Changes

December 2024 — reviewed. A literature search was conducted in November 2024 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. The recommendations on when to arrange additional imaging have been expanded. The basis for recommendation sections have been updated in line with current evidence in the literature.

Update

Goals

To support primary healthcare professionals to:

• Suspect a diagnosis of plantar fasciitis following clinical assessment.
• Give appropriate self-care advice where appropriate.
• Offer referral to a podiatrist, physiotherapist, and/or orthopaedic surgeon if symptoms persist despite management in primary care, to consider minimally invasive or other surgical treatment options.

Outcome measures

Audit criteria

QOF indicators

QIPP - Options for local implementation

No QIPP indicators were found during the review of this topic.

NICE quality standards

What is it?

• Plantar fasciitis (also known as 'plantar fasciopathy' or 'plantar fasciosis') is a biomechanical overuse condition due to repetitive stress to the plantar fascia at its origin, resulting in degenerative changes at its attachment to the calcaneus (rather than a primary inflammatory condition) [Trojian, 2019] [Latt, 2020] [Rhim, 2021].
  • It is characterized by medial plantar heel pain with tenderness at the medial calcaneal tuberosity, with typical symptoms on weight-bearing first thing in the morning or after a period of rest [Rhim, 2021; Koc, 2023].
  • The plantar fascia is a thick band of fibrous connective tissue which originates from the posteromedial calcaneal tuberosity and inserts into each metatarsal head to form the longitudinal arch of the foot. It tightens during walking, stabilizing the longitudinal arch of the foot [Trojian, 2019; Latt, 2020; Rhim, 2021; Cooper, 2023].

What are the causes and risk factors?

The pathogenesis of plantar fasciitis is not completely understood but is likely to be multifactorial, with abnormal biomechanics and delayed healing contributing to the condition [Luffy, 2018].

• The origin of the plantar fascia at the medial calcaneal tuberosity may be subjected to high levels of stress as it helps to support the medial longitudinal arch during the 'push-off' phase of the gait cycle [Koc, 2023]. Repetitive mechanical overload can induce microscopic tears, primarily at the origin of the plantar fascia [Cooper, 2023].
  • The tears may be associated with 'collagen degeneration, fibre disorientation, increased mucoid ground substance, and calcification' [Cooper, 2023]. Histology samples from surgical patients with plantar fasciitis show myxoid degeneration with fragmentation and degeneration of the plantar fascia, reflecting a chronic degenerative process [Trojian, 2019].
• Risk factors for plantar fasciitis include:
  • Age — plantar fasciitis most commonly affects people aged 40–60 years [Rhim, 2021].
  • Overweight or obesity — due to excessive loading, especially in non-athletic populations [Latt, 2020; Rhim, 2021; Morrissey, 2019; Trojian, 2019; Koc, 2023].
  • Prolonged standing, walking, or running — repetitive stress may cause microtears in the plantar fascia as part of an overuse injury [Latt, 2020; Morrissey, 2019]  [Rhim, 2021]  [Koc, 2023].[Trojian, 2019]
  • Structural foot deformities — such as excessive foot pronation (pes planus), high foot arches (pes cavus), tight Achilles tendon or gastrocnemius muscle (equinus), and/or limb length discrepancy, which may all involve tight intrinsic foot muscles [Morrissey, 2019; Trojian, 2019; Latt, 2020].
  • Limited ankle dorsiflexion — causes the foot to overpronate, putting more load on the plantar fascia [Trojian, 2019; Rhim, 2021].
  • Ill-fitting footwear and/or poor support from footwear [Morrissey, 2019].
  • Systemic conditions such as axial spondyloarthritis — may have a current or past history of peripheral enthesitis, especially if persistent and/or in multiple sites such as the plantar fascia and Achilles tendon insertions [Morrissey, 2019; Magrey, 2020; Navarro-Compan, 2021; Koc, 2023].

How common is it?

Plantar fasciitis is the most commonly recognized cause of plantar heel pain in adults [Trojian, 2019] [Koc, 2023]. The prevalence information in the literature is variable depending on the different studies used.

