Plantar fasciitis

A strong band under the foot, the plantar fascia, braces the arch and spreads your weight at every stride. Plantar fasciitis follows repeated strain that leaves tiny areas of wear and irritation at its attachment to the heel bone; for all its name, it is now seen as a wear problem more than a truly inflamed one.

It is more likely with:

• A sudden jump in activity, many hours on your feet, or a change of surface, such as taking up running on hard ground
• Tightness in the calf or the Achilles tendon, or feet with flat or high arches
• Extra body weight, which loads the heel with every step
• Shoes with poor cushioning or support, flip-flops and going barefoot on hard floors

It is commonest between 40 and 60. Now and then heel pain is part of a wider inflammatory condition, where the tendons and ligaments are inflamed where they anchor to bone (enthesitis), which is one reason the cause is worth confirming.

The first steps of the day often give it away:

• Pain under the heel and into the arch, sharp with the first steps after sleeping or sitting
• Pain that fades once you are walking, only to come back after hours on your feet
• Pain when the sole is stretched, as when you lift your toes off the floor or climb stairs
• A sore spot when you press under the heel

Heel pain in both feet, pain that wakes you at night, or pain that comes with stiffness or swelling in other joints can point to a different pattern; the section on when to seek help gives each its route.

A doctor can usually recognise plantar fasciitis from your account and by examining the foot. The diagnosis is still worth confirming, because other things hurt the heel: an Achilles tendon problem, a stress fracture, a trapped nerve, or the enthesitis of an inflammatory arthritis.

Ultrasound can show a thickened fascia at the heel, and the scan can help exclude the alternatives. Point-of-care ultrasound is part of the consultation with Dr Borukhson, so the heel can often be scanned on the day; the ultrasound clinic page tells you more.

Treatment starts simple and works for most people: stretching the calf and the sole, cushioned shoes with good arch support, insoles or heel pads, less time on the feet for a while, and pain relief. A physiotherapist can guide the exercises, and a podiatrist can advise on insoles, shoes and night splints. Where the pain lasts despite these, an ultrasound-guided injection may be considered, the scan placing it accurately; its relief can be short-lived, the injection can be very painful, with pain that can last several days afterwards, and it carries a rare risk of thinning the heel's fat pad or tearing the fascia. Shock-wave therapy is another option, and surgery is rarely needed. You and Dr Borukhson settle the plan together.

Everyday habits carry much of the load, but heel pain can take months to clear, so sticking with them matters more than any short cut:

• Stretch the calf and the sole each day, gently and regularly
• Wear cushioned shoes that support the arch, ideally with a small heel, and skip bare feet on hard floors, flat flip-flops and backless slippers
• A gel heel pad or a ready-made insole can spread the load away from the sore spot
• A cold pack, frozen peas in a towel, on the heel for up to 20 minutes every two to three hours, can ease a sore spell
• Painkillers from a pharmacy: paracetamol, or ibuprofen gel rubbed into the heel, with tablets only where needed and safe for you. Garments that have picked up ibuprofen gel burn more easily, so do not smoke while you use it, and keep well back from naked flames
• If running aggravates it, swim instead for a while, exercise that keeps weight off the feet

If extra weight is part of it, losing some takes load off the heel. Most people do recover, though it can take many months.

Plantar fasciitis itself is seldom dangerous, but a few heel pictures point to something else, and the lists below give each its route: an injured foot that may be broken, a torn Achilles tendon, an infection, which can become sepsis, and a sudden numbness or weakness that can be a stroke.

Treat any of these as a 999 or A&E emergency: call 999 and do not drive yourself to A&E.

• Severe illness with suspected sepsis: a high fever with shaking, confusion, rapid breathing, or feeling dramatically worse over hours
• With a fever or feeling unwell, a rash that does not fade when you press it, a stiff neck with eyes that cannot bear bright light, or skin, lips or tongue turning blue, grey, pale or blotchy, since these can be signs of meningitis or sepsis; on black or brown skin the rash and the change of colour may be easier to see on the palms of the hands or the soles of the feet
• A joint you cannot put weight on or move, or that has moved out of place, or, after a fall or injury, very bad pain or any tingling or numbness
• After an injury, a crack heard as it happened, or skin around it that has turned blue, grey or cold, since these can be signs of a broken bone
• Sudden weakness or numbness on one side, a drooping face or difficulty speaking, a sudden severe headache, sudden confusion or a seizure, or sudden loss of vision, any of which can be a stroke, even if it stops after a short time, and a foot or a leg that suddenly turns numb, or suddenly turns weak when no snap, pop or sudden severe pain in it came first to explain it, is one of these signs
• An eye that suddenly and completely loses its sight
• Lips, mouth, throat or tongue that suddenly swell, a throat that feels tight, very fast breathing or a struggle to breathe or to swallow, skin, tongue or lips turning blue, grey or pale (on black or brown skin this may be easier to see on the palms of the hands or the soles of the feet), becoming suddenly very confused, drowsy or dizzy, or fainting and not being able to be woken, since this can be a severe allergic reaction, anaphylaxis, which can follow a dose of any medicine

Any of these needs an assessment that is urgent, on the same day, from your GP or NHS 111:

