Plantar fasciitis (plantar fasciopathy) 2026 update

Clinical synthesis based on the JOSPT 2023 Clinical Practice Guideline (Koc TC Jr et al.), the BJSM 2016-2023 meta-analyses (van Leeuwen, Whittaker, Hamstra-Wright) and the FIX-Heel RCT (Riel 2023).

What are the fundamentals to know about plantar fasciitis?🔗 Copy

How is this condition defined, who does it affect and what are the risk factors?

Certain subgroups are particularly exposed: runners (peaking in distance runners, Hamstra-Wright 2021),⁹ military personnel (uneven ground, load carriage), workers on hard floors (checkout staff, construction workers, care staff).¹ ⁴ These subgroups are covered in the dedicated chapter further on.

What happens in the body, and how does plantar fasciitis evolve naturally?

The natural course is broadly favourable but slow. The classic estimates (Trojian 2019; Koc CPG 2023) indicate complete resolution in about 80 % of patients at 12 months under conservative treatment.¹ ⁵ However, one third of cases progress to pain persisting beyond a year, which is why early, structured management matters.¹ ⁵

How do you assess and diagnose plantar fasciitis with certainty?🔗 Copy

Diagnosing plantar fasciopathy is essentially clinical according to the JOSPT 2023 Clinical Practice Guideline (Koc TC Jr et al.).¹ ² Imaging is not recommended routinely: it is reserved for atypical presentations, suspected red flags, or failure after 3 to 6 months of well-conducted conservative treatment.¹ ³

Which questions should you ask to understand the patient and their history?

The history seeks to recognise the characteristic clinical pattern and to identify modifiable risk factors:

• Pain on the first steps : the most discriminating sign. Sharp, stabbing pain in the morning or after any prolonged rest (sitting through a film, a long car journey). The pain fades within a few minutes, then can return at the end of the day.¹ ²
• Location : the medial calcaneal tubercle (anteromedial heel). Diffuse or night pain should raise another aetiology.¹ ³
• Triggering factors : an abrupt increase in activity (running, walking, hiking), a change of footwear, weight gain, a new standing job.⁴ ⁵
• Risk factors : BMI, occupation, sport practised (running above all), a history of heel pain on the other side.⁵ ⁶
• Psychosocial factors : Cotchett 2016 shows a significant association between plantar fasciopathy and catastrophising / kinesiophobia, to be screened with the TSK-11 or the PCS in chronic cases.⁷

Which clinical tests should you perform, and which other conditions should you rule out?

The physical examination aims to reproduce the patient's pain and to exclude the differential diagnoses. No single test is sufficient; it is the convergence of the picture that makes the diagnosis.²

• Palpation of the medial calcaneal tubercle : the most sensitive test. Immediate reproduction of sharp pain on digital pressure.¹ ²
• Windlass test : passive dorsiflexion of the toes (the great toe in particular) with the patient weight-bearing. Positive if it reproduces the heel pain. High specificity but low sensitivity : a negative test does not exclude the diagnosis.¹ ²
• Assessment of ankle dorsiflexion : range < 10° with the knee extended = a risk factor and a treatment target.¹ ⁴ ⁵
• Neural tension tests (SLR / slump) : to rule out S1 radiculopathy.³ ⁸
• Retromalleolar Tinel test : to rule out tarsal tunnel syndrome (compression of the posterior tibial nerve).³ ⁸

Should patients with plantar fasciopathy be classified, and what are the benefits?

