listed in Harvard format.

Al-Boloushi, Z., López-Royo, M.P., Arian, M., Gómez-Trullén, E.M. and Herrero, P., 2019. Minimally invasive non-surgical management of plantar fasciitis: A systematic review. Journal of Bodywork and Movement Therapies, 23(1), pp.122-137.
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Aldridge, T., 2004. Diagnosing heel pain in adults. American family physician, 70(2), pp.332-338.
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Attard, J. and Singh, D., 2012. A comparison of two night ankle-foot orthoses used in the treatment of inferior heel pain: a preliminary investigation. Foot and Ankle Surgery, 18(2), pp.108-110.
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Babatunde, O.O., Legha, A., Littlewood, C., Chesterton, L.S., Thomas, M.J., Menz, H.B., van der Windt, D. and Roddy, E., 2019. Comparative effectiveness of treatment options for plantar heel pain: a systematic review with network meta-analysis. British journal of sports medicine, 53(3), pp.182-194.
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Baldassin, V., Gomes, C.R. and Beraldo, P.S., 2009. Effectiveness of prefabricated and customized foot orthoses made from low-cost foam for noncomplicated plantar fasciitis: a randomized controlled trial. Archives of physical medicine and rehabilitation, 90(4), pp.701-706.
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Bonanno, D.R., Landorf, K.B. and Menz, H.B., 2011. Pressure-relieving properties of various shoe inserts in older people with plantar heel pain. Gait & posture, 33(3), pp.385-389.
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Crawford, F., Atkins, D. and Edwards, J., 2001. Interventions for treating plantar heel pain. The foot, 11(4), pp.228-250.
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Digiovanni, B.F., Nawoczenski, D.A., Malay, D.P., Graci, P.A., Williams, T.T., Wilding, G.E. and Baumhauer, J.F., 2006. Plantar fascia-specific stretching exercise improves outcomes in patients with chronic plantar fasciitis: a prospective clinical trial with two-year follow-up. JBJS, 88(8), pp.1775-1781.
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Fabrikant, J.M. and Park, T.S., 2011. Plantar fasciitis (fasciosis) treatment outcome study: plantar fascia thickness measured by ultrasound and correlated with patient self-reported improvement. The Foot, 21(2), pp.79-83.
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Gooding, T.M., Feger, M.A., Hart, J.M. and Hertel, J., 2016. Intrinsic foot muscle activation during specific exercises: a T2 time magnetic resonance imaging study. Journal of athletic training, 51(8), pp.644-650.
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Hansen, L., Krogh, T.P., Ellingsen, T., Bolvig, L. and Fredberg, U., 2018. Long-term prognosis of plantar fasciitis: a 5-to 15-year follow-up study of 174 patients with ultrasound examination. Orthopaedic journal of sports medicine, 6(3), p.2325967118757983.
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Hawke, F., Burns, J., Radford, J.A. and Du Toit, V., 2008. Custom‐made foot orthoses for the treatment of foot pain. Cochrane Database of Systematic Reviews, (3).
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Hendrix, C.L., Jolly, G.P., Garbalosa, J.C., Blume, P. and DosRemedios, E., 1998. Entrapment neuropathy: the etiology of intractable chronic heel pain syndrome. The Journal of foot and ankle surgery, 37(4), pp.273-279.
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Hossain, M. and Makwana, N., 2011. “Not Plantar Fasciitis”: the differential diagnosis and management of heel pain syndrome. Orthopaedics and trauma, 25(3), pp.198-206.
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Hyland, M.R., Webber-Gaffney, A., Cohen, L. and Lichtman, S.W., 2006. Randomized controlled trial of calcaneal taping, sham taping, and plantar fascia stretching for the short-term management of plantar heel pain. Journal of Orthopaedic & Sports Physical Therapy, 36(6), pp.364-371.
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Irving, D.B., Cook, J.L. and Menz, H.B., 2006. Factors associated with chronic plantar heel pain: a systematic review. Journal of science and medicine in sport, 9(1-2), pp.11-22.
