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

Plantar fasciitis, more precisely called plantar fasciopathy in the modern scientific literature, is the most common cause of heel pain in adults.¹ ² The term “fasciitis” is kept by tradition but remains improper: histological studies show that it is a degenerative process without acute signs of inflammation.³ This condition affects the overweight sedentary person and the long-distance runner alike, with partly different biomechanical mechanisms.

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

Plantar fasciopathy corresponds to pain in the heel arising from the plantar fascia at its insertion on the medial calcaneal tubercle. The pain is typically sharp with the first step in the morning or after a prolonged period of rest, then eases after a few minutes of walking and reappears at the end of the day.¹ ²

The lifetime prevalence is estimated at 1 person in 10 in the review in American Family Physician 2019.¹ It accounts for about 15% of foot conditions seen in primary care.¹ ² The peak age is between 40 and 60 years, with a bimodal distribution: overweight middle-aged sedentary people and runners of all ages.²

Certain subpopulations are particularly exposed: runners (peak in the long-distance runner, Hamstra-Wright 2021),⁹ military personnel (uneven terrain, equipment load), workers on hard floors (cashiers, construction workers, healthcare workers).¹ ⁴ These subpopulations are detailed in the dedicated chapter further on.

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

Pathophysiology is now recognised as a tendinosis-like condition of the plantar fascia.³ ⁵ The histological studies of Lemont et al. (2003, 50 surgical cases of chronic heel pain) put an end to the inflammatory dogma by showing: myxoid degeneration, disorganisation of the collagen fibres, increased fibroblasts and neovascularisation, without acute inflammatory cells.³ These data are in line with those established since for tendinopathies (cf. the Cook & Purdam continuum model).

The mechanism is typically a repeated mechanical overload exceeding the adaptive capacity of the fascia: the tissue enters a loop of incomplete degradation/repair. The presence of a radiological calcaneal spur is frequent but not causal (it is interpreted today as an adaptive response to chronic traction).² ⁵

The natural course is broadly favourable but slow. The Trojian 2019 review indicates improvement in about 80% of patients at 12 months with conservative treatment.¹ ⁵ However, one third of cases progress to persistent pain beyond one year, which justifies early, structured management.¹ ⁵

Diagnosis of plantar fasciopathy is essentially clinical according to the 2023 JOSPT 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:

• First-step pain : the most discriminating sign. Sharp, stabbing pain in the morning or after any prolonged rest (sitting at the cinema, a long car journey). The pain eases within a few minutes and may reappear at the end of the day.¹ ²
• Location : medial calcaneal tubercle (anteromedial heel). Diffuse or night pain should suggest another aetiology.¹ ³
• Triggering factors : sudden increase in activity (running, walking, hiking), change of footwear, weight gain, new standing workstation.⁴ ⁵
• Risk factors : BMI, occupation, sport practised (running +++), history of contralateral heel pain.⁵ ⁶
• Psychosocial factors : Cotchett 2016 shows a significant association between plantar fasciopathy and catastrophising/kinesiophobia, to be screened for with the TSK-11 or PCS in chronic cases.⁷

Which clinical tests should you perform and which other conditions must be ruled out?

The physical examination aims to reproduce the patient's pain and to rule out 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 (plantar band test) : passive dorsiflexion of the toes (the big toe in particular), patient weight-bearing. Positive if heel pain is reproduced. High specificity but low sensitivity : a negative test does not rule out the diagnosis.¹ ²
• Assessment of ankle dorsiflexion : range < 10° with the knee extended = risk factor and therapeutic target.¹ ⁴ ⁵
• Neural tension test (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 for what benefits?

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

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

The 2023 JOSPT CPG (Koc TC Jr et al.) is the current international reference.¹ It incorporates a major update of the 2014 CPG (Martin) and grades its recommendations from A (strong evidence) to F (expert opinion); shock waves, injections and PRP are outside its scope and are covered only by a scoping review.