The JOSPT CPG 2023 (Koc) incorporates the ICF classification (International Classification of Functioning) and acknowledges that patients are not homogeneous. Without formal validation of therapeutic subtypes, several clinical profiles emerge:⁴ ⁵

• The “mechanical overload” profile : an athlete, a suddenly increased load, limited dorsiflexion. Treatment target: load management + HSR strengthening.
• The “weight” profile : a high BMI, prolonged standing, a flattened biomechanics. Target: orthoses + weight loss + non-impact aerobic activity.⁵ ⁶
• The “chronic pain” profile : pain > 6 months, kinesiophobia, catastrophising. Target: therapeutic education + a biopsychosocial approach + ESWT if refractory.⁷

Which treatment strategies are the most effective for plantar fasciitis?🔗 Copy

The JOSPT CPG 2023 (Koc TC Jr et al.) is the current international reference.¹ It carries a major update of the 2014 CPG (Martin) and ranks the interventions using the GRADE system.

Where do you start? What is the recommended hierarchy of interventions?

The Grade A recommendations of the 2023 CPG are:¹

• Patient education : explaining the condition (degenerative, not inflammatory), a favourable but slow prognosis, and the principle of optimal load management.¹ ²
• Plantar fascia-specific stretching (the DiGiovanni 2006 protocol): preferable to stretching the triceps surae alone. To be done 3 times a day, 10 repetitions of 10 seconds, above all on getting up.²
• Anti-pronation taping : a well-documented short-term analgesic effect (3 weeks).¹
• Foot orthoses (prefabricated or custom): moderate evidence of efficacy at 2-12 weeks (Whittaker 2018, meta-analysis of 19 RCTs, 1660 participants).³ No superiority of custom over prefabricated orthoses has been demonstrated.³ ⁴
• Manual therapy plus exercise (Grade B): a positive effect on ankle mobility and on pain in the short term.¹

What is the place of exercise, and is there a superior approach?

Rathleff's randomised controlled trial (2015, Scand J Med Sci Sports) was a turning point.⁵ 48 patients with fasciopathy confirmed on ultrasound were randomised to two arms: fascia-specific stretching (DiGiovanni) or high-load strengthening (HSR). At 3 months, the HSR group had an FFI score 29 points lower (a clinically and statistically significant superiority). At 12 months the two groups converged, so HSR delivers a faster recovery without additional long-term benefit.⁵

The HSR protocol, Rathleff 2015:

• Position: standing single-leg heel raise, toes in dorsiflexion over a rolled towel (to put the fascia under tension through the windlass effect).
• Slow tempo: 3 seconds concentric phase (up), 2 seconds isometric at the top, 3 seconds eccentric (down).
• Progression: weeks 1-2 = 3 × 12 repetitions at 12RM. Weeks 3-4 = 4 × 10 repetitions at 10RM (wearing a weighted backpack). Weeks 5-8 = 5 × 8 repetitions at 8RM. Beyond that: maintain 3 sessions a week.
• Frequency: every other day. Acceptable pain during the exercise ≤ 3-5/10.⁵ ⁶

The FIX-Heel RCT (Riel 2023, BJSM, n = 180) compared advice plus a heel cup ± exercise ± corticosteroid injection. At 12 weeks the three arms showed similar improvement: neither exercise (on a background of education) nor the addition of an injection outperformed education alone on the primary outcome.⁷ A nuanced reading: education is powerful; exercise brings a clinical benefit but a moderate one; corticosteroids bring no added value and expose the patient to adverse effects.

Manual therapies, shockwave, injections: how effective are they really?

ESWT is the best-validated second-line option for chronic cases of more than 6 months.¹ Focused or radial shockwave (3 to 5 weekly sessions) shows significant superiority over placebo in several recent meta-analyses.¹

Corticosteroid injection gives marked relief at 1-4 weeks, but the effect has gone by 3-6 months.⁷ The risk of fascia rupture and of fat pad atrophy calls for sparing use and limits repetition (a maximum of 1 to 2 injections).¹ The FIX-Heel trial 2023 confirmed the absence of added value at 12 weeks over exercise plus education.⁷

Beyond the physical: how do you educate the patient and address psychological factors?