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Kelly, L.A., Kuitunen, S., Racinais, S. and Cresswell, A.G., 2012. Recruitment of the plantar intrinsic foot muscles with increasing postural demand. Clinical biomechanics, 27(1), pp.46-51.
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Martin, R.L., Davenport, T.E., Reischl, S.F., McPoil, T.G., Matheson, J.W., Wukich, D.K., McDonough, C.M., Altman, R.D., Beattie, P., Cornwall, M. and Davis, I., 2014. Heel pain—plantar fasciitis: revision 2014. Journal of Orthopaedic & Sports Physical Therapy, 44(11), pp.A1-A33.
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McPoil, T.G., Martin, R.L., Cornwall, M.W., Wukich, D.K., Irrgang, J.J. and Godges, J.J., 2008. Heel pain—plantar fasciitis. journal of orthopaedic & sports physical therapy, 38(4), pp.A1-A18.
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Neufeld, S.K. and Cerrato, R., 2008. Plantar fasciitis: evaluation and treatment. JAAOS-Journal of the American Academy of Orthopaedic Surgeons, 16(6), pp.338-346.
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Ozdemir, H., Söyüncü, Y., Ozgörgen, M. and Dabak, K., 2004. Effects of changes in heel fat pad thickness and elasticity on heel pain. Journal of the American Podiatric Medical Association, 94(1), p.47.
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Rathleff, M.S., Mølgaard, C.M., Fredberg, U., Kaalund, S., Andersen, K.B., Jensen, T.T., Aaskov, S. and Olesen, J.L., 2015. 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, 25(3), pp.e292-e300.
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Ribeiro, A.P., Trombini-Souza, F., Tessutti, V.D., Lima, F.R., João, S.M. and Sacco, I.C., 2011. The effects of plantar fasciitis and pain on plantar pressure distribution of recreational runners. Clinical Biomechanics, 26(2), pp.194-199.
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Riel, H., Jensen, M.B., Olesen, J.L., Vicenzino, B. and Rathleff, M.S., 2019. Self-dosed and pre-determined progressive heavy-slow resistance training have similar effects in people with plantar fasciopathy: a randomised trial. Journal of physiotherapy, 65(3), pp.144-151.
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Sullivan, J., Pappas, E. and Burns, J., 2020. Role of mechanical factors in the clinical presentation of plantar heel pain: implications for management. The Foot, 42, p.101636.
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Thomas, J.L., Christensen, J.C., Kravitz, S.R., Mendicino, R.W., Schuberth, J.M., Vanore, J.V., Weil Sr, L.S., Zlotoff, H.J., Bouché, R. and Baker, J., 2010. The diagnosis and treatment of heel pain: a clinical practice guideline–revision 2010. The Journal of Foot and Ankle Surgery, 49(3), pp.S1-S19.
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Tong, J., Lim, C.S. and Goh, O.L., 2003. Technique to study the biomechanical properties of the human calcaneal heel pad. The Foot, 13(2), pp.83-91.
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Toomey, E.P., 2009. Plantar heel pain. Foot and ankle clinics, 14(2), pp.229-245.
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Uden, H., Boesch, E. and Kumar, S., 2011. Plantar fasciitis–to jab or to support? A systematic review of the current best evidence. Journal of multidisciplinary healthcare, 4, p.155.
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Van Leeuwen, K.D.B., Rogers, J., Winzenberg, T. and van Middelkoop, M., 2016. Higher body mass index is associated with plantar fasciopathy/‘plantar fasciitis’: systematic review and meta-analysis of various clinical and imaging risk factors. British journal of sports medicine, 50(16), pp.972-981.
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Wearing, S.C., Hennig, E.M., Byrne, N.M., Steele, J.R. and Hills, A.P., 2006. Musculoskeletal disorders associated with obesity: a biomechanical perspective. Obesity reviews, 7(3), pp.239-250.
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Wrobel, J.S., Fleischer, A.E., Crews, R.T., Jarrett, B. and Najafi, B., 2015. A randomized controlled trial of custom foot orthoses for the treatment of plantar heel pain. Journal of the American Podiatric Medical Association, 105(4), pp.281-294.
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