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

The recommendations of the 2023 CPG, with their grade (from A, strong evidence, to F, expert opinion):¹

• Patient education : explanation of the condition (degenerative, non-inflammatory), favourable but slow prognosis, principle of optimal load management. The CPG does not grade it (only advice on weight is graded, at grade E); in FIX-Heel, advice and a heel cup do as well as the same advice with exercises or injection.¹ ⁷
• Specific stretching of the plantar fascia and of the triceps surae (grade A; DiGiovanni 2006 protocol): those of the fascia are preferable to stretching of the triceps surae alone. To be performed 3 times/day, 10 repetitions of 10 seconds, especially on getting up.¹ ²
• Anti-pronation strapping (taping), rigid or elastic (grade A): combined with the other treatments, effect on pain and function in the short term.¹
• Manual therapy of the joints and soft tissues of the lower limb (grade A): joint and flexibility restrictions, pain and function.¹
• Night splints for 1 to 3 months (grade A) if first-step pain persists.¹
• Foot orthoses (prefabricated or customised): combined with other treatments (grade C), not alone for short-term relief (grade B); moderate evidence of efficacy at 2-12 weeks (Whittaker 2018, meta-analysis of 19 RCTs, 1660 participants).¹ ³ No demonstrated superiority of custom-made over prefabricated orthoses.³ ⁴
• Strengthening of the foot and ankle muscles, dry needling and low-level laser (grade B each); ultrasound added to stretching is not recommended (grade A).¹

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

The randomised controlled trial by Rathleff (2015, Scand J Med Sci Sports) was a turning point.⁵ 48 patients with ultrasound-confirmed fasciopathy were randomised into two arms: specific fascia stretching (DiGiovanni) or high-load strengthening (HSR). At 3 months, the HSR group had an FFI score 29 points lower (statistically significant superiority, with a wide confidence interval: 6 to 52 points). At 1, 6 and 12 months, the groups did not differ: HSR therefore provides a faster recovery at 3 months, with no additional benefit in the longer term.⁵

HSR protocol (Rathleff 2015):

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

The FIX-Heel RCT (Riel 2023, BJSM, n=180) compared advice + heel cup alone, with exercises, or with exercises and a corticosteroid injection. At 12 weeks, no difference between the arms reaches the minimal important difference: added exercise is not distinguishable from advice alone, and injection added to exercise does slightly better than advice alone (9 points out of 100), below the threshold of clinical relevance (14 points).⁷ Interpretation: advice and the heel cup carry most of the effect; neither added exercise nor added injection brings a clinically relevant added value, and corticosteroids expose patients to adverse effects.

In a four-arm trial (Heide 2024, 200 patients), a standardised exercise programme added to advice and a custom-made orthosis likewise did not reduce pain further at 6 months.¹⁰ A 2026 meta-analysis (3 trials, 146 participants) finds exercise favourable compared with no intervention, with a benefit of uncertain relevance (low certainty).¹⁴ High-load strengthening remains an option; advice and load management carry most of the effect.

Manual therapy, shock waves, injections: how effective are they really?

ESWT is a second-line option for chronic cases of more than 6 months, on evidence that remains conflicting; the 2023 CPG places it outside its scope (the practice of American physiotherapists) and does not grade it, its scoping review citing a meta-analysis favourable in the medium and long term.¹ Against sham, one large trial was negative (Haake 2003, 272 patients)¹² and another, with focused waves, positive (Gollwitzer 2015, 250 patients)¹³; in the sham-controlled trial of Heide 2024 (200 patients), radial waves added to advice and a custom-made orthosis bring nothing more at 6 months (−0.02 points out of 10; 95% CI −1.01 to 0.96).¹⁰ A network meta-analysis of 22 trials (Zhao 2025) finds them superior to placebo on success rate, with low to very low certainty;¹¹ another meta-analysis (Charles 2023) on the contrary rates as high the evidence of a large effect on pain and function: certainty ratings diverge between reviews.¹⁶ Radial and focused waves are to be distinguished (3 to 5 weekly sessions).

Corticosteroid injection has, in FIX-Heel, only a statistically significant effect, below the threshold of clinical relevance, at 12 weeks;⁷ the scoping review of the 2023 CPG reports effects that vary widely from one trial to another and low-quality evidence.¹ The risk of rupture of the fascia and of fat pad atrophy calls for sparing use and limits repetition (maximum 1 to 2 injections).¹ The FIX-Heel trial 2023 confirmed the absence of added value at 12 weeks vs exercise + education.⁷

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

Therapeutic education is the basis of management : in FIX-Heel, advice and a heel cup do as well as the same advice with exercises or injection.⁷ It must cover:

• Reconceptualisation : plantar fasciopathy is a degenerative fasciosis, not an acute inflammation (Lemont 2003).⁸ ⇒ Move away from the “rest + NSAIDs” logic.
• Prognosis : 80% improvement at 12 months, but slow: prepare the patient for a horizon of 3 to 6 months.¹
• Load management : gradual progression, paced by tolerance (pain during exercise and the next day); no progression threshold has been validated in runners.
• Demystifying pain : pain does not equal active tissue damage. Keep moving below the 3/10 threshold.⁹
• Working on beliefs : “I have a spur, it has to be removed” (false), “complete rest is needed” (false), “injections will cure it” (limited effect).