• Plantar fasciitis is a common condition, especially in people aged 40–60 years, with no evidence of sex bias [Koc, 2023].
• A best practice guideline states the prevalence of plantar heel pain is estimated to range from 4–7% in the general population. It predominantly affects sedentary middle-aged and older adults, and is estimated to account for 8% of all running-related injuries [Morrissey, 2019].
• Expert opinion in a review article notes that plantar fasciitis is a common problem with a lifetime incidence of about 10% [Trojian, 2019].
• A Dutch cohort study using a primary care database (n = 1.9 million patients) found [Rasenberg, 2019]:
  • The overall incidence of plantar heel pain was 3.83 cases per 1000 patient-years.
  • There was a higher incidence in women compared with men.
  • The mean age of affected individuals was 50.25 years.
• In a UK community population-based study of plantar heel pain in adults aged 50 years and over using a postal health survey (n = 5,109) [Thomas, 2019]:
  • The population prevalence of plantar heel pain was 9.6%, and 7.9% for 'disabling plantar heel pain'.
  • Plantar heel pain was slightly more prevalent in women and comparable across age groups and was most common in people with routine and manual occupations.
  • The prevalence of 'disabling plantar heel pain' was slightly higher in women, older age groups, and people working in routine or manual occupations.
  • The 12-month period prevalence of foot pain-related consultation with a general practitioner, physiotherapist, or podiatrist/chiropodist was 43%, 15.1%, and 32.8%, respectively.

What is the prognosis?

Plantar fasciitis is usually a self-limiting condition [Latt, 2020]. Literature on the prognosis is variable, based on a limited number of studies with different populations and often small sample sizes.

• The American Physical Therapy Association (APTA) clinical practice guideline on plantar fasciitis cites evidence from two retrospective cohort studies involving 432 people diagnosed with chronic plantar heel pain, which found the mean duration of symptoms ranged from 13.3 to 14.1 months [Martin, 2014].
• Expert opinion in a review article states that with non-surgical treatment, 80% of people with plantar fasciitis improve within 12 months [Trojian, 2019]. Expert opinion in another review article states that more than 90% of people have relief of symptoms with 3–6 months of conservative treatment [Latt, 2020].
• A prospective observational cohort study of people with plantar fasciitis (n = 174) with a mean follow-up of 9.4 years from symptom-onset found [Hansen, 2018]:
  • At follow-up, 54% of participants were asymptomatic, and 46% were still symptomatic.
  • The mean duration of symptoms was 725 days in participants whose symptoms had resolved.
  • The risk of having plantar fasciitis was 80.5% after 1 year, 50.0% after 5 years, 45.6% after 10 years, and 44% after 15 years from the onset of symptoms.
  • The risk of ongoing symptoms was increased in women and people with bilateral symptoms.

How should I assess a person with suspected plantar fasciitis?

If a person presents with plantar heel pain and has a suspected diagnosis of plantar fasciitis, assess for typical clinical features that support the diagnosis.

• Ask about:
  • Symptoms of plantar heel pain include its timing, onset, character, location, and intensity, as well as its impact on daily occupational, recreational, or other functioning. Typically, heel pain is:
    • Localized to the inferomedial area of the heel, and is of insidious onset, usually related to a change in weight-bearing activity.
    • Intense 'first step pain' or pain after initial steps in the morning or after a period of inactivity such as sitting, which may improve with activity. It may worsen with prolonged weight-bearing activity such as standing, walking, or running and may be worse by the end of the day.
    • Usually unilateral, but may be bilateral in up to 30% of people.
  • Occupation and usual physical activity levels, or recent increase in weight-bearing activity, including episodes of prolonged standing, walking, or regular running.
  • Any other risk factors or preceding injury.
  • Any predisposing systemic conditions such as axial spondyloarthritis.
  • Any previous episodes and treatment(s), including self-care measures, drug treatments, physiotherapy, and/or surgical treatment.
• Examine the person:
  • Assess posture and gait, looking for antalgic gait (an abnormal walking pattern to avoid pain) and compensatory movements.
  • Assess the type and fit of footwear.
  • Assess weight and body mass index (BMI).
  • Examine the foot at rest (sitting) and when standing and walking for typical signs, such as:
    • Point tenderness on palpation of the plantar heel area, particularly localized around the medial calcaneal tuberosity (proximal insertion of the plantar fascia).
    • Limited ankle dorsiflexion range of movement with the knee extended.
    • Positive 'Windlass test' — reproduction of heel pain by forced dorsiflexion of the toes at the metatarsophalangeal joints with the ankle stabilised.
    • Foot alignment changes such as pes planus or pes cavus, or tight Achilles tendon or gastrocnemius muscle (equinus).
  • Examine for clinical features which may suggest an alternative diagnosis, such as referred or neuropathic pain, pain on palpation of the body, plantar surface, or posterior aspect of the calcaneus, or mid-section plantar fascia tenderness.
• Consider whether additional imaging is needed if there are atypical clinical features and/or persistent symptoms following initial management.
  • Consider arranging weight-bearing foot X-ray(s) and/or foot ultrasound scan to assess for an alternative diagnosis, and manage appropriately.
    • Foot X-ray(s) may help to assess foot alignment, exclude bony lesions, and may identify a subcalcaneal spur on lateral heel X-ray (this is not pathognomonic of plantar fasciitis, does not affect prognosis, and is a common incidental finding in people who are asymptomatic).
    • Foot ultrasound scan may show plantar fascia thickening and hypoechoic areas, and may help to rule out other pathology such as plantar fibroma.

