From the Clinic; "I'd been told to rest it... but six months later it still hurt."

Plantar heel pain is one of the most common conditions I see in clinic. Almost everyone has heard the term "plantar fasciitis", yet many patients are surprised to learn that the condition often isn't an inflammatory problem at all.

This patient had already spent several months trying to manage the pain themselves. They had rested, stretched, changed footwear and reduced activity, but the discomfort remained.

By the time they attended my clinic, they wanted to know two things:

"What is actually causing my pain?"

and

"What do we do about it?"

Patient presentation

The patient presented with gradually worsening pain beneath the inside of the heel.

The symptoms were worst during the first few steps in the morning and after periods of prolonged sitting, gradually easing as they became more active before returning again after longer periods on their feet.

Walking for exercise had become increasingly limited and they had started avoiding activities they previously enjoyed.

Although they had read extensively about plantar fasciitis online, they were becoming increasingly frustrated that nothing seemed to be making a lasting difference.

Assessment

One of the first things I explain during an assessment is that heel pain should never be diagnosed from the history alone.

Although this patient's symptoms were highly suggestive of plantar fasciopathy, several other conditions can produce remarkably similar pain, including nerve entrapment, stress injury, fat pad pathology and inflammatory disease.

Clinical examination demonstrated localised tenderness at the medial calcaneal tubercle, discomfort with palpation of the plantar fascia origin and pain during specific loading tests.

These findings increased my suspicion of plantar fasciopathy, but I wanted objective confirmation before discussing treatment.

Diagnostic ultrasound was performed during the consultation.

The scan demonstrated thickening of the medial band of the plantar fascia at its calcaneal attachment with loss of the normal fibrillar appearance and focal hypoechoic change. Importantly, there was no evidence of a fascial tear, significant calcification or other pathology requiring an alternative management approach.

The ultrasound findings correlated closely with the patient's symptoms and clinical examination, allowing a confident diagnosis of plantar fasciopathy to be made.

The diagnosis explained

Despite the name "plantar fasciitis" still being widely used, we now know that many long-standing cases are not driven primarily by inflammation.

Instead, the plantar fascia undergoes a process of degeneration and failed healing following repeated overload.

This is why the term plantar fasciopathy is often more accurate.

The condition develops when the plantar fascia is repeatedly asked to tolerate more load than it can comfortably manage. Over time, the collagen fibres become disorganised, the tissue thickens and the fascia becomes less able to cope with the demands placed upon it.

Understanding this changes the way we think about treatment.

Rather than simply trying to reduce inflammation, our aim becomes improving the fascia's ability to tolerate load once again.

What we did

After confirming the diagnosis, we discussed the factors likely to have contributed to the problem.

These included recent activity levels, footwear, lower limb biomechanics, calf flexibility and loading patterns during walking.

Because the diagnosis had been confirmed, we could focus our treatment specifically on the plantar fascia rather than considering multiple competing diagnoses.

The patient was reassured that the ultrasound showed no evidence of a tear and that surgery was neither necessary nor appropriate at this stage.

The treatment plan

Treatment focused on reducing excessive load while progressively improving the strength and resilience of the plantar fascia.

We discussed activity modification rather than complete rest, appropriate footwear, stretching where indicated and a progressive loading programme.

We also discussed the role of custom foot orthoses in selected patients where abnormal loading patterns contribute to persistent symptoms.

Given the duration of symptoms, extracorporeal shockwave therapy was also discussed as an evidence-based treatment option should symptoms fail to improve with rehabilitation alone.

The patient left understanding not only what the diagnosis was, but why each part of the treatment plan had been recommended.

What can we learn from this?

One of the biggest misconceptions surrounding plantar heel pain is that complete rest will allow the fascia to heal.

In reality, prolonged rest often results in temporary improvement followed by recurrence as soon as activity resumes.

Successful treatment usually requires the fascia to be loaded appropriately rather than simply avoiding activity altogether.

Equally important is establishing the correct diagnosis first.

Treatments such as shockwave therapy or injections should only be considered once we are confident that plantar fasciopathy is genuinely the cause of the patient's symptoms.

My specialist thoughts

Plantar fasciopathy is one of the most rewarding conditions to treat because the vast majority of patients improve without surgery when the diagnosis is correct and treatment is tailored appropriately.

One of the most important parts of my consultation isn't performing the ultrasound—it's explaining why the condition has developed.

When patients understand that their fascia has become overloaded rather than simply "inflamed", the treatment plan begins to make much more sense.

My goal is never simply to reduce pain.

It's to restore the fascia's ability to tolerate the demands of everyday life so that patients can confidently return to the activities they enjoy.

About the author

Mr Liam Stapleton MSc, PGCert, PGDip, FFPM RCPS(Glas), FRCPodM

Mr Liam Stapleton is a Consulting Podiatrist, Independent Prescriber and Specialist in Podiatric Sports Medicine. He has completed postgraduate qualifications in Independent Prescribing, Musculoskeletal Ultrasound, Advanced Clinical Practice, the Theory of Podiatric Surgery, and Podiatric Sports Medicine. His clinical practice focuses on the diagnosis and management of complex foot and ankle conditions, combining detailed clinical assessment with diagnostic ultrasound to provide accurate diagnosis and evidence-based treatment.

If you're struggling with persistent foot or ankle pain and would like a specialist assessment, including diagnostic ultrasound where appropriate, appointments can be booked with Kent Sports Podiatry at clinics across Kent.