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

The recurrence rate of plantar fasciopathy remains poorly quantified in the literature, but clinical experience and the 2023 JOSPT CPG stress that prevention rests on three pillars: patient self-management, a maintained exercise programme, and progressive load management on return 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 : plantar fasciopathy is a response to a load exceeding the fascia's current capacity. The patient learns to modulate their activities to stay below the irritation threshold, while gradually increasing tissue tolerance.² ³
• Home exercises : specific stretching (DiGiovanni 2006) and, optionally, high-load strengthening, which speeds up recovery at 3 months compared with stretching alone (Rathleff 2015), with no difference at 6 and 12 months. 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 exercise, and any provoked pain must subside quickly without persisting the next morning.¹ ⁶
• Choice of footwear and use of orthoses : shoes with impact absorption and arch support. Orthoses are a temporary tool allowing continuity of activity, not a permanent solution.⁷

When and how do you plan a safe return to sport and activities?

Return to sport must be based on functional criteria, not on a timetable.⁶ ⁸

Prerequisite criteria before resuming running/impact sport:

• Walking for 30-60 minutes without pain in the heel
• No first-step pain 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° knee extended)

Typical return-to-running programme :

• Weeks 1-2: intervals 1 min running / 2 min walking × 5 (3 sessions/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: gradual resumption of the usual volume, paced by tolerance, watching for any run that exceeds the longest run of the last 30 days by more than 10%, a situation associated with injuries in a cohort of runners (see the chapter on the runner)

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

Plantar fasciopathy is a heterogeneous condition. Three subpopulations deserve a differentiated approach: the runner, the patient with a high BMI, and the worker with prolonged standing. Each shares the same tissue target (plantar fascia) but with distinct biomechanical drivers.

The runner: biomechanical risk factors and load management

The meta-analysis of Hamstra-Wright 2021 (Sports Health, 16 included studies and 11 pooled factors) is the reference for risk factors specific to physically active individuals.¹ The variables significantly associated with plantar fasciopathy in the runner are:

• Reduced ankle dorsiflexion (< 10° knee extended): a major biomechanical factor, with less absorption in the stance phase and increased traction on the fascia.¹ ²
• High BMI in the recreational runner (BMI > 27 in the runner, not only the sedentary).¹
• Recent lower-limb injury history : deconditioning and persistent imbalance.¹
• Poor load management : sudden increase in running mileage, rapid transition to minimalist shoes or sudden addition of interval training/hills.² ³
• Hard surface (concrete, asphalt) predominating, especially with worn shoes (> 800 km).

The acute-to-chronic workload ratio (ACWR) comes from team sports: Gabbett (2016) drew his “optimal zone” of 0.8 to 1.3 and his “danger zone” from 1.5 upwards from data on cricket, Australian football and rugby, calling for caution for individual sports.⁸ It is now contested: a reanalysis of published data finds no predictive value of its own, and the authors of that reanalysis propose abandoning it.⁹ A 2025 meta-analysis finds, according to its authors, an association with injuries, to be used with caution given the heterogeneity of the studies.¹⁰ Another, in 2026 in team sports, judges it small to moderate and highly heterogeneous, and concludes that it should not be used alone, only as one indicator among others.¹¹ It is therefore neither a validated prevention tool nor a return criterion: progression is paced by tolerance, including next-day pain and stiffness, and no weekly progression threshold is validated. In runners, a cohort of 5,205 runners links overuse injuries neither to the acute-to-chronic ratio (the relationship there is inverse) nor to the week-to-week increase, but to the session whose distance exceeds the longest run of the previous 30 days by more than 10% (observational study).¹²

Obesity and prolonged standing: weight as the main driver

The meta-analysis of van Leeuwen 2016 (BJSM, n > 5000 patients) remains the reference on the role of BMI.⁴ A BMI > 27 is associated with an odds ratio of 3.7 for plantar fasciopathy. In the overweight sedentary person with prolonged standing, the dominant mechanism is not “sports overload” but cumulative static load on a poorly vascularised, degenerated fascia.

