Plantar Heel Pain: Is It Always Plantar Fasciitis and When Is Imaging Useful?

Direct Answer

Pain beneath the heel is commonly caused by plantar fasciitis, particularly when the first steps after rest are painful. However, not every case is plantar fasciitis. Stress fractures, nerve irritation, heel-pad disorders and inflammatory conditions can produce similar symptoms. Imaging is not routinely required when the presentation is typical, but it may help when symptoms are unusual, severe or not improving as expected.

What is plantar fasciitis?

The plantar fascia is a strong band of connective tissue extending from the heel towards the toes. It helps support the arch and transmits force when the foot bears weight.

Plantar fasciitis—also called plantar fasciopathy or plantar heel pain—is a condition involving pain where the plantar fascia attaches near the heel bone.

Although the name contains “-itis,” persistent plantar heel pain is not necessarily caused by inflammation alone. Long-standing cases can involve changes in the fascia’s structure and its ability to tolerate repeated loading.

The condition commonly develops without one specific injury.

What does plantar fasciitis usually feel like?

A typical symptom pattern includes:

  • Pain beneath or slightly towards the inner side of the heel
  • Pain during the first steps after waking
  • Pain when standing after prolonged sitting
  • Temporary improvement after moving around
  • Pain returning after prolonged walking or standing
  • Tenderness near the plantar fascia’s attachment to the heel
  • Pain when walking barefoot on hard surfaces
  • Pain after a sudden increase in physical activity

Some people describe the pain as sharp during their first steps and duller after they have been moving.

This pattern can support the diagnosis, but no single symptom proves that the plantar fascia is the source.

Why does plantar heel pain develop?

Plantar heel pain commonly appears when the load placed on the foot increases faster than the tissues can adapt.

Possible contributors include:

  • A sudden increase in walking or running
  • Prolonged standing at work
  • Starting a new exercise programme
  • Changing running distance, terrain or speed
  • Reduced calf or foot strength
  • Restricted ankle movement
  • A change in footwear
  • Returning to activity after a period of inactivity
  • Higher body weight
  • Reduced recovery between demanding activities

Age, health conditions and individual foot mechanics may also influence load distribution.

It is usually inaccurate to attribute the condition to one simple cause such as “flat feet,” “poor shoes” or a heel spur without considering the entire clinical picture.

Is every case of heel pain plantar fasciitis?

No. “Heel pain” describes a location, not a diagnosis.

The likely cause depends on where the pain is felt, how it began and which activities reproduce it.

Plantar fascia-related pain

Pain is usually located near the inner underside of the heel. First-step pain after rest is common, although not universal.

Heel-pad pain

The heel’s fatty pad helps absorb force. Pain may feel like deep bruising in the centre of the heel and may be aggravated by hard surfaces or prolonged standing.

Calcaneal stress injury

A stress reaction or stress fracture of the heel bone can cause progressively worsening pain with weight-bearing.

It may be more likely after:

  • A sudden increase in running, marching or jumping
  • A major rise in walking volume
  • Reduced bone density
  • Low energy availability
  • Menstrual disturbance
  • Previous stress fracture
  • Certain medicines or health conditions

Unlike typical plantar fasciitis, pain may become increasingly constant and make ordinary walking difficult.

Nerve-related pain

Nerves around the ankle and heel can become irritated or compressed. Possible features include:

  • Burning pain
  • Tingling
  • Numbness
  • Electric or shooting sensations
  • Pain spreading beyond the heel
  • Symptoms that do not follow the usual first-step pattern

Pain may occasionally be referred from a nerve higher in the leg or lower back.

Achilles insertional pain

Pain at the back of the heel may originate from the Achilles tendon rather than the plantar fascia. It may be aggravated by uphill walking, running, shoe pressure or deep ankle bending.

Inflammatory conditions

Inflammatory arthritis can affect the attachment of the plantar fascia or Achilles tendon.

Features that may prompt broader assessment include:

  • Pain affecting both heels
  • Prolonged morning stiffness
  • Several painful joints or tendon attachments
  • Joint swelling
  • Psoriasis
  • Inflammatory bowel disease
  • Recurrent eye inflammation
  • A family history of inflammatory arthritis

Infection or another uncommon condition

Infection, tumour and other serious causes of heel pain are uncommon but should be considered when warning features are present.

Does a heel spur cause plantar heel pain?

Not necessarily.

A heel spur is a bony projection that may be visible on an X-ray. It can occur in people with heel pain, but it is also found in people without symptoms.

