Plantar fasciitis and heel spurs: what really helps when your heel stabs at the first step

You get out of bed in the morning, put your foot on the floor, and a sharp, burning pain shoots through your heel. After a few steps it eases somewhat, but after a long spell of sitting or a run the pain comes back. This very typical pattern is the cardinal symptom of plantar fasciitis, an irritation of the thick band of tissue under the sole of your foot. In most cases the course can be managed conservatively, provided the right measures are started early and applied consistently.

:::answer-block{eyebrow="In short"} Plantar fasciitis is a painful irritation of the plantar fascia, the band of connective tissue between the heel bone and the joints at the base of the toes. It is the most common cause of heel pain in adults and affects around ten per cent of the population at some point in life [Trojian T, Tucker AK, Am Fam Physician 2019]. The classic sign is a stabbing pain under the heel during the first steps in the morning or after prolonged sitting. A bony heel spur, often visible on X-ray, is usually a consequence of chronic traction rather than the actual source of the pain [Buchbinder R, N Engl J Med 2004]. Conservative treatment with stretching exercises for the calf muscles and the plantar fascia, cushioned shoes, insoles and targeted adjustment of load leaves around ninety per cent of those affected symptom-free within six to twelve months [Goff JD, Crawford R, Am Fam Physician 2011]. :::

How plantar fasciitis develops

The plantar fascia is a taut plate of connective tissue that spans the longitudinal arch of the foot like a bowstring. With every step, a pulling force acts on its attachment at the heel bone. If this load stays too high for too long, tiny micro-tears form at the tendon attachment and set off local irritation with degenerative changes. This is therefore an overload reaction of the fascia with inflammatory components rather than a classic inflammation in the acute sense.

On X-ray, many of those affected show a bony spur on the heel bone. The key point: the heel spur is usually not what hurts. It is the bone's adaptation to chronic traction. People without any symptoms often have such a spur as well [Buchbinder R, N Engl J Med 2004]. The actual source of pain remains the irritated fascia itself. Effective treatment therefore targets the fascia and the surrounding muscles rather than the bone.

Typical risk factors include several loading patterns that often combine:

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• Overuse from sport, especially running on hard surfaces
• Prolonged standing or walking at work
• Unsuitable or insufficiently cushioned footwear
• Fallen arches, flat feet or a similar misalignment of the foot
• Shortened or untrained calf muscles
• Excess weight and sudden weight gain :::

Diagnosis in the practice

In most cases the diagnosis of plantar fasciitis is clinical. Typical findings are local tenderness at the medial attachment on the heel bone, combined with pain on the first steps in the morning and worsening after load. Imaging is not needed in every case. It does help in unclear situations or in longer-running cases.

In our practice we prefer to work with high-resolution ultrasound. The ultrasound examination allows a direct assessment of the plantar fascia, its thickness and any structural changes. A fascia thicker than four millimetres at the heel bone attachment is considered an imaging sign of plantar fasciitis [Goff JD, Crawford R, Am Fam Physician 2011]. MRI is reserved for rarer questions, for instance when other causes such as a stress fracture, tarsal tunnel syndrome or a systemic rheumatic disease are under consideration.

Conservative treatment: what you can do yourself

The good news first: in around nine out of ten people, plantar fasciitis can be treated conservatively. Patience is the decisive factor, because healing often stretches over several months. The following measures form the foundation of any treatment:

Stretching exercises for the plantar fascia and the calf muscles. Performed deliberately several times a day, they are the single most effective measure. A proven exercise is the stair stretch: stand with the ball of your foot on a step and let the heel sink slowly until you feel a clear stretch in your calf and the sole of your foot. Hold the position for thirty seconds and repeat it three to five times. Rolling the sole of the foot over a small ball or a frozen water bottle helps as well.

Cooling. A frozen water bottle under the foot combines cold and massage. Five to ten minutes of this after activity relieves pain and the swelling caused by the irritation.

Footwear and insoles. Well-cushioned shoes with a stable heel area are the basis. Soft heel pads or off-the-shelf sports medicine insoles take the strain off the tendon attachment. If the foot is markedly misaligned, custom-fitted insoles are worthwhile.

Adjusting the load. Temporarily reduced running or standing time gives the tissue a chance to recover. Alternative forms of training such as swimming or cycling maintain fitness without loading the fascia.

Non-steroidal anti-inflammatory drugs. Short-term use of NSAIDs such as ibuprofen or diclofenac can relieve pain and irritation in the acute phase. Longer-term use is not advisable because of the known stomach and kidney risks, and it does not replace the measures that address the cause.

What helps when: extended treatment options

If the symptoms do not subside after six to eight weeks of consistent self-treatment, extended therapy starts to make sense. The order follows the course of the condition and the demands of everyday life:

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• Structured physiotherapy with a stretching and strengthening programme
• Focused or radial shockwave therapy (ESWT)
• Sports medicine insole fitting
• Injection with the body's own growth factors (PRP)
• Low-dose radiotherapy for pain (LDRT)
• Corticosteroid infiltration, used with restraint :::

Shockwave therapy has gained a growing evidence base for chronic plantar fasciitis in recent years. Three to five sessions at weekly intervals can reduce pain markedly, especially in combination with a consistent stretching programme [Rompe JD et al., Int J Surg 2015]. It is usually outpatient and causes little pain; local anaesthesia is generally not required.

PRP injection (platelet-rich plasma) uses growth factors taken from your own blood to stimulate the tissue's self-healing. It is an option for chronic, recurring courses when other measures are not enough.

Low-dose radiotherapy for pain (LDRT) is an established option for particularly stubborn cases. Several controlled studies show a marked reduction in pain in a large proportion of those treated who had not responded to conservative therapy [Niewald M et al., Int J Radiat Oncol Biol Phys 2012]. The radiation dose is many times lower than in oncology, and the benefit-risk ratio is favourable in adults over forty.

Corticosteroid injections often relieve pain quickly, but with repeated use they weaken the fascia and increase the risk of a plantar fascia rupture. So we use them rarely and selectively, never as the standard treatment.

How we proceed in the practice

At our practice Dein Team fürs Leben we start with a detailed medical history and a clinical examination, supplemented by an ultrasound examination of the plantar fascia. On this basis we discuss a step-by-step plan with you: which measures you can carry out yourself at home, which we coordinate with the physiotherapists in our network, and at what point we extend treatment to include shockwave, PRP or LDRT. The aim is to get most cases symptom-free conservatively and without surgery.

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How long does plantar fasciitis take to heal?

Most cases need between six and twelve months of consistent treatment. The largest part of the pain reduction comes in the first three months; the rest takes patience and continuous stretching.

Does a heel spur have to be removed surgically?

As a rule, no. The heel spur is a consequence of the overload rather than its cause. Surgical removal makes sense only in rare exceptional cases and is hardly ever performed today.

Do insoles really help?

For many people, yes. Well-cushioned standard insoles or soft heel cushions are enough in many cases. If the foot is markedly misaligned, a custom sports medicine fitting is recommended.

When does a cortisone injection make sense?

Only with great restraint and in selected situations. Repeated injections weaken the fascia and can do more harm than good in the long run. Shockwave and PRP are the better option in most cases.

Can I keep doing sport with plantar fasciitis?

Activities that reproduce the pain should be reduced for the time being. Alternatives such as swimming, aqua jogging or cycling maintain fitness and muscle without irritating the fascia. :::

Author: Prof. Dr. C.K. Fritz M.Sc., Physician Associate for General Internal Medicine, Pain Medicine, Practice Lead Dein Team fürs Leben.