• A snap or pop, or sudden severe pain, in the heel or the calf, with walking, standing on tiptoe or climbing stairs made hard, short of the signs in the first list, since the Achilles tendon may have torn or the heel bone broken: NHS 111 or an urgent treatment centre the same day; swelling or bruising may follow
• After a heel or foot injury, short of the signs in the first list, pain that keeps getting worse or a swelling or bruise that is large or still growing, since a bone may be broken; NHS 111 can say where to go, and an urgent treatment centre can sometimes X-ray it
• A heel that has turned painful, hot and swollen together, usually red as well, though redness may be harder to see on brown or black skin, since an infection there needs treating quickly; with a fever or feeling unwell, short of the signs that follow, at A&E or through NHS 111; with a very high temperature or feeling hot, cold or shivery, a fast heartbeat or fast breathing, purple patches on the skin, which may be less obvious on black or brown skin, feeling dizzy or faint, confusion, or skin that is cold, clammy or pale, it is a 999 or A&E emergency: call 999 and do not drive yourself to A&E

See a GP within days if heel pain comes with morning stiffness that needs over half an hour to wear off, back pain that eases when you move, a joint newly swollen but not hot, a toe or a finger swollen from end to end, or a new rash, since an inflammatory arthritis can begin at the heel, as our enthesitis guide explains; a joint that has turned hot as well as swollen is a same-day matter instead, at A&E or through NHS 111 with a fever or feeling unwell, and otherwise by your GP or NHS 111. Pain in both heels, heel pain with elbow pain, or heel pain with psoriasis in you or your family is worth a routine appointment with your GP or a specialist. Heel pain that wakes you at night, together with weight lost without trying, sweats at night or feeling worn out for weeks, needs a GP within days, as does a foot that is slowly growing weak or numbness that no longer clears; heel pain that keeps waking you at night on its own is for a GP. See a GP if the heel pain is severe or stopping your normal activities, if it is getting worse or keeps returning, if a fortnight of care at home brings no improvement, if you have tingling in the foot, or a loss of feeling there that has come on slowly, with no injury and no back pain, or if you have diabetes and foot pain, since foot problems can be more serious then. A foot or leg that turns numb all at once, or weak all at once when no snap, pop or sudden severe pain came first to explain it, or numb after an injury, belongs to the first list, and with back pain as well, our back pain guide says where a leg's tingling or weakness belongs. After an injury, a foot or ankle left at an odd angle or out of shape is a 999 or A&E emergency. No referral is needed to be seen here; next-working-day appointments can almost always be arranged, and same-day appointments are sometimes possible. If you cannot tell how urgent something is, asking is never a mistake.

A heel that keeps hurting is worth a proper examination, so the cause is confirmed and a plan that works is in place. An assessment tells plantar fasciitis from the tendon problems, the stress fracture and the inflammatory heel that can look like it, and ultrasound in the same visit can often settle the question there and then. If your heel pain is lasting, a specialist review can make sense of it and set out what to do.

Does plantar fasciitis get better by itself?

In most people it does, though slowly, often over months rather than weeks, and the simple measures help it along: stretching the calf and the sole, cushioned shoes with good arch support, cutting back on whatever aggravates it, and pain relief. See a GP if two weeks of that have not helped, if the pain is severe or stopping normal activities, or if it keeps returning; a specialist can confirm what it is and add further treatment if it lingers.

How do doctors recognise plantar fasciitis?

Mostly from what you describe and an examination of the heel, with no scan needed. When a scan would help, ultrasound can show a thickened fascia where it joins the heel and can help exclude other sources of heel pain. Point-of-care ultrasound is part of the consultation with Dr Borukhson, so the heel can often be scanned there and then.

Why is the pain worst when I first get up?

Pain on the first steps after sleep, or after sitting for a while, that eases as you keep walking is one of the typical features of plantar fasciitis. Other conditions can hurt the heel as well, though, so it is still worth having the diagnosis confirmed.

Will I need an operation?

Very seldom. Most people improve with stretching, good shoes, insoles, less time on their feet and pain relief. If the pain persists in spite of all that, a steroid injection guided by ultrasound may be considered, though its relief can be short-lived, and shock-wave therapy is another option a foot specialist may offer; surgery is reserved for the small number for whom nothing else has helped.

When is heel pain urgent?

A foot you cannot put weight on; after an injury, a crack heard at the moment it happened, very bad pain, any tingling or numbness, a foot or ankle left at an odd angle, or skin around it turned blue, grey or cold; a heel that is painful, hot and swollen together with a very high temperature or feeling hot, cold or shivery, feeling dizzy or faint, or another of the signs set out for a hot heel under when to seek help; and the sepsis signs that open the first list: any of these is a 999 or A&E emergency. Call 999 and do not drive yourself to A&E. Short of those signs, a snap or pop, or sudden severe pain, in the heel or calf, with walking or standing on tiptoe made hard, needs NHS 111 or an urgent treatment centre the same day, since the Achilles tendon may have torn or the heel bone broken. A heel or foot injury short of the 999 signs, where a bone may be broken, needs NHS 111 the same day too; a heel that is painful, hot and swollen together needs your GP or NHS 111 the same day, at A&E or through NHS 111 if you have a fever or feel unwell, short of the 999 signs above. The lists under when to seek help hold the rest.