The spur does not automatically establish the source of pain, determine its severity or mean that surgery is required.

Treatment should therefore not be directed at the X-ray finding alone.

How is plantar fasciitis diagnosed?

Plantar fasciitis can often be diagnosed clinically without imaging.

Assessment may include:

Symptom pattern

The clinician may ask:

  • Where exactly is the pain?
  • Is it worst during the first steps after rest?
  • Does it settle after warming up?
  • How much walking or standing is possible?
  • Was there a recent increase in activity?
  • Are there neurological or inflammatory symptoms?
  • Is pain present at rest or during the night?
  • What treatments have already been tried?

Palpation

Tenderness is commonly found near the plantar fascia’s attachment to the heel. Tenderness elsewhere may suggest a different diagnosis.

Foot and ankle movement

Restricted ankle dorsiflexion may influence loading through the foot. Movement of the big toe and other foot joints may also be assessed.

Strength and function

The examination may consider:

  • Calf strength
  • Single-leg balance
  • Walking pattern
  • Ability to perform heel raises
  • Squatting or stepping
  • Running mechanics when relevant
  • Foot muscle function

No single examination test should be treated as definitive.

Is an X-ray necessary?

An X-ray is not routinely necessary for a typical presentation of plantar fasciitis.

It may be considered when there is concern about:

  • Fracture
  • Significant arthritis
  • Unusual bone changes
  • Another diagnosis
  • Persistent symptoms that have not responded as expected

An X-ray may show a heel spur, but finding one does not prove that it is responsible for the pain.

The American College of Radiology generally recommends radiography as the initial imaging test when chronic foot pain requires imaging. Subsequent ultrasound, MRI or CT depends on the suspected condition and initial findings. ACR Appropriateness Criteria for Chronic Foot Pain

When might ultrasound be useful?

Ultrasound can assess the plantar fascia and surrounding superficial tissues. It may show:

  • Thickening of the fascia
  • Changes in tissue appearance
  • A partial tear
  • Fluid or another superficial abnormality

It can also be used to guide selected procedures.

However, an abnormal-looking plantar fascia does not automatically explain the pain. Imaging findings must be matched to the symptom location and examination.

When might MRI be useful?

MRI is not routinely required for uncomplicated plantar fasciitis.

It may be considered when:

  • The diagnosis remains uncertain
  • A stress injury is suspected
  • Symptoms are severe or atypical
  • Pain persists despite an appropriate treatment programme
  • There is concern about a plantar fascia tear
  • Nerve, bone or soft-tissue pathology is possible
  • A procedure or surgery is being considered

MRI provides detailed information, but the additional detail is only valuable if it answers a relevant clinical question and may change management.

What is the first-line treatment?

Treatment generally begins with a combination of education, load adjustment, stretching and strengthening.

Adjust aggravating activity

Load modification may involve temporarily reducing:

  • Running volume
  • Hill training
  • Jumping
  • Prolonged standing
  • Barefoot walking on hard floors
  • Sudden increases in daily steps

Complete rest is rarely required. The objective is to reduce repeated aggravation while maintaining tolerable activity and gradually rebuilding capacity.

Plantar fascia-specific stretching

Stretching the plantar fascia may help, particularly for first-step pain.

One method involves gently pulling the toes backwards until tension is felt along the sole of the foot. The correct dosage should be individualised.

Calf stretching

Calf stretching may be useful when ankle movement or calf flexibility is restricted. It should be performed without forcing severe heel pain.

Strengthening

Strengthening may address the calf, foot and lower limb.

Exercises can progress from:

  • Seated calf raises
  • Double-leg standing calf raises
  • Single-leg calf raises
  • Heavier resistance
  • Functional exercises
  • Running or jumping preparation

Strengthening should be adjusted to the person’s symptoms and activity goals.

The 2023 clinical practice guideline for heel pain supports plantar fascia and calf stretching, resistance exercise for the foot and ankle, and selected manual therapy as components of management. Heel Pain—Plantar Fasciitis Clinical Practice Guideline

Should I stop walking until the pain disappears?

Not usually.

Complete avoidance may reduce symptoms temporarily but can also reduce general fitness and tissue capacity.

A better approach is often to identify a tolerable walking level. Useful questions include:

  • Does the pain cause limping?
  • Does it steadily worsen during the walk?
  • Is the heel substantially worse later that day?
  • Is first-step pain significantly worse the next morning?
  • Is walking tolerance improving over time?