What else might it be?

Other conditions which may cause plantar heel pain include:

• Musculoskeletal
  • Achilles tendonosis — may present with insertional tenderness at the posterior aspect of the calcaneus and along the Achilles tendon, with pain radiating up the calf with extension of the foot or when on tiptoes. See the CKS topic on Achilles tendinopathy for more information.
  • Fibromyalgia or other causes of chronic pain. See the CKS topic on Chronic pain for more information.
  • Seronegative spondyloarthropathy or psoriatic arthropathy — may cause heel pain at the Achilles tendon insertion or plantar fascia insertion. See the CKS topics on Axial spondyloarthritis (including ankylosing spondylitis) and Spondyloarthritis and psoriatic arthropathy for more information.
  • Rheumatoid arthritis. See the CKS topic on Rheumatoid arthritis for more information.
  • Flexor hallucis longus tendinopathy — typically causes pain with resisted plantarflexion of the great toe.
  • Posterior tibial tendonitis — causes foot pain with resistance to foot inversion.
  • Calcaneal fracture — typically presents with swelling, heat, inability to weight bear, and pain on pressing the calcaneum. May be caused by falling from a height onto the heel or landing on an uneven surface. Calcaneal stress fracture may cause slow-onset heel pain secondary to repetitive loading.
  • Fat pad atrophy — causes centralized heel pain which is activity-related; may be flattened atrophied plantar surface of the calcaneus on palpation. May be a history of trauma, such as landing on the heel. Walking barefoot or on hard surfaces exacerbates the pain.
  • Sub-calcaneal bursitis — more common in elderly people; can be caused by a fall from a height onto the heel. Causes swelling and pain of the retrocalcaneal region. Pain is typically not worsened by dorsiflexion of the toes.
  • Plantar fascia tear or rupture — presents as sudden-onset pain and bruising, often located within the mid-section of the plantar fascia after a 'pop' is heard.
  • Proximal plantar fibroma — causes pain in the mid-section of the plantar fascia and palpable nodule(s).
  • Haglund deformity — a prominence of the superior aspect of the posterior calcaneus. Repeated pressure, such as from ill-fitting footwear, can lead to retrocalcaneal bursitis, which presents with pain, redness, swelling, and tenderness to palpation between the calcaneus and Achilles tendon.
  • Sinus tarsi syndrome — caused by repeated hyperpronation of the foot or lateral ankle sprain. The talocalcaneal sulcus (sinus tarsi) is the anatomical space bounded by the talus, calcaneus, talocalcaneonavicular joint, and posterior facet of the subtalar joint. Pain is worse when walking on an uneven surface and after exercise.
• Other
  • Neurological — may be due to peripheral neuropathy or a compression neuropathy such as L5/S1 radiculopathy (may cause back pain, radicular leg pain, or sensory loss in the foot or leg); medial calcaneal nerve entrapment (causes burning over the inferomedial aspect of the calcaneus); tarsal tunnel syndrome (due to compression of the posterior tibial nerve, causes burning pain and paraesthesia along the plantar aspect of the foot); or Baxter neuroma or neuritis (causes a burning sensation across the heel pad). See the CKS topics on Sciatica (lumbar radiculopathy) and Morton's neuroma for more information.
  • Neoplasm — may cause deep bone pain and/or night pain (rare). See the CKS topic on Bone and soft tissue sarcoma - recognition and referral for more information.
  • Vascular — such as arteriovenous malformation (rare).

Scenario: Management of plantar fasciitis

From age 16 years onwards.

Search strategy

Scope of search

A literature search was conducted for guidelines and systematic reviews on primary care management of plantar fasciitis.