Differentiated clinical implications:

• The runner benefits above all from a temporary reduction in volume, HSR strengthening, and progressive reloading.
• 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 with prolonged standing benefits in particular from anti-pronation strapping, orthoses, and micro-breaks from standing (5 min seated break per hour).⁵ ⁶

Clinical stratification: a practical decision tool

Published clinical cases illustrate the practical application of the recommendations and warn of diagnostic pitfalls. We present three representative situations, referring to case series published in the peer-reviewed literature.

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

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

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/yellow flags.
2. First-line multimodal plan :
   • Education: degenerative nature (not inflammatory), prognosis, principle of load
   • Specific fascia stretching (DiGiovanni) × 3/day
   • Gastrocnemius stretching × 2/day
   • Prefabricated orthosis worn daily
   • Anti-pronation strapping for 2-3 weeks at the start
3. Phase 2 (weeks 3-4) : addition of HSR strengthening (Rathleff) 3×/week
4. Phase 3 (weeks 6-12) : gradual withdrawal of strapping and orthosis, progression of strengthening, progressive return to sport with the 3/10 rule
5. Discharge criteria : walking for 30-60 min without pain, FAAM-ADL increased by ≥ 8 points (MCID), return to the initial activity

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

The diagnostic challenge: when plantar fasciitis mimics another condition

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

• S1 radiculopathy : pain starting from 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 neurodynamic tests.³
• Baxter's nerve compression (1^st branch of the lateral plantar nerve): pain similar to the fasciopathy, but more lateral palpation (between abductor hallucis and quadratus plantae), possible weakness of abduction of the 5^th toe, ultrasound sometimes showing atrophy of the abductor digiti minimi muscle.³ ⁴
• Tarsal tunnel syndrome : burning pain, plantar paraesthesia, positive medial retromalleolar Tinel, sometimes worse at night.³
• Calcaneal stress fracture : history of sudden loading (military, ultra-trail), diffuse heel pain, positive squeeze test. In the amenorrhoeic female runner: think of BSI in the context of the triad/REDs.
• Rare but critical cases : soft tissue tumours (sarcomas), seronegative arthritis (spondyloarthritis, especially if bilateral in a young man), osteomyelitis (immunocompromised, diabetic).¹ ³

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

Study of a complex case

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

• ESWT (3-5 sessions) : second-line option for chronic cases, on conflicting evidence; to be discussed before injections.¹ ⁵
• Corticosteroid injection : short-term effect, to be limited to 1-2 spaced injections. Document informed consent about the risk of rupture/atrophy.⁶
• PRP (Platelet-Rich Plasma) : alternative under evaluation, heterogeneous evidence, off-label indication.
• Reinforced biopsychosocial approach : if catastrophising / kinesiophobia / depression are high (Cotchett 2016) ⇒ CBT, psychological intervention.
• Surgery (partial release) : considered only after 12 months of strict conservative failure. Documented adverse effects (arch instability, residual pain).¹

When, and to which other healthcare professionals, should you refer?

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

Referral to a physician / emergency in the presence of red flags (Finucane 2020):

• Recent trauma, suspected fracture (positive calcaneal squeeze test)
• Intense, non-mechanical night pain, not relieved by rest
• Fever, deterioration in general condition, unexplained weight loss
• History of cancer, immunosuppression
• Progressive neurological signs (motor, sensory, sphincter deficit)
• Bilateral heel pain + low back pain in a young man (spondyloarthritis)
• Runner with amenorrhoea or hypogonadism + heel pain (calcaneal BSI)

Referral to a podiatrist / orthotist : if marked pronated stance, structural deformities, failure of a prefabricated orthosis, or need for a customised orthosis for a specific activity (elite sport).²

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

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

How do you measure outcomes and overcome barriers to implementation?

The PROMs recommended by the 2023 JOSPT CPG (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 plantar fasciopathy.
• FFI (Foot Function Index) : 23 items, 3 subscores (pain, disability, limitation). Often used in research.
• FHSQ (Foot Health Status Questionnaire) : 13 items, includes the foot-related quality of life dimension.
• NPRS / VAS : first-step pain 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.

Barriers to implementation as documented:⁵

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

Practical levers :

• Written patient handout (load management + exercises + 3/10 rule)
• Exercise video sent through secure messaging
• Mobile app for monitoring pain and adherence
• Review at 4 weeks with PROMs to objectify progress
• Explicit discussion of expectations at the start of care (“the pain will take 3-6 months to disappear completely”)