If even short periods of ordinary walking cause severe or escalating pain, the diagnosis should be reassessed.

Can footwear help?

Footwear may reduce symptoms by altering pressure and providing cushioning or support.

Potentially helpful features include:

  • Adequate cushioning
  • A comfortable fit
  • Avoidance of pressure over painful areas
  • Sufficient stability for the intended activity
  • Gradual transition when changing shoe type

No single shoe works for everyone. Very soft shoes are not necessarily better, and expensive footwear is not automatically more effective.

Do orthotics cure plantar fasciitis?

Orthoses may provide symptom relief for some patients, especially when combined with other treatments. They are not a guaranteed cure and should generally not replace exercise and load management.

Options include:

  • Prefabricated insoles
  • Heel cups
  • Cushioned inserts
  • Custom orthoses in selected circumstances

Evidence does not consistently show that custom devices are superior for every patient. A systematic review found that foot orthoses were not clearly superior to sham or other conservative treatments across patients with plantar heel pain. British Journal of Sports Medicine systematic review

A short trial of an affordable prefabricated device may therefore be reasonable before assuming that custom orthotics are necessary.

Are night splints useful?

Night splints hold the ankle and toes in a position that reduces prolonged shortening of the plantar fascia and calf during sleep.

They may be considered when first-step pain remains prominent, particularly when symptoms have continued for several months. Some people find them uncomfortable or difficult to tolerate.

Night splints should be viewed as an adjunct rather than the entire treatment programme.

Does taping help?

Foot taping may provide short-term symptom relief and can sometimes help determine whether temporary support changes walking comfort.

Its effects are generally temporary. It may be useful while longer-term strength and activity tolerance are being developed.

Does massage break down plantar fascia scar tissue?

There is limited basis for claiming that massage physically breaks down harmful scar tissue or permanently repairs the plantar fascia.

Soft-tissue treatment may temporarily reduce discomfort or improve movement for some people. It should not replace progressive strengthening, load management and reassessment when progress is limited.

Does therapeutic ultrasound help?

Therapeutic ultrasound is different from diagnostic ultrasound imaging.

Evidence has not established therapeutic ultrasound as an essential treatment for plantar heel pain. It may be offered as an adjunct in some settings, but patients should not assume that repeated passive treatment alone will restore the foot’s loading capacity.

When may shockwave therapy be considered?

Extracorporeal shockwave therapy may be considered for persistent plantar heel pain that has not improved adequately with an appropriate initial programme.

Evidence suggests that it may reduce pain in some patients, but:

  • Results vary
  • Treatment protocols differ
  • It does not help everyone
  • Exercise and load management may still be required
  • The diagnosis should be reviewed first
  • It should not be used as proof that every case is plantar fasciitis

Shockwave should be presented as a possible option for selected patients, not as a guaranteed cure.

Do steroid injections help?

A corticosteroid injection may provide short-term pain relief in selected cases. However, potential risks include:

  • Plantar fascia rupture
  • Fat-pad damage or thinning
  • Infection
  • Skin or pigment changes
  • Temporary increase in pain
  • Failure to provide lasting improvement

Repeated steroid injections require particular caution. Reducing pain does not necessarily restore tissue capacity, so a gradual rehabilitation plan remains important.

The potential short-term benefit should be balanced against the risks and other available options.

What does the evidence say about PRP?

Platelet-rich plasma has been studied for persistent plantar fasciitis. Some studies report better medium-term outcomes than corticosteroid injections, while other findings are less conclusive.

Important limitations include:

  • Variation in how PRP is prepared
  • Different injection methods
  • Inconsistent comparison treatments
  • Variable study quality
  • Uncertain cost-effectiveness
  • Lack of evidence that PRP restores a completely normal fascia

PRP should therefore not be described as proven regeneration or a guaranteed alternative to surgery.

Is surgery necessary?

Most people with plantar heel pain do not require surgery.

A surgical opinion may be considered when:

  • Symptoms have remained substantially disabling
  • The diagnosis has been reviewed
  • Appropriate non-surgical treatments have been tried
  • Another surgically treatable problem has been identified
  • The likely benefits justify the risks and recovery demands

Surgery can have complications and does not guarantee complete pain relief. It should not be considered simply because a heel spur appears on an X-ray.

When should treatment be reassessed?