Therapeutic education is the first recommendation of the 2023 CPG.¹ It should cover:

• Reconceptualisation : fasciopathy is a degenerative fasciosis, not acute inflammation (Lemont 2003).⁸ ⇒ Move away from the “rest + NSAIDs” logic.
• Prognosis : 80 % recovery at 12 months, but slowly, so prepare the patient for a horizon of 3 to 6 months.¹
• Load management : the principle of an “optimal zone” of stimulation (neither too much nor too little). The progressive load concept borrowed from Gabbett 2016.
• Demystifying pain : pain does not equal active tissue damage. Keep moving below the 3/10 threshold.⁹
• Addressing beliefs : “I have a spur, it needs removing” (false), “complete rest is needed” (false), “injections will cure it” (a limited effect).

In chronic cases with catastrophising or kinesiophobia (Cotchett 2016), a strengthened biopsychosocial approach is needed, possibly including CBT or a referral.⁹

How do you secure lasting recovery and prevent recurrence of plantar fasciitis?🔗 Copy

The recurrence rate of plantar fasciopathy remains poorly quantified in the literature, but clinical experience and the JOSPT CPG 2023 stress that prevention rests on three pillars: patient self-management, a maintained exercise programme, and progressive load management on returning to activity.¹

How do you make the patient an active participant in their recovery through self-management?

Self-management rests on four main components:

• Understanding load management : fasciopathy is a response to a load that exceeds the current capacity of the fascia. The patient learns to modulate their activities to stay below the irritation threshold, while progressively increasing tissue tolerance.² ³
• Home exercises : a programme combining specific stretching (DiGiovanni 2006) and high-load strengthening (Rathleff 2015) is superior to stretching alone. Adherence is the major predictor of success.⁴ ⁵
• Self-monitoring with the 3/10 rule : pain must not exceed 3 out of 10 during the exercise, and any pain provoked must settle quickly without persisting into the next morning.¹ ⁶
• Choice of footwear and use of orthoses : shoes with impact absorption and arch support. Orthoses are a temporary tool that allows activity to continue, not a permanent solution.⁷

When and how should a safe return to sport and to activity be planned?

The return to sport should be based on functional criteria, not on a calendar.⁶ ⁸

Prerequisites before resuming running or impact sport:

• Walking 30-60 minutes without heel pain
• No pain on the first steps in the morning
• 10 pain-free single-leg hops on the affected foot
• Plantar flexor strength symmetrical or > 90 % of the healthy side
• Functional ankle dorsiflexion (≥ 10° with the knee extended)

A typical return-to-running programme :

• Weeks 1-2: intervals of 1 min running / 2 min walking × 5 (3 sessions a week)
• Weeks 3-4: 2 min running / 1 min walking × 5
• Weeks 5-6: 5 min continuous running / 1 min walking × 3
• Weeks 7-8: 10-15 min continuous × 2-3
• Beyond that: a progressive return to the usual volume, +10 % a week at most

Monitoring : pain ≤ 3/10 during the session, no worsening at 24 h. If not, reduce the load or add a rest day.⁶

What is specific to plantar fasciopathy in runners and in at-risk subgroups?🔗 Copy

Plantar fasciopathy is a heterogeneous condition. Three subgroups deserve a differentiated approach: the runner, the patient with a high BMI, and the worker who stands for long periods. Each shares the same tissue target (the plantar fascia) but with distinct biomechanical drivers.

The runner: biomechanical risk factors and load management

The meta-analysis by Hamstra-Wright 2021 (Sports Health, 13 pooled studies) is the reference for risk factors specific to physically active individuals.¹ The variables significantly associated with fasciopathy in runners are:

• Reduced ankle dorsiflexion (< 10° with the knee extended): a major biomechanical factor, with less absorption during the stance phase, increased traction on the fascia.¹ ²
• A high BMI in the recreational runner (BMI > 27 in runners, not only in sedentary people).¹
• A recent history of lower-limb injury : deconditioning and persistent imbalance.¹
• Poor load management : an increase in weekly mileage > 10 %, a rapid transition to minimalist shoes, or the abrupt addition of interval or hill work.² ³
• Hard surfaces (concrete, asphalt) predominantly, above all in worn shoes (> 800 km).