Search dates

January 2020 - November 2024

Key search terms

The terms listed below are the core search terms that were used for EBSCOhost MEDLINE (searched 28th January 2020). These were combined with filters to identify guidelines, systematic reviews and primary care relevant literature in EBSCOhost MEDLINE. The strategy was adapted for The Cochrane Library databases.

S4    S1 OR S2 OR S3 
S3    AB ( (heel or plantar) N2 pain* ) OR TI ( (heel or plantar) N2 pain* ) 
S2    AB ( (plantar N2 (fasciitis OR fasciopathy OR fasciosis)) ) OR TI ( (plantar N2 (fasciitis OR fasciopathy OR fasciosis)) ) 
S1    (MH "Fasciitis, Plantar")  

Sources of guidelines

• National Institute for Health and Care Excellence (NICE)
• Scottish Intercollegiate Guidelines Network (SIGN)
• Royal College of Physicians
• Royal College of General Practitioners
• Royal College of Nursing
• NICE Evidence
• World Health Organization
• Guidelines International Network
• TRIP database
• Agency for Healthcare Research and Quality
• Institute for Clinical Systems Improvement
• National Health and Medical Research Council (Australia)
• Royal Australian College of General Practitioners
• British Columbia Medical Association
• Canadian Medical Association
• Alberta Medical Association
• Michigan Quality Improvement Consortium
• Singapore Ministry of Health
• National Resource for Infection Control
• RefHELP NHS Lothian Referral Guidelines
• Medline (with guideline filter)
• Driver and Vehicle Licensing Agency
• NHS Health at Work (occupational health practice)

Sources of systematic reviews and meta-analyses

• The Cochrane Library:
  • Systematic reviews
  • Protocols
  • Database of Abstracts of Reviews of Effects
• Medline (with systematic review filter)
• EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

• NIHR Health Technology Assessment programme
• The Cochrane Library:
  • NHS Economic Evaluations
  • Health Technology Assessments
• Canadian Agency for Drugs and Technologies in Health
• International Network of Agencies for Health Technology Assessment

Sources of randomized controlled trials

• The Cochrane Library:
  • Central Register of Controlled Trials
• Medline (with randomized controlled trial filter)
• EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

• Bandolier
• Drug and Therapeutics Bulletin
• TRIP database
• Central Services Agency COMPASS Therapeutic Notes

Sources of national policy

• Department of Health
• Health Management Information Consortium (HMIC)

Patient experiences

• Healthtalk
• BMJ - Patient Journeys

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

• British National Formulary (BNF)
• electronic Medicines Compendium (eMC)
• European Medicines Agency (EMEA)
• LactMed
• Medicines and Healthcare products Regulatory Agency (MHRA)
• REPROTOX
• Scottish Medicines Consortium
• Stockley's Drug Interactions
• TERIS
• TOXBASE
• Micromedex
• UK Medicines Information

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

• Clinical accuracy.
• Consistency with other providers of clinical knowledge for primary care.
• Accuracy of implementation of national guidance (in particular NICE guidelines).
• Usability.

Principles of the consultation process

• The process is inclusive and any individual may participate.
• To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
• Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
• Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
• External reviewers are not paid for commenting on the draft topics.
• Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
• All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
• All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

• Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
• Stakeholders identified from the following groups are invited to review draft topics:
  • Experts in the topic area.
  • Professional organizations and societies (for example, Royal Colleges).
  • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
  • Guideline development groups where the topic is an implementation of a guideline.
  • The British National Formulary team.
  • The editorial team that develop MeReC Publications.
• Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

• Topic selection
• Scoping of topic
• Selection of clinical scenarios
• First draft internal review
• Second draft internal review
• External review
• Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

• Animal studies
• Original research is not written in English

Possible exclusions for reviewed literature:

• Sample size too small or study underpowered
• Bias evident or promotional literature
• Population not relevant
• Intervention/treatment not relevant
• Outcomes not relevant
• Outcomes have no clear evidence of clinical effectiveness
• Setting not relevant
• Not relevant to UK
• Incorrect study type
• Review article
• Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

• Feasibility
  • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
• Organizational and Financial Impact Analysis
• Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
  • Eligible population
  • Current interventions
  • Likely uptake of new intervention or recommendation
  • Cost of the current or new intervention mix
  • Impact on other costs
  • Condition-related costs
  • In-direct costs and service impacts
  • Time dependencies
• Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

• Personal financial interests
• Personal family interest
• Personal non-financial interest
• Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.