Reassessment is reasonable when:

  • There has been little meaningful improvement
  • Walking tolerance is declining
  • Pain is becoming more constant
  • Pain occurs prominently at rest or at night
  • Symptoms are bilateral or associated with other joints
  • Burning, tingling or numbness is present
  • The heel is unusually swollen, red or warm
  • Pain began after a major increase in running or marching
  • There is concern about bone health
  • Repeated treatment provides only brief relief
  • Exercise cannot be progressed
  • The diagnosis was made without examining the foot

Reassessment may ask whether the original diagnosis is correct, whether imaging is now useful and whether the rehabilitation programme should be changed.

When does heel pain require prompt medical assessment?

Seek timely medical attention for:

  • Inability to bear weight
  • Sudden severe pain after an injury
  • A snap, pop or suspected tendon rupture
  • A hot, red and markedly swollen foot
  • Fever or feeling systemically unwell
  • An open wound or ulcer
  • New loss of sensation
  • A pale, cold or discoloured foot
  • Rapidly increasing swelling
  • Persistent night pain unrelated to position or activity
  • Unexplained weight loss
  • Heel pain in a person with diabetes and a new wound or skin change

These features are not typical of uncomplicated plantar fasciitis.

Practical considerations in Singapore

Initial assessment may be obtained through a polyclinic, general practitioner, private medical clinic or physiotherapy provider. A medical assessment may be preferable when the diagnosis is uncertain, symptoms are severe or imaging might be required.

Where medically appropriate:

  • X-ray can assess bone and alignment.
  • Ultrasound can examine the plantar fascia and superficial soft tissues.
  • MRI can assess stress injury, deeper tissues and atypical persistent pain.
  • Physiotherapy can address loading, strength, mobility and functional progression.
  • Referral may be considered if another condition or surgical problem is suspected.

Insurance coverage and referral requirements vary. Patients intending to claim should check whether their policy requires a medical referral, pre-authorisation or specific documentation.

Frequently Asked Questions

Is first-step pain always plantar fasciitis?

It is a characteristic symptom, but it is not completely specific. The location of pain, examination and other symptoms should also be considered.

Can plantar fasciitis go away on its own?

Some cases improve with time and sensible activity adjustment. Persistent symptoms may benefit from targeted stretching, strengthening and review of contributing loads.

Should I walk barefoot?

Walking barefoot on hard floors aggravates symptoms for some people. Temporary use of supportive or cushioned footwear indoors may help, but long-term management should still address capacity and activity tolerance.

Does weight loss cure plantar fasciitis?

Weight management may reduce load where relevant, but plantar heel pain has multiple contributors. People should not be denied assessment or treatment solely because of body weight, especially when pain itself makes exercise difficult.

Is a heel spur causing my pain?

Not necessarily. Heel spurs are common and may be painless. Their presence does not prove that they are the pain source or that they need removal.

Is an MRI better than ultrasound?

Neither test is universally better. Ultrasound can assess the plantar fascia dynamically and economically, while MRI provides broader detail of bone and soft tissue. The appropriate test depends on the clinical question.

How long does plantar fasciitis take to improve?

Improvement may take weeks to months. Long-standing symptoms can take longer. Progress should be assessed through first-step pain, walking tolerance, strength and daily function rather than expecting immediate resolution.

Can I continue running?

Some people can continue a reduced or modified running programme. Others need a temporary break. Running should be adjusted according to pain, gait, recovery and next-morning symptoms.

When should I consider shockwave therapy?

It may be considered when symptoms remain persistent after a properly delivered initial programme and the diagnosis has been reviewed. It is generally an adjunct rather than a substitute for rehabilitation.

When is a second opinion reasonable?

A second opinion may help when the pain remains unexplained, symptoms do not fit typical plantar fasciitis, treatment is not producing progress, injections or surgery have been proposed, or imaging findings do not match the symptoms.

References

This article is for general education and does not replace an individual medical assessment. Diagnosis and treatment depend on the symptom pattern, examination, medical history and personal circumstances. Urgent warning symptoms require prompt medical care. Evidence for emerging injections and procedures may still be developing, regulatory status varies, and some treatments may not be approved or routinely recommended in Singapore.

If heel pain remains persistent, the diagnosis is uncertain or treatment is not producing meaningful improvement, medical reassessment may help determine whether rehabilitation should be adjusted or whether X-ray, ultrasound, MRI or onward referral is appropriate. The Pain Relief Clinic provides assessment by a licensed medical doctor and in-house physiotherapy for integrated management where suitable.

Call or WhatsApp: +65 9068 9605

Reviewed by Dr Terence Tan, Founder of The Pain Relief Clinic — 19 September 2026

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