Obesity and prolonged standing: weight as the main driver

The meta-analysis by van Leeuwen 2016 (BJSM, n > 5000 patients) remains the reference on the role of BMI.⁴ A BMI > 30 multiplies the risk of fasciopathy by about 2.5. In the overweight sedentary patient who stands for long periods, the dominant mechanism is not “sporting overload” but the cumulative static load on a poorly vascularised, degenerate fascia.

The clinical implications differ accordingly:

• The runner benefits above all from a temporary reduction in volume, from HSR strengthening, and from a progressive return to load.
• The overweight sedentary patient benefits from a multimodal approach including weight loss (cardiovascular and locomotor effects), non-impact aerobic activity (cycling, swimming, progressive walking), and an orthosis to cushion the static load.⁴ ⁵
• The worker who stands benefits particularly from anti-pronation taping, from orthoses, and from micro-breaks in standing (5 min seated each hour).⁵ ⁶

Clinical stratification: a practical decision tool

What do real clinical cases teach us about plantar fasciitis?🔗 Copy

Published clinical cases illustrate how the recommendations apply in practice and flag the diagnostic traps. We present three representative situations, referring to the case series published in the peer-reviewed literature.

Analysis of a “classic” case: from assessment to resolution

The typical profile is a person of 40-55 years with unilateral morning heel pain for 4 to 8 weeks, following an increase in activity (walking, resuming running) or a change of footwear.¹ ² Structured management following the JOSPT CPG 2023 (Koc) comprises:

1. Initial assessment : clinical examination (palpation of the medial tubercle, Windlass), assessment of dorsiflexion (often < 10° with the knee extended), BMI and activity review, screening for red and yellow flags.
2. A first-line multimodal plan :
   • Education: the degenerative (not inflammatory) nature, the prognosis, the load principle
   • Fascia-specific stretching (DiGiovanni) × 3 a day
   • Gastrocnemius stretching × 2 a day
   • A prefabricated orthosis worn daily
   • Anti-pronation taping for the first 2-3 weeks
3. Phase 2 (weeks 3-4) : adding HSR strengthening (Rathleff) 3 × a week
4. Phase 3 (weeks 6-12) : progressive withdrawal of the taping and the orthosis, progression of the strengthening, a progressive return to sport with the 3/10 rule
5. Discharge criteria : walking 30-60 min without pain, FAAM-ADL improved by ≥ 8 points (MCID), a return to the original activity

The expected course in this typical case: significant improvement at 6-12 weeks, complete resolution at 3-6 months, discharge at 4-6 months depending on functional demands.¹ ²

The diagnostic challenge: when plantar fasciitis mimics another condition

The case reports published on PubMed/PMC document several situations where a presumed “plantar fasciitis” turns out to be something else. The critical differential diagnoses always to consider:³ ⁴

• S1 radiculopathy : pain starting in the buttock, radiating down the leg to the heel, absent Achilles reflex, positive SLR. The heel pain is not reproduced by local palpation but by the neurodynamic tests.³
• Baxter's nerve compression (1^st branch of the lateral plantar nerve): pain similar to fasciopathy, but palpation more lateral (between abductor hallucis and quadratus plantae), possible weakness of abduction of the 5^th toe, with ultrasound sometimes showing atrophy of abductor digiti minimi.³ ⁴
• Tarsal tunnel syndrome : burning pain, plantar paraesthesia, positive retromalleolar Tinel, sometimes worse at night.³
• Calcaneal stress fracture : a history of abrupt loading (military service, ultra-trail), diffuse heel pain, positive squeeze test. In the amenorrhoeic female runner: think BSI in the context of a triad or REDs.
• Rare but critical cases : soft-tissue tumours (sarcomas), seronegative arthritis (spondyloarthritis, above all where bilateral in a young man), osteomyelitis (immunosuppressed or diabetic patients).¹ ³

The practical rule: any heel pain that does not respond to 3-6 months of well-conducted conservative treatment, or that carries an atypical signal (night pain, neurological signs, fever, deterioration in general health, a history of cancer), warrants a diagnostic reassessment and targeted imaging.¹ ³

A complex case

The refractory chronic profile (pain > 6 months despite well-conducted first-line treatment) remains a challenge. The individualised second-line options are:⁵ ⁶

• ESWT (3-5 sessions) : the most solid evidence for chronic cases. To be considered ahead of injections.¹ ⁵
• Corticosteroid injection : a short-term effect, to be limited to 1-2 spaced injections. Document informed consent about the risk of rupture and atrophy.⁶
• PRP (platelet-rich plasma) : an alternative under evaluation, with heterogeneous evidence and an off-label indication.
• A strengthened biopsychosocial approach : where catastrophising, kinesiophobia or depression are high (Cotchett 2016) ⇒ CBT, psychological intervention.
• Surgery (partial release) : considered only after 12 months of strictly conducted conservative treatment has failed. Adverse effects are documented (arch instability, residual pain).¹

How do you apply these recommendations concretely in your practice?🔗 Copy

When and to which other health professionals should you refer?

The autonomy of the physiotherapist in direct access comes with a responsibility to identify the situations that go beyond their scope.¹

Referral to a physician or the emergency department where red flags are present (Finucane 2020):

• Recent trauma, suspected fracture (positive calcaneal squeeze test)
• Intense, non-mechanical night pain that rest does not relieve
• Fever, deterioration in general health, unexplained weight loss
• A history of cancer, immunosuppression
• Progressive neurological signs (motor, sensory or sphincter deficit)
• Bilateral heel pain + low back pain in a young man (spondyloarthritis)
• An amenorrhoeic or hypogonadal runner with heel pain (calcaneal BSI)

Referral to a podiatrist or orthotist : where there is marked pronated loading, structural deformity, failure of a prefabricated orthosis, or a need for a custom orthosis for a specific activity (elite sport).²

Referral to an orthopaedic surgeon : only after 12 months of well-conducted conservative treatment has failed, and with the diagnosis confirmed on imaging. Surgical release remains marginal and demands an informed discussion of the risks.¹

Referral to a psychologist or chronic pain specialist : where yellow flags predominate (TSK-11 > 37, PCS > 30, clinically significant depression). Cotchett 2016 confirms the association of catastrophising and kinesiophobia with chronic plantar fasciopathy.³ ⁴

How do you measure outcomes and overcome barriers to implementation?

The PROMs recommended by the JOSPT CPG 2023 (Koc) are:¹

• FAAM (Foot and Ankle Ability Measure) : 21 ADL items + 8 Sports items. MCID about 8 points (ADL) and 9 points (Sports). The most widely validated for fasciopathy.
• FFI (Foot Function Index) : 23 items, 3 subscores (pain, disability, activity limitation). Often used in research.
• FHSQ (Foot Health Status Questionnaire) : 13 items, including the foot-related quality-of-life dimension.
• NPRS / VAS : pain on the first steps in the morning and overall pain at the end of the day, a simple daily measure.

Recommended clinical follow-up: baseline → 4 weeks → 12 weeks → 6 months. Aim to exceed the MCID at 12 weeks.

Documented barriers to implementation :⁵

• Lack of time in consultation (patient education = 15-20 min)
• Clinicians' beliefs and habits (a preference for passive modalities)
• Patients' expectations (“a massage”, “an injection”)
• Difficulty accessing resources and continuing education

Practical levers :

• A written patient handout (load management + exercises + the 3/10 rule)
• A video of the exercises sent by secure messaging
• A mobile app for tracking pain and adherence
• A review at 4 weeks with PROMs to make progress objective
• An explicit discussion of expectations at the start of care (“the pain will take 3-6 months to